Cẩm Nang Các Quy Trình Cốt Lõi Trong Phẫu Thuật Tạo Hình (Core Procedures)

189
Operative techniques
Figure 11.6  Pectoralis major serves as the foundation for the female breast and
when absent, such as in Poland syndrome, reconstruction may be indicated for
aesthetic reasons.
A
B
Figure 11.5  Bilateral pectoralis advancement flaps. Allis clamps on pectoralis
muscle. Muscle sutured together in midline. (Courtesy of Dr David Song.)
A
B
grafting or damaged during wide debridement of a
post-sternotomy wound.
• The muscle may also be placed intrathoracically;
however, this will necessitate resection of a portion of the
2nd, 3rd, or 4th rib (Fig. 11.7).
• May be harvested with or without a skin paddle.
• Donor site deformity including scar placement and loss
of anterior axillary fold may be aesthetically displeasing.
Latissimus dorsi
• Latissimus dorsi, a large, flat muscle covering the mid
and lower back is often recruited for chest wall
reconstruction especially when significant bulk and
mobility is required. It is easily placed into the chest for
intrathoracic space-filling.
• Main function is to adduct, extend, and internally rotate
the arm.
• Originates from the thoracolumbar fascia and posterior
iliac crest and inserts into the superior humerus at the
intertubercular groove. Superiorly, it is attached to the
scapula and care must be taken to carefully separate this
muscle from the serratus at this point to avoid harvesting
both muscles.
• Dominant blood supply is the thoracodorsal artery which
enters the undersurface of the muscle 5 cm from the
posterior axillary fold.
• Segmental blood supply is derived from the posterior
intercostal arteries as well as the lumbar artery.
• Based upon its thoracodorsal pedicle, the muscle can
easily reach the ipsilateral posterior and lateral chest

190
•
• Chest reconstruction
11
Figure 11.7  Pectoralis anatomy and flap reach, standard and as turnover.
A
B
C
D
E
wall, including those defects involving either the anterior
chest wall, sternum, or mediastinum.
• It can also be turned over and based upon the lumbar
perforators and can cross the midline of the back
• Donor site morbidity can include shoulder dysfunction,
weakness and pain, as well as unattractive scarring.
• Also, transposition of this muscle can blunt or obliterate
the posterior axillary fold, resulting in some asymmetry
(Figs 11.8, 11.9).
• Care must be taken to properly drain the donor
site, as seromas are common. Quilting or progressive
tension sutures may mitigate against seroma
formation.
Serratus anterior
• Serratus anterior is a thin broad multi-pennate muscle
lying deep along the anterolateral chest wall.

191
Operative techniques
Figure 11.8  Latissimus dorsi, anatomy and standard arc of rotation.
A
B
C
D
Thoracodorsal
artery

192
•
• Chest reconstruction
11
A
B
Thoracodorsal
artery
Lumbar perforator
arteries
Subclavian
artery
Figure 11.9  Latissimus turnover flap. Thoracodorsal pedicle ligated, muscle
turned over based upon thoracolumbar perforators. Provides coverage of
contralateral posterior chest wall.
Thoracodorsal
artery
Subclavian artery
Figure 11.10  Serratus anatomy and arc of rotation.
• Main function is to stabilize the scapula and move it
forward on the chest wall such as when throwing a
punch.
• Originates from the upper 8 or 9 ribs and inserts on the
ventral-medial scapula.
• Two dominant pedicles include the lateral thoracic and
the thoracodorsal arteries.
• Division of the lateral thoracic pedicle will increase the
arc posteriorly and similarly division of the thoracodorsal
will increase the arc anteriorly.
• The muscle will reach the midline of the anterior
or posterior chest. More commonly, however, it is
used for intrathoracic coverage, again requiring rib
resection.
• An osteomyocutaneous flap may be harvested by
preservation of the muscular connections with the
underlying ribs.
• Donor site morbidity is related to winging of the scapula
and can be avoided if the muscle is harvested
segmentally and the superior five or six digitations are
preserved (Fig. 11.10).
Rectus abdominus
• Rectus abdominus is a long, flat muscle which constitutes
the medial abdominal wall.
• Main function is trunk flexion.
• Originates from the pubis and inserts onto the costal
margin. It can easily cover sternal and anterior chest
wall defects and can also fill space within the
mediastinum.
• Two dominant pedicles, the superior and inferior
epigastric arteries.
• It may be utilized despite previous IMA harvest based
upon its minor pedicle, the 8th intercostal artery.
• With division of the inferior pedicle, the muscle will
cover the mediastinum and the anterior chest wall.

193
Postoperative considerations
• Right-sided transposition obviates the need to navigate
the flap around the heart.
• Care must be taken when interpolating the omentum as it
is often of very little substance and can easily be avulsed
during passage through the diaphragm.
• Strategies to protect the omentum during transposition
include placing the omentum into a bowel bag. The
empty bag can be passed from the mediastinum into the
abdomen via the diaphragm incision, past the left lobe of
the liver. The omentum is then gently packed into the
bowel bag with tension transferred to the bowel bag
rather than the omentum during interpolation.
• Caution is again advised for patients with prior
laparotomy incisions as the omentum may have
significant intra-abdominal adhesions or have been
previously resected (Figs 11.12–11.14).
Postoperative considerations
• As with most reconstructive surgeries, after chest wall
reconstruction, the patient should limit physical activity
for several days. In particular with sternal reconstruction,
upper extremity use should be limited and patients
• When taken with overlying fascia, there is a risk for
resultant hernia, and at times, mesh reinforcement of the
abdominal wall is necessary. Caution is also advised for
patients with prior abdominal incisions as the skin
perforators or intramuscular blood supply may have
been previously violated (Fig. 11.11).
Omentum
• The omentum is comprised of visceral fat and blood
vessels and arises from the greater curve of the stomach
and is also attached to the transverse colon.
• This flap can easily cover wounds in the mediastinum,
anterior, lateral and posterior chest wall.
• Two dominant pedicles, the right and left gastroepiploic
arteries.
• The greatest benefit of this flap is the pedicle length,
which can be easily elongated with division of internal
arcades.
• The flap is mobilized onto the chest or into the
mediastinum through the diaphragm or over the costal
margin.
• Ideally, the flap is mobilized through a cruciate incision
in the right diaphragm as the liver helps to buttress the
incision and prevent diaphragmatic hernia.
Figure 11.11  Rectus anatomy and arc of rotation.
A
B
Superior
epigastric
artery
Inferior
epigastric
artery

194
•
• Chest reconstruction
11
Original
incision
Incision
Omentum
Left gastroepiploic vessels divided
Omentum
A
B
C
Figure 11.12  Omentum anatomy.
Omentum passing
through diaphragm
into thoracic cavity
Left lobe of liver
Stomach
Incision in diaphragm
Figure 11.13  Omentum is passed through cruciate incision in the diaphragm under the left lobe of the liver.
instructed to avoid lifting, reaching for objects, and/or
raising arms above their heads to avoid undue tension on
the reconstruction.
• Flap monitoring should be employed where appropriate.
• Patients will likely require postoperative monitoring in
an intensive or acute care unit postoperatively to monitor
pulmonary function.
Complications and outcomes
• Chest wall reconstruction has been, over the last three
decades, very successful.
• Cases of failure commonly result from inadequate control
of infection or residual tumor burden.

195
Further reading
Figure 11.14  Omentum arc of rotation.
• In either case, an aggressive resection is often indicated
and use of a second flap.
• An unfortunate complication of skeletal chest wall
reconstruction is the potential for infection of alloplastic
mesh products or implanted hardware.
• In these cases, removal of the infected prosthesis/
hardware is required.
• In cases of mesh removal, use of acellular dermal matrix
or autologous fascia or even contralateral ribs may be
indicated.
• At least 50% of patients undergoing sternal debridement
and muscle flap reconstruction will complain of
persistent chest and shoulder pain.
• And of these patients, 43% will complain of sternal
instability which is thought to result from irritation of
intercostal nerves when the residual sternal edges abut
one another.
• Strength, following use of popular muscle flaps (i.e.,
pectoralis major, latissimus dorsi, and rectus abdominus),
has been both surveyed and objectively measured and is
somewhat decreased following sternectomy and muscle
flap reconstruction.
• Patients’ abilities to perform activities of daily living
(ADLs) and return to preoperative activities was found to
be no different when compared to their peers with
uneventful healing poststernotomy.
• Pulmonary function following sternectomy and
reconstruction with pectoralis muscle flaps has been
measured pre- and postoperatively and seems to be
nearly unchanged following reconstruction.
• When patients were surveyed regarding their general
condition following sternal osteomyelitis and
reconstruction, 83% of patients reported improvement in
quality of life following their chest wall reconstruction.
• Outcomes following muscle flap transposition for
empyema or bronchopleural fistula reconstruction are
reported as quite successful, with 73% resolution or
prevention of infection in Arnold and Pairolero’s
retrospective review of 100 patients with severe
intrathoracic infections.
• Rib plating has been shown to reduce ventilator-
dependence and ICU stay as well as incidence of
pneumonia in patients with flail chest.
Further reading
Arnold PG, Pairolero PC. Intrathoracic muscle flaps. An
account of their use in the management of 100
consecutive patients. Ann Surg. 1990;211(6):656–660.
The authors detail a 73% success rate with treatment and
prevention of intrathoracic infection following muscle
transposition into the chest of high risk patients.
Deschamps C, et al. Early and long-term results of
prosthetic chest wall reconstruction. J Thorac Cardiovasc
Surg. 1999;117(3):588–592.
The authors review their experience with nearly 200 patients
requiring chest wall reconstruction over 15 years. Mesh is
utilized (polypropylene and polytetrafluoroethylene) for
skeletal support and over half of the patients required muscle
transposition for soft tissue coverage. Wound healing was
complete for 95% of patients, although 24% experienced
local cancer recurrence.
Dickie SR, Dorafshar AH, Song DH. Definitive closure of the
infected median sternotomy wound: A treatment
algorithm utilizing vacuum-assisted closure followed
by rigid plate fixation. Ann Plast Surg.
2006;56(6):680–685.
This paper contains a treatment algorithm for mediastinitis
emphasizing debridement, the use of subatmospheric
pressure, rigid fixation, and soft tissue coverage.
Mathes SJ, Nahai F. Reconstructive Surgery. Principles,
Anatomy, and Technique. Edinburgh: Churchill
Livingstone; 1997.
This textbook detailing nearly all commonly-used flaps in
plastic surgery continues to be an excellent reference for
relevant anatomy, flap selection, and arc of rotation.
Song DH, Lohman RF, Renucci JD, et al. Primary sternal
plating in high-risk patients prevents mediastinitis. Eur
J Cardiothorac Surg. 2004;26:367–372.
This is a case-controlled study of prophylactic sternal
plating in high risk patients. The group who were plated
experienced no mediastinitis, while 14.8% of the control
group, closed with wire, developed mediastinitis.

©2014, Elsevier Inc. All rights reserved.
Chapter
12 
Back reconstruction
• It is difficult, if not impossible, to define exactly who
should need a prophylactic soft tissue reconstruction of
the back.
■ Patients with previous hardware infections, a woody
feel to the soft tissues at the time of surgery, prior back
surgery, long reconstructions greater than six vertebral
bodies, CSF leaks, and a radiation history to the area
all seem to be appropriate candidates to receive a
soft tissue reconstruction.
■ In our center, we limit prophylactic closures to patients
with prior infections, when the muscles will not close
in the midline due to tissue loss or prior surgery, a
history of radiation with a woody feel to the tissues,
and CSF leaks.
• Chronic hardware exposures, those which occur 6 months
after placement, act differently from acute exposures.
From experience, long-term coverage of chronically
exposed hardware is not successful.
• When patients present with small areas of drainage and
by palpation a piece of hardware can be reached, this
defines a hardware infection. Similarly, patients with
fluid collections or “fluid cysts” in association with
hardware have chronic infections.
• These infections can be present for months or years and
yet not suppurate, nor make the patient overly ill and are
undoubtedly due to the low virulence of the organism,
such as Staphylococcus epidermidis.
• Debridement, irrigation, and soft tissue coverage of these
chronic exposures may be initially successful, but
eventually fail. Thus, for most patients the involved
hardware should be removed.
• The question is whether all of the hardware needs to be
removed, or if just a local portion (such as a large bolt)
should be removed and the soft tissues closed. These are
decisions made in the operating room.
■ All hardware in association with exudative fluid
should be removed.
This chapter was created using content from
Neligan & Song, Plastic Surgery 3rd edition,
Volume 4, Lower Extremity, Trunk and Burns,
Chapter 11, Reconstruction of the soft tissues of the
back, Gregory A. Dumanian.
SYNOPSIS
■ Reconstruction of the soft tissues of the back at first may seem to
be a daunting task compounded by large wounds, unfamiliar and
segmental anatomy, radiation, hardware, and difficulties with
postoperative positioning.
■ Many of the conditions treated require significant coordination with
surgical colleagues.
■ Many of the conditions are unfamiliar to the plastic surgeon and
without parallel conditions elsewhere in the body, an example being
pseudomeningoceles filled with cerebrospinal fluid (CSF).
■ The goal of this chapter is to provide the reader with real-life
solutions to difficult problems involving back wounds.
Brief introduction
• The back is 18% of the total body surface area, yet it is an
area commonly neglected in older texts of plastic surgery.
However, with advancements in spine instrumentation
and surgery, and subsequent wound related
complications, surgical procedures to close the back
reliably have been developed.
• Spine teams have noted the efficacy of muscle flap
closure of open spine wounds, and this has led to the
introduction of prophylactic use of muscle flaps at the
time of spine surgery. The same algorithms described in
the chapter below are used, but now at the time of the
back procedure, rather than only when there is a
complication.

197
Technical pearls
seen deep to the musculature, a deep hardware infection
is more likely.
Non-midline back wounds
• While midline wounds are either due to pressure sores or
spine procedures, non-midline wounds represent a much
more heterogeneous collection of etiologies and therefore
require a wide range of solutions.
• Much like acquired wounds elsewhere in the body,
wounds of the non-midline back are due to poor wound
healing after access incisions of the chest cavity or
retroperitoneum, necrotizing infections, or after tumor
excision.
• For these patients, a more standard thought process often
suffices in the absence of hardware, deep wounds, and
CSF leaks.
• The wounds are typically flat, and often allow skin
grafting.
• When flaps are needed to cover bone or prosthetic
material, the muscles that are used to cover the midline
spine are often available and even easier to mobilize to
the lateral back due to the lateral placement of their
pedicles.
• The lateral tissues, being more mobile than the midline
tissues, are easier to transpose for adjacent tissue
transfers.
• Free flaps are facilitated by having larger inflow vessels
available, such as the axillary artery, than exist for
midline reconstructions.
Technical pearls
Flap selection by region
Cervical region
• The cervical spine area is more often instrumented from
the anterior than the posterior approach.
• Wounds of the anterior cervical spine are uncommon,
and when they occur can be in association with
esophageal injuries. Wounds of the posterior cervical
spine are more common.
• Soft tissue defects without spine involvement are treated
depending on the size and location of the defect either
with skin grafts or adjacent tissue transfers. Pressure
sores tend to be treated conservatively with pressure
relief. Laminectomies are performed for spinal cord
pressure from metastases, and the wound beds are
typically radiated.
• Trapezius pedicled flaps are the preferred treatment for
patients who have received radiation following
laminectomy and oncologic tumor resection.
Thoracic region
• Soft tissue defects without spine involvement are treated
depending on the size and location of the defect either
with skin grafts or adjacent tissue transfers.
■ Well-incorporated hardware encased in bone can be
allowed to remain.
■ No flaps are typically required for closure when all of
the hardware is removed.
■ Patient outcomes depend more on the structural
stability of the spine than on any soft tissue work.
■ The soft tissues are simply approximated over drains,
and complete healing is the rule rather than the
exception. Antibiotics are not needed for prolonged
periods in these situations.
Preoperative considerations
Midline back wounds
• When a spine surgeon calls to discuss new drainage from
a midline spine wound, the thought process for treatment
should be methodical and thorough. A review of
operative details, and thorough history and physical
examination are critical.
• A complete history should include operative details, the
presence, visibility, and/or palpability of hardware, any
history of postoperative complications and/or dural
injury with associated CSF leak, and a review of imaging
demonstrating hardware position relative to areas of
wounds or drainage.
• An evaluation of patient co-morbidities and potential
wound healing issues is also necessary, including a
history of malnourishment, diabetes, obesity, dead-space
management problems, and/or prior radiation.
• A thorough examination should note wound
characteristics including the presence of persistent
drainage and dieback of wound edges commonly seen
with deep fluid collections, new pressure points as a
result of new postoperative spinal alignment.
• The time course of the presentation is critical.
• Early postoperative episodes of drainage less than 4–6
weeks after the spine surgery are typically successfully
treated with repeat surgery and soft tissue reconstruction
with hardware preservation.
• However, drainage that has been only partially treated
with a small debridement or treated solely with
intravenous antibiotics, only to resurface months later, is
more difficult to treat.
• A chronic hardware infection, defined as bacteria in
association with hardware greater than 6 months after
placement, is typically not a situation that plastic surgery
can definitively treat without hardware removal.
• Much can be learned with the simple examination of a
patient’s chest X-ray in terms of the existence and
location of hardware. Otherwise, plain films of the spine
are obtained to reveal the length of the construct when
present, degenerative spine disease, and the presence or
absence of fusion.
• CT scans and magnetic resonance imaging (MRI) are
helpful to look for fluid collections, pseudomeningoceles,
and inflammation of the soft tissues.
• A key issue is if fluid collections are above or below the
standard back muscle closure. If fluid or hematoma is

198
•
• Back reconstruction
12
• Patients undergoing a full sacrectomy for tumor
can undergo bilateral gluteus myocutaneous flaps
if the superior and/or inferior gluteal arteries are
preserved during the sacrectomy. Closure of the
gluteus muscles in the midline, like a pressure sore, can
be done with V-Y advancement of the skin paddles if
necessary.
• For low rectal tumors with invasion into the sacrum, a
transabdominal flap using a flap based on the inferior
epigastric artery is also feasible.
■ The oblique rectus abdominis musculocutaneous
flap, using a skin paddle based in an oblique
direction off the periumbilical perforators
and using only the lower aspect of the rectus
muscle, can easily bring non-radiated skin to the
lumbosacral area.
■ The vertical rectus abdominis musculocutaneous flap
is another common design to achieve wound closure,
but requires the harvest of more muscle.
■ These abdominal flaps need to be parked adjacent to
the sacrum and the abdomen closed. After sacrectomy,
the flap can be retrieved from the posterior approach
into the abdomen.
• For the majority of patients with lumbosacral defects, the
tissue near the trochanter can be elevated with the blood
vessels in continuity with the superior gluteal artery for
soft tissue coverage (Fig. 12.1).
■ This can be done as a pure perforator flap, or else with
a strip of gluteus muscle under the skin paddle (which
is de-epithelialized).
■ As the flap is typically flipped 180°, the skin
paddle will rest over the dura. To re-emphasize,
this is a different design than for superior
gluteal artery perforator flaps done for sacral
pressure sores.
Wounds of the lateral back
• Soft tissue reconstruction of the lateral back has certain
special characteristics.
• In the thoracic area, if the ribcage is intact, then most
wounds would be closeable with local wound care,
latissimus flaps, parascapular/scapular flaps, serratus
flaps, or posterior movement of a perforator flap from
tissues in the anterior axillary line area.
• If the ribs are involved, then a decision about possible
reconstitution of the pleural line needs to be made. Most
authorities recommend that three or more ribs be
reconstructed with a prosthetic patch, and this patch
would then need to be covered with soft tissues.
However, when the rib defect is located under the
scapula, then the scapula serves to protect and
camouflage any defect, and so larger rib resections are
tolerated.
• The lateral lumbar area in adults typically is protected
by its lordotic shape, and the only structure that needs
to be reconstructed is the posterior aspect of the
abdominal wall. All other wounds can be closed
with local wound care, skin grafts, or transfer of the
latissimus muscle.
• The scapular and parascapular flaps can be helpful in
closing some of these soft tissue defects without spine
involvement, and the donor site should be oriented
perpendicular to the long axis of the wound to facilitate
closure.
• Latissimus flaps based on the paraspinous perforators are
ideal in radiated wounds to allow the muscle to be
“dropped in” these defects, and thereby not manipulate
the radiated and stiff erector spinae muscles.
Myocutaneous latissimus flaps have easier insets with the
overlying skin paddle sewn to the adjacent midline back
skin.
• Wounds of the thoracic back after spine surgery and
placement of hardware are best treated with erector
spinae flaps. There is no need for a “double muscle”
closure with further mobilization of a latissimus
flap if the erector spinae muscles come together
normally.
• Rarely, in extremely deep wounds, the pedicled omental
flap is ideal to fill the defect and to help achieve closure.
These unusual circumstances often also require either
erector spinae flaps or latissimus flaps to aid in the
closure.
Lumbar region
• The high lumbar area is the optimal area for reclosure
with erector spinae flaps. The muscles are largest in this
area, and exist in a lordotic area of the back that is
protected from pressure.
• Other flaps are also possible for the lumbar area and
include turnover latissimus flaps, which can reach this
area, but only with some difficulty. Sliding of
myocutaneous latissimus flaps elevated from the lower
lumbar area and transposed medially provides thick
coverage of the spine, but only at the expense of a
skin-grafted donor site. The omentum will also reach this
area with some ease.
• The inferior region of the lumbar spine is best covered
with superior gluteal artery-based flaps.
• Often, a gluteal flap will be combined with erector spinae
flaps for coverage of a longer lumbar and lumbosacral
defect.
Lumbosacral region
• The recess between the sacrum and the inferior
aspect of the spine is best filled with a superior
gluteal artery-based flap as the erector spinae muscles
are thin and laterally displaced in this area, precluding
their use.
• Omental flaps are possible but require position changes
in the operating room and bowel dissection. Random-
pattern skin flaps of the lumbar tissue or perforator-based
flaps are also possible, but are difficult to inset and
control in an area that is subjected to high shear forces
with position changes. Finally, while latissimus flaps can
be mobilized to reach this area, there are many wounds
that are simply too big to have the latissimus muscle both
reach and fill the entire cavity.

199
Operative techniques
Figure 12.1  (A) Large Marjolin’s ulcer found in a chronic pilonidal cyst in an ambulatory patient. (B) Tumor excision. (C) A superior gluteal artery perforator flap is drawn
out. The long axis of the skin paddle is perpendicular to the long axis of the defect to facilitate closure. The tumor excision and the final closure were staged to allow for
definitive pathologic clearance of the margins. (D) Flap inset into defect.
A
B
C
D
Operative techniques
Local wound care
• For superficial, relatively painless wounds without
exposed hardware, local wound care with dressings is a
relatively risk-free way to achieve wound closure.
• Draining midline incisions tend to have wide areas of
undermining along the length of the closure. These
tunnels can typically be opened in the office with local
injection of anesthesia and finger fracturing of the
incision.
• A long wound without tunnels with a saucer shape
typically heals faster than small wounds with a fishbowl-
shaped internal wound; therefore, tunnels should be
opened along old incision lines.
• All necrotic tissue should be debrided. All non-absorbable
sutures such as braided polyester should be removed.
• Patients are often unaware of the real size of the wound,
and must be prepared for the resulting appearance of the
surgical site after opening of tunnels.
• Dressings can be simple wet-to-wet saline dressings, with
twice-a-day showers to cleanse the surface of the wound.
Subatmospheric-pressure dressings can be employed, but
the tubing is sometimes difficult to place under back-
bracing devices.
• After a wound has granulated, or if it is painful, then
delayed primary closure or skin grafts can be performed
if the wound is sizeable.
Operative debridement
• Patients with persistently draining wounds after spine
surgery associated with hardware should be evaluated
critically for an operating room debridement.
• Secondary indications for a debridement include
unexplained fevers and fluid collections seen on imaging
scans.
• The maneuvers in the operating room are a critical step
in the treatment of patients with postsurgical back
wounds.
• A thorough incision and drainage should be performed
for patients with unexplained or purulent drainage
through their incision.
• The entire length of the incision should be opened as
widely as necessary to explore for purulence and drain
fluid collections.

200
•
• Back reconstruction
12
the midline. This requires a more redundant soft tissue
flap such as an omentum to fill the defect appropriately.
Flap closure
Principles
• The first step in reconstruction is a timely debridement.
• The second step is local wound control with a radical
debridement of all stiff and scarred tissue.
• Finally, the reconstruction should be performed to do the
“maximum for the minimum.”
• The procedure with the highest chance for success and
with the lowest morbidity should be selected for the
patient.
• Central questions to be answered include the presence or
absence of a fusion, and the vertebral levels involved.
• When an instrumented fusion has been performed, then
the erector spinae musculature function is no longer
necessary, and the muscles are completely expendable in
terms of a reconstruction. The fusion rods prevent
postoperative motion, and so when the erector spinae
muscles are reapproximated in the midline, they tend to
stay there.
• Spine patients without fusions still require the function of
the erector spinae musculature when healing is
completed for flexion and extension of the spine. These
patients do better with flaps that are “dropped into the
hole,” rather than with erector spinae muscles that are
closed side to side and that would dehisce with back
flexion.
• Local wound care often suffices for superficial wound
problems above the erector spinae.
Possible flap choices for spine closure
Erector spinae muscle flaps
• The erector spinae muscles, also called the paraspinous
muscles, are expendable after a previous spine fusion and
no longer are functional for spine extension and flexion.
• This flap is appropriate from the high cervical area to the
low lumbar area, but it will not adequately cover an
occipitospinal fusion, and nor will it be sufficient for
lumbosacral soft tissue coverage.
• One must be careful in its use when a lateral approach to
the spine has been made, because the muscle can be
transected for access.
• First, skin flaps are elevated superficial to the
thoracolumbar fascia (Fig. 12.2).
• The latissimus muscle and trapezius muscle should stay
attached to the skin and skin flap.
• The dissection is easiest inferiorly in the lumbar area
where the muscle is round and large, and most confusing
superiorly where the muscle is thinnest and becomes
attached to the undersurface of the trapezius.
• The erector spinae muscles have a convex shape, and
there is a rounded aspect of the muscle that then
descends laterally towards the more lateral neck, thoracic,
and lumbar areas.
• The erector spinae muscle closure should be reopened for
cultures and to evaluate for liquefying hematomas.
• The surgeon should be knowledgeable at the beginning
of the debridement if a laminectomy had been performed
at the original spine surgery in order to prevent injury to
the spinal cord and dura during the incision and
drainage.
• After adequate exposure, the surgeon will need to make a
decision as to the quality of the tissues.
• Non-purulent benign fluid collections in the
subcutaneous tissues with no purulence deep to the
musculature can be reclosed over drains, or else closed
secondarily with a subatmospheric-pressure dressing.
• Purulent and deep collections require additional
decisions.
• If the local wound is so purulent as to preclude an
immediate reclosure, then all non-viable tissue should be
debrided, the wound irrigated and left open for local
wound care.
• Alternatively, a subatmospheric-pressure dressing may be
applied, but this often involves a return trip to the
operating room for its next exchange.
• For those deep wounds judged amenable to reclosure, a
radical incision and drainage are performed. This should
involve the surgical excision of scarred tissues where
possible to reveal supple soft tissues with pulsatile
bleeding.
• Pulsatile bleeding at wound margins has been shown to
correlate with wound healing in problematic incisions,
such as distal foot amputations.
• Tissues with a pseudobursa should be excised, as this too
represents scar. Tissue that is stiff is unyielding and does
not conform well, and so the tissues should be removed
until they are soft to palpation.
• An interesting issue is the removal of non-viable elements
such as hardware and bone graft.
• Hardware that is well fixed should remain in place in
early hardware infections. This is done both to stabilize
the wound for improved healing as well as to avoid the
surgery involved with removal and later replacement of
hardware.
• Long-term maintenance of the hardware as well as
clinical and radiographic evidence of fusion are well
documented in patients who were returned to the
operating room for washouts within 6–8 weeks of
placement.
• In the absence of definitive studies, it seems reasonable to
remove non-incorporated and easy-to-remove graft, but
to leave in place graft that has in any way begun to stick
to the local tissues due to inosculation.
• In the treatment of wounds of the spine, the three-
dimensional shape should be evaluated and converted as
much as possible to a two-dimensional wound.
• Prominent hardware should be exchanged for something
with a lower profile.
• Patients with incomplete corrections of the spine
deformities should be revised to recreate better the
natural contours.
• The deeper the hole, the more a flap should be “dropped
into” the defect, rather than tissue simply slid towards

201
Operative techniques
• Again with tension applied on to the tissue with
retractors, cautery dissection of the deep and medial
attachments of the erector spinae will mobilize the
muscle and detach it from the lateral aspects of the
transverse processes of the spine.
• This move will by necessity divide the medial
row of blood vessels entering the paraspinous
muscles, but the prior dissection to identify the lateral
vessels entering the muscle will suffice to preserve
vascularity.
• The medial muscle elevation is a powerful means
to allow the paraspinous muscles to “unfold” like
an accordion to be advanced toward the midline
(Figs 12.4, 12.5).
• The medial aspect of the skin, subcutaneous tissue, and
paraspinous muscles is sharply debrided. The muscles
are brought together in the midline (Fig. 12.6), and any
extra tissue can be imbricated to help fold the soft tissue
into crevices between vertically oriented hardware bars
(Fig. 12.7).
• It is in this groove that segmental blood vessels enter the
lateral and deep aspects of the longissimus and
iliocostalis muscles. Continuation of these blood vessels
continues more superficially to the skin and to the
latissimus muscle in the thoracolumbar area.
• While the surgeon is elevating the skin flaps, the
perforators and dorsal sensory nerves going up to the
skin often can be identified and preserved to maintain
skin vascularity.
• The thoracolumbar fascia is incised much like the
development of any standard bipedicled flap in order to
mobilize the erector spinae muscle and/or overlying skin
to the midline.
• The dissection up until this point is rather easy and
bloodless, but only moves the muscle an estimated 30%
of its potential.
• Complete mobilization of the muscle requires a dissection
along the deep aspect of the erector spinae (Fig. 12.3).
Figure 12.2  Cross-section of lumbar spine area. Skin flaps are elevated to expose
the thoracolumbar fascia and to reach the region of the lateral pedicle entering the
erector spinae muscles. The thoracolumbar fascia is incised to allow a medial
movement of the muscles.
Necrotic tissue
Fascia
Incise fascia
Lateral perforator
Medial perforator
Cutaneous
perforator
Exposed instrumentation
Longissimus
Iliocostalis
Spinalis
Figure 12.3  A dissection is then performed to release the medial and deep
attachments of the erector spinae muscles to the spine and transverse processes.
The lateral blood supply is approached from the deep aspect of the muscle.
Raise
flaps
Figure 12.4  Cadaver dissection of the erector spinae muscles at the lumbar level.
Figure 12.5  Release and medial movement of the muscles.

202
•
• Back reconstruction
12
medially, rather than turned 90°. This flap can be
re-elevated and moved a second time if necessary.
Trapezius muscle flap
• The trapezius flap is useful for high cervical wounds
because the paraspinous musculature is of limited
mobility and size at that level.
• The dissection begins with identification of the distal and
inferior triangular aspect of the trapezius where it just
overlaps the latissimus muscle, because the crossing
muscle fiber directions of the two muscles are quite
distinct in this area.
• A skin paddle overlying this inferior muscle can be taken
to help with the inset. The more cephalad and larger the
skin paddle, the better in terms of reliability (Fig. 12.9).
• The inclusion of the superficial dorsal scapular artery on
the lateral border of the trapezius also helps skin flap
viability.
• Further cephalad and lateral to the elevated skin paddle,
the upper back skin is elevated off the trapezius. The
main pedicle is the transverse cervical artery and it enters
the muscle approximately 7–8 cm lateral to the midline
and at the level of the spinous process of C7 on its deep
aspect.
• The deep dissection is then performed, with the muscle
elevated off the paraspinous musculature and the
rhomboids.
• The main pedicle is encountered, and with this vessel
under direct view, the lateral aspect of the muscle is
divided.
• Movement of the flap is tested, and the lateral muscle
division is extended if greater mobility is required for
wound coverage. The higher the dissection continues, the
higher the morbidity due to shoulder drop, but the
greater the arc of rotation of the muscle.
• Because of its sizeable donor site morbidity to the
shoulder, the indication for the trapezius flap is in a
non-fused patient with a radiated deep back wound
where the erector spinae have been involved in the field
of radiation.
• As the muscle is typically turned 90° for inset, the length
of midline coverage of the trapezius is typically short,
and so either a combination of two trapezius flaps, or else
the trapezius flap with erector spinae flaps, should be
planned for long wounds.
Superior gluteal artery
• The superior gluteal artery flap technique is the most
challenging of all of the reconstructive soft tissue
procedures for the spine, but it is a necessary and useful
procedure.
• A line is drawn between the superior lateral aspect of the
sacrum and the posterior superior iliac spine.
• From a point that bisects this line, a second line is drawn
toward the greater trochanter.
• This second line represents the path of the superior
gluteal artery, and is the long axis of the flap.
• A skin paddle is designed that encompasses the Doppler
signal of the perforator of the superior gluteal artery and
Figure 12.6  The muscles are approximated in the midline. The erector spinae
muscles unfurl, changing shape from circular to elliptical.
Extend
flaps
• Drains are left both deep and superficial to the erector
spinae closure, and are left in until the drainage is
minimal.
• When the erector spinae muscle closure is of good
quality, there is no need for a second overlying muscle
flap using the trapezius or the latissimus muscles.
Latissimus muscle or myocutaneous flap
• The latissimus muscle is a well-known and understood
flap. Based on the thoracodorsal pedicle, the muscle can
be moved superiorly up to the level of the top of the
scapula. Based on its minor perforators that also supply
the paraspinous muscles, the latissimus can reach the
lower lumbar area.
• An advantage to the latissimus is being able to be
“dropped in” to a hole, and so it is useful for patients
who have not been fused, or for more lateral defects.
• The muscle can reliably carry a skin paddle, and this
often helps in the inset of the flap.
• Caution should be taken in patients who have had
thoracotomy incisions, as the muscle is often
divided.
• The latissimus muscle is a good but still second-line flap
for the coverage of midline back wounds. In comparison
to the paraspinous flaps, the latissimus flap can only
cover a spine wound 10–12 cm in length, while the
erector spinae flaps can cover practically the entire length
of the spine.
• The latissimus muscle is a good choice for a radiated
non-fused wound of the midback, where the patient has
not been fused, and the erector spinae musculature is in
the field of radiation (Fig. 12.8).
• The orientation and design of the skin paddle should be
done carefully.
• For flaps based on the thoracodorsal pedicle, a skin
paddle oriented with its long axis perpendicular to the
midline will result in the skin paddle vertically oriented.
Closure of the donor site initially oriented perpendicular
to the spine does not make the midline spine any more
difficult to close due to added tension.
• Another helpful skin paddle design is a V-Y design. The
donor site for the skin is in the midaxillary line. The
latissimus muscle is elevated and the skin paddle moved

203
Operative techniques
• The superior border of the skin is incised, and the skin
flap elevated until the perforator from the superior
gluteal artery is seen to be entering the skin paddle.
• Medial to this, the gluteus muscle is split to aid in the
dissection of the pedicle.
• With the pedicle under full view, the remainder of the
skin paddle can be incised and the flap dissection
completed.
is oriented laterally towards the greater trochanter
(Fig. 12.10). This is a different orientation than
the skin paddle used for closure of sacral pressure
sores, where extra skin is taken medial to the Doppler
signal.
• To improve the reliability of the tissue, a strip of gluteus
muscle oriented underneath the skin paddle can be taken
along with the perforator.
Figure 12.7  (A) Patient with a long thoracolumbar fusion with drainage 3 weeks after a posterior spinal fusion. Note the erythema of the staple line. (B) Complete opening
of the superficial and deep tissues reveals an infected fluid collection surrounding the hardware. A crossbar is visible. (C) The wound is radically debrided to reveal the entire
spinal hardware construct. The hardware seems solidly fixed to the bone. (D) Dissection deep to the thoracolumbar fascia to the lateral border of the erector spinae muscles.
A large nerve traveling through the muscle to the overlying skin is spared. (E) Dissection on the deep aspect of the erector spinae muscles to the level of the lateral
perforators. (F) Erector spinae muscles closed in the midline.
A
B
C
D
E
F

Figure 12.8  (A) A 26-year-old man had a recurrent desmoid tumor removed from his thoracic spine area. There is exposure of the spinous processes. There is no hardware
present. (B) A skin paddle slightly less wide than the defect and oriented at a right angle to the long axis of the wound is drawn out. (C) Final inset of the flap. The flap
donor site is oriented perpendicular to the long axis of the defect, so that closure of the donor site will not make the recipient site more difficult to close.
A
B
C
Figure 12.9  (A) A 60-year-old patient with painful metastatic neuroendocrine tumors to the cervical spine area. The tumors have been radiated, precluding closure with skin
grafts. (B) Wound after tumor excision. (C) Incised myocutaneous trapezius flap. The skin paddle was oriented at the inferior aspect of the muscle. (D) Trapezius flap during
inset with 180° twist. The superficial dorsal scapular artery was not included with this flap, resulting in mild hypoperfusion of the skin paddle. The donor site was closed in
the vertical midline.
A
B
C
D

205
Operative techniques
A
B
C
D
E
F
Figure 12.10  (A) Radiograph of low lumbar fusion of a patient with drainage 3 weeks after spinal fusion. (B) Intraoperative view after debridement of fusion site.
(C) Incised skin paddle for left superior gluteal artery perforator (SGAP) flap. The staple marks the audible Doppler signal of the SGAP perforator to the skin. (D) Vascular
pedicle to the superior gluteal artery perforator flap. Muscle around the pedicle must be minimized to allow for a facile flip of the flap to the midline. (E) The skin paddle is
de-epithelialized and placed to fill the lumbosacral recess. (F) Closed incisions.

206
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• Back reconstruction
12
• If there is difficulty with identification of the superior
gluteal artery perforator, additional muscle should be
elevated with the skin paddle, or a decision made to
dissect the other buttock.
• Medially, any muscle along the pedicle will resist the 180°
flip required of the pedicle for the flap to reach the
midline.
• Muscle found around the pedicle that impedes this 180°
turn should be excised so that there is no tension on the
flap to reach the lumbosacral spine.
• The skin paddle is de-epithelialized and will be able to
cover the dura.
• The donor and recipient sites are closed over drains.
• Both buttocks should be prepped into the field, in case
there is an injury to the pedicle.
• In patients with buttock weakness preoperatively, the
stronger side should be used.
• Caution should be taken in patients who are
markedly obese, and those with prior pressure sore
procedures.
• A complete pressure relief bed is necessary for 10–14
days after the procedure to prevent pressure on the
pedicle as it runs from the lateral sacrum towards the
midline.
Omentum
• The primary criteria for using a pedicled
omental flap include scarred, irradiated, divided,
and otherwise unusable back musculature suitable for
local flap transfer in a patient in need of soft tissue
coverage of thoracolumbar spinal instrumentation
(Fig. 12.11).
• Secondary criteria include extremely deep wounds,
such as for those patients with coverage needs of both
anterior and posterior instrumentation, and for patients
in whom the abdominal cavity is already entered for
exposure.
• Absolute contraindications to the use of a pedicled
omental flap include a history of intra-abdominal
malignancy and a previously resected omentum.
A
B
C
Right gastroepiploic artery
Omental flap is passed behind hepatic flexure of colon
Left gastroepiploic
artery divided
Gastric branches
divided
Greater omentum
Right kidney
12th rib
Figure 12.11  (A–C) Diagram of a pedicled omental flap for coverage of the spine.

207
Operative techniques
■ The 12th rib is identified by palpation after elevating
the latissimus muscle and skin off the ribcage. Lateral
to the paraspinous muscles, the 12th rib is excised, the
periosteum opened, and the omental flap will be
immediately identifiable.
■ When skin is not available for coverage of the
omentum, a negative-pressure suction dressing is
applied immediately on to the flap, and a delayed skin
graft performed.
Adjacent tissue transfers/perforator flaps
• Adjacent tissue transfers without a defined blood supply
and perforator flaps are two ends of a spectrum of
possible reconstructions of the soft tissues of the back.
• In adjacent tissue transfers such as V-Y flaps,
transposition flaps, and rotation flaps, the thick soft
tissues of the back will create large dog ears; donor sites
will typically need to be covered with skin grafts.
• Perforator flaps, on the other hand, will allow
transposition and insets in a more facile manner, and are
especially useful in the iliolumbar and scapular area.
However, the stresses on the soft tissues of the back with
movement in and out of bed and with position changes
will make the delicate nature of perforator flaps difficult
to protect.
External oblique flap
• Patients with huge lower lateral thoracic and lumbar
wounds can have these closed with pedicled external
oblique turnover flaps.
• These patients will have large radiated wounds where
the remaining soft tissues would not be expected to
accept a skin graft, or where there was a prosthetic
material used for reconstruction of the posterior
abdominal wall.
• These large flat flaps can be thought of as an interface to
help with healing of skin grafts to the wound bed.
• The muscle is exposed with wide elevation of the
abdominal skin, done through an oblique incision
paralleling the dermatomes. Then, the insertion of the
muscle is divided, just as it fuses with the anterior rectus
fascia. Much like a components separation procedure, the
external oblique is bluntly elevated towards the posterior
axillary line off the internal oblique, to the point where
segmental vessels enter the muscle. The muscle is flipped
on itself 180° to cover the defect and subsequently to be
skin-grafted. When the flap is done unilaterally, the
corresponding muscle imbalance of the anterior abdomen
may cause an unusual contour of the abdominal wall.
Tissue expansion
• Tissue expansion can be preferable to other solutions for
reconstruction of the soft tissues of the back in certain
instances. Those situations are more for pediatric cases
than for adults, and include the closure of wounds for
giant congenital nevi excisions.
• The indication for tissue expansion is scarred local
tissues, laterally displaced muscles, and need for spinal
instrumentation (Fig. 12.12).
• Relative contraindications include morbid obesity and the
potential for intra-abdominal adhesions from previous
laparotomies.
• The zone of coverage for an omental flap is from the
lumbosacral recess inferiorly up to the level of the
midscapula superiorly.
• Typically, a posterior spinal instrumentation for
stabilization has been performed before the omental flap
is harvested and the abdomen is entered either through
an upper midline incision, a Kocher, or a right
paramedian incision.
• After entering the peritoneal cavity and identifying the
omentum, dissection begins by liberating the omentum
and transverse colon such that they can be lifted out of
the abdominal cavity. The omentum can be dissected
from its attachments to the transverse colon. Performed
correctly, the entire colon from the hepatic flexure to the
splenic flexure can be mobilized away from the omentum
and stomach.
• Next, a decision is made regarding whether to base the
flap on the right or left gastroepiploic (gastro-omental)
artery.
■ The right-sided vessel is usually larger; the left is used
when the spine exposure includes a left-flank incision.
• The omentum is mobilized off the stomach by taking
down the short gastric vessels between snaps and ties.
One should not attempt to travel great distances for each
tie, as this tends to shorten the reach of the flap.
• The stomach should be decompressed with a nasogastric
tube, and this tube should remain in place for several
days so that gastric distension will not cause any of the
vessel ligatures on the greater curve to pull off.
• After complete mobilization of the gastroepiploic vessel
off the stomach, it can be followed to the area where
it emerges as the gastroduodenal artery (a branch
off the hepatic artery/celiac plexus just inferior to the
pylorus and still superior to the transverse colon
mesentery).
• The artery and vein should not be skeletonized, so that
the surrounding soft tissue will help to prevent
unexpected tension on the vessels during the tunneling
process.
• The passage of the omentum toward the spinal column
requires creativity and knowledge of anatomy of the
gastroduodenal artery and its relationship to the
attachments of the colon to the retroperitoneum.
■ The most straightforward means to tunnel the
omentum to the spine is to mobilize the hepatic flexure
and right colon toward the midline. This is an
avascular plane, and the mobilization of the colon is
greatly simplified by the prior elevation of the
omentum off the colon. The line of lateral peritoneal
reflection (the white line of Toldt) is incised, exposing
the retroperitoneum.
■ The omental flap is then positioned behind the colon
in the right paracolic gutter. The right kidney and
Gerota’s fascia are mobilized medially, and the
omentum is “parked” on top of the 12th rib, which is
confirmed by palpation. The abdomen is then closed in
standard fashion and the patient reprepped in the
prone position.

208
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• Back reconstruction
12
Figure 12.12  (A) Lateral photo of a young child with a significant congenital spine defect. (B) Previous attempts at correction have produced numerous scars. A well-cared
for pressure sore is at the apex of the deformity. (C) Bilateral subcutaneous tissue expanders placed on the posterior trunk. (D) Healed incision after spine correction and
advancement flap closure with expanded skin flaps.
A
B
C
D
• The largest expanders possible should be placed
immediately adjacent to the area that will require
coverage, and the long axis of the expander should be
oriented in a superior–inferior direction to allow for a
medial sliding of the expanded tissue with a minimum of
back-cuts and transposition flaps.
• Incisions for placement should be parallel to the axis of
the expander to decrease the chance of extrusion of the
implant through this newly placed scar.
• Ports should be placed over bony prominences to
facilitate their palpability.
Free flap coverage of the back
Soft tissues
• In patients with scarred erector spinae muscles from
previous advancements or neuromuscular conditions
such as polio, patients who have received wide-field
radiation with defects longer than 12 cm precluding
transposition flaps, or when an omental flap is not
possible, free flaps may be required.
• The difficulties with free flap coverage of the spine is
finding a suitable donor vessel. Possibilities include the
superior gluteal artery pedicle and intercostal vessels. A
long saphenous vein graft anastomosed to the common
femoral artery can provide both inflow and outflow when
divided for a lower trunk defect, and a long cephalic vein
graft tied to the external carotid can bring inflow for an
upper trunk flap.
Bone
• The vertebral bodies of the spine are typically
reconstructed with cages and bone grafts when
corpectomies are performed, and with good results.

209
Operative techniques
contaminated drainage, and it easily conforms to
the space crevices. Pectoralis flaps are perhaps best
avoided in spinal cord patients who use their
accessory chest muscles to breathe.
■ Patients who develop pressure sores of the hardware
into the cervical esophagus are often found months
after the cervical fusion, and the hardware can often be
removed.
○ Repair of the esophagus if possible and interposition
of the soft tissue flap are much easier in the absence
of hardware and when the bone is fused.
○ Replacement of the esophageal wall using a radial
forearm flap is possible in these situations of a fused
cervical spine and a persistent leak.
“Tethered cord surgery” or “lipomas of the spine”
• Infants will sometimes receive procedures in their infancy
for closure of their spinal canal or removal of large
“lipomas of the spine”. After these procedures, the spinal
cord can become adherent to the spinal canal, and with
growth and age, the spinal cord can be unusually
stretched. Management of this tethered cord involves
opening of the dura and freeing the spinal cord from scar
attachments, which typically allows the cord to slide
cephalad.
• Some patients with just thick fat over the lumbosacral
recess have done well with preoperative liposuction.
Patients with thick scars can be resurfaced with tissue
expanders prior to the spine exploration. Others with
pseudomeningoceles and need for cord re-exploration do
best with superior gluteal artery-based soft tissue
reconstructions, as described below.
Pseudomeningocele repair and cerebrospinal
fluid leaks
• Pseudomeningoceles are contained leaks of CSF
through dura into the soft tissues of the back, while CSF
leaks of the spinal cord exit through drains or through
the skin. The former situation typically requires treatment
due to pressure of the fluid on the spinal cord with
worsening motor and sensory function. The latter
situation must be addressed to prevent an ascending
meningitis.
• Typically, the hole in the dura must be repaired or
patched by the neurosurgeon and it is up to the plastic
surgery team to improve the soft tissue envelope for the
dural reconstruction to heal.
• Important adjuncts to the above procedures are a
temporary or permanent decompression of the CSF
pressure on the flap, which can include:
■ Flat patient positioning on a pressure relief air-
fluidized sand bed for a week after the procedure.
■ A lumbar or head drain of CSF monitored by the
neurosurgery team to keep the pressure low on the
reconstruction.
■ The CSF pressure is probably more important than the
quality of the soft tissue reconstruction long-term for
pseudomeningocele recurrences.
• Certain patient subpopulations exist where vascularized
bone is preferable. In these patients, more rapid
incorporation of the bone graft due to its viable
osteocytes reduces the chance of construct failure and
infection.
• It is difficult to define exactly who should receive
vascularized bone flaps, as the success rates of
non-vascularized autograft and allograft are high.
• Fusions longer than three vertebral bodies in length,
previous failed reconstructions, a history of radiation,
esophagocutaneous fistula on to the fusion site, and
active osteomyelitis may all be indications for a free
fibula flap to the anterior spinal column.
• In the thoracic area, vascular inflow is either
end-to-end from a segmental lumbar vessel, or
off a saphenous vein patch of the aorta fashioned
by vascular surgery.
Vascularized bone reconstruction of the spine
• A straightforward means of bringing vascularized bone
to the anterior aspect of the thoracic spine is with a
pedicled rib flap.
• For patients undergoing both anterior and posterior
fusion of the spine with an associated thoracotomy for
access, a pedicled rib based on its intercostal
neurovascular bundle can be harvested.
• Unlike vascularized fibula flaps, the vascularized rib
brings viable osteocytes but no structural support to the
spine. The rib graft can either be placed next to or within
the metal cage that is used for structural replacement of
the vertebral body.
Special clinical situations
Esophageal fistula after spine procedures
• A small number of patients undergoing cervical spine
fusion will suffer a traumatic injury to the esophagus,
causing drainage and contamination of the fusion
site. Another group of patients will develop a pressure
sore of the cervical spine hardware into the esophagus,
and so the hardware can be seen during an
esophagoscopy.
• Everything depends on the timing of the esophageal leak
with the placement of the hardware.
■ If the esophageal injury occurred at the time of
hardware placement, then the spinal fusion is not
solid, and the hardware is still needed.
○ Simple repair of the esophageal defect is
problematic even without the spine issues, as the
standard treatment by otolaryngology is to drain
fluid collections and let the wounds heal by
secondary intention.
○ Improvement of the soft tissues between the spinal
hardware and the cervical esophageal repair is
important and local flaps from the neck, the
pectoralis flap, and the omental free flaps are all
thin flaps that can be interposed into this space. The
omentum is perhaps best able to deal with the

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Large series of prophylactic flaps from the MD Anderson
group demonstrates improved outcomes.
Glass BS, Disa JJ, Mehrara BJ, et al. Reconstruction
of extensive partial or total sacractomy defects
with a transabdominal vertical rectus abdominis
myocutaneous flap. Ann Plast Surg. 2006;56:
526–530.
Lee MJ, Ondra SL, Mindea SA, et al. Indications and
rationale for use of vascularized fibula bone flaps in
cervical spine arthrodeses. Plast Reconstr Surg.
2005;116:1–7.
Mathes DW, Thornton JF, Rohrich RJ. Management of
posterior trunk defects. Plast Reconstr Surg.
2006;118:73e–83e.
Mitra A, Mitra A, Harlin S. Treatment of massive
thoracolumbar wounds and vertebral osteomyelitis
following scoliosis surgery. Plast Reconstr Surg.
2004;113:206–213.
Nojima K, Brown SA, Acikel C, et al. Defining vascular
supply and territory of thinned perforator flaps: Part
II. Superior gluteal artery perforator flap. Plast Reconstr
Surg. 2006;118:1338–1348.
O’Shaughnessy BA, Dumanian GA, Liu JC, et al. Pedicled
omental flaps as an adjunct in complex spine surgery.
Spine. 2007;32:3074–3080.
Small series illustrating the use of pedicled omental flaps in
spine reconstruction surgery.
Said HK, O’Shaughnessy BA, Ondra SL, et al. Integrated
titanium and vascular bone: A new approach for high
risk thoracic spine reconstruction: P34. Plast Reconstr
Surg. 2005;116:160–162.
Wilhelmi BJ, Snyder N, Colquhoun T, et al. Bipedicle
paraspinous muscle flaps for spinal wound closure: An
anatomic and clinical study. Plast Reconstr Surg.
2000;106:1305–1311.
This is an early description of paraspinous muscle
flaps for repair of soft tissue defects after spine surgery.
This paper illustrates the performance of superior
gluteal artery flaps that can then be used for spine
reconstruction.
Postoperative considerations
• There are two critical components to postoperative care
following reconstruction of back wounds: closed suction
drainage and pressure relief.
■ Closed suction drainage between the base of the
wound and the flap should be maintained until less
than 30 cc/day emerges in the bulbs. The more drains
the better, and for large procedures even 6–8 bulbs
have been required.
■ Postoperative placement on a pressure relief air-
fluidized bed will allow the patient to lie directly on
the flap and yet not cause a pressure injury to the
tissues. It is suspected that compression of the flap
directly on to the wound bed has beneficial effects in
helping the wound to seal.
Further reading
Duffy FJ, Weprin BE, Swift DM. A new approach to closure
of large lumbosacral myelomeningoceles: The superior
gluteal artery perforator flap. Plast Reconstr Surg.
2004;114:1864–1868.
Dumanian GA, Ondra SL, Liu J, et al. Muscle flap salvage of
spine wounds with soft tissue defects or infection.
Spine. 2003;28:1203–1211.
Long-term results of successful salvage of posterior
hardware with soft tissue reconstruction of the back are
presented.
Erdmann D, Meade RA, Lins RE, et al. Use of the
microvascular free fibula transfer as a salvage
reconstruction for failed anterior spine surgery due to
chronic osteomyelitis. Plast Reconstr Surg.
2006;117:2438.
Garvey PB, Rhines LD, Dong Wenli, et al. Immediate
soft-tissue reconstruction for complex defects of the
spine following surgery for spinal neoplasms. Plast
Reconstr Surg. 2010;125:1460–1466.

©2014, Elsevier Inc. All rights reserved.
Chapter
13 
Abdominal wall reconstruction
although more dramatic, are less likely to cause bowel
trauma.
• Risk factors for postoperative infection and repair failure
include co-morbidities of smoking, diabetes mellitus,
chronic obstructive pulmonary disease (COPD), coronary
artery disease, poor nutritional status/low serum
albumin, immunosuppression, chronic corticosteroid use,
obesity, and advanced age.
• Some hernias begin as multiple small “Swiss cheese”
defects, and when one defect is repaired, the other
unrepaired defect(s) can enlarge.
• Rectus diastases are not true abdominal wall fascial
defects but are pathological stretching to the linea alba
either congenitally or, most frequently, postpartum.
• Functionally, a diastasis is analogous to an aneurysm
– wherein the adventitia (fascia) and intima (peritoneum)
are intact but the muscular layer is absent (Fig. 13.1).
• In techniques for abdominal wall reconstruction that do
not centralize muscle, or cases in which the abdominal
muscles have retracted beyond the possibility to be
reapproximated, a functional diastasis remains, in lieu of
the tendinous fusion of the paired rectus abdominis
muscles.
• This diastasis can enlarge over time from intra-abdominal
pressure, even to the point of requiring repair.
• Repair is achieved without intraperitoneal entry, by
plicating or imbricating the defect so that the rectus
abdominis muscles are returned to the midline
(Fig. 13.2).
Preoperative considerations
• Hernias should be treated as a chronic disease process – a
conglomeration of collagen disorders, excess mechanical
loads, co-morbidities, and outdated surgical techniques,
and other poorly understood factors.
This chapter was created using content from
Neligan & Song, Plastic Surgery 3rd edition,
Volume 4, Lower Extremity, Trunk and Burns,
Chapter 12, Abdominal wall reconstruction, Navin
K. Singh, Marwan R. Khalifeh and Jonathan Bank
Brief introduction
• Hernias and abdominal wall defects may be
asymptomatic or symptomatic, and range from the minor
cosmetic inconvenience to major destructive processes of
the abdominal wall.
• Narrow-neck hernias are at greater risk for incarceration
and strangulation of bowel, whereas large-neck hernias,
SYNOPSIS
■ Abdominal wall reconstruction techniques are indicated for hernia
repair, reconstruction of tumor defects, congenital defects, and
correction of traumatic defects (e.g., from damage control
laparotomies).
■ Patients may be complicated by fistulae, adhesions, infections,
scarring from previous injury or surgery, and presence of dehisced
prior mesh.
■ Preoperative optimization of patients is requisite – smoking
cessation, weight loss if indicated, and nutritional restitution.
■ Autologous techniques are ideal in reconstruction, utilizing muscle
and fascia – utilizing separation of components and fascia lata
grafts.
■ Prosthetic meshes and bioprosthetics may be utilized in addition
to, or in lieu of, flaps for recalcitrant cases.
■ Advanced techniques may include tissue expanders, laparoscopic
methods, free flaps, and even abdominal wall transplantation.
■ Postoperative management begins in the intensive care unit (ICU)
and continues into postoperative rehabilitation.

212
•
• Abdominal wall reconstruction
13
over time and abdominal viscera extrude into the
hernia sac.
• The only absolute contraindication to abdominal wall
reconstruction is if the patient is medically unsuitable for
surgical clearance.
• Success is predicated on a systematic approach from
understanding the etiology of prior failure, risk factors,
metabolic status, the biology and biomechanics of repair
materials, employment of an appropriate surgical
technique (i.e., open or laparoscopic), to postoperative
vigilance.
• Diagnosis is made on physical exam and confirmed by
CT scan.
• Loss of domain occurs when muscle, fascia, and/or skin
have necrosed or retracted and have become contracted
Figure 13.1  Rectus diastases are not true abdominal wall fascial defects but are
pathological, stretching to the linea alba. (A) A diastasis is analogous to an
aneurysm – here the adventitia (fascia) and intima (peritoneum) are intact but the
muscular layer is absent. (B) Diastases can enlarge over time to the point of
requiring repair. Repair is achieved without intraperitoneal entry, by plicating or
imbricating the defect and restoring midline approximation of the rectus abdominis
muscles.
A
B
Fusiform
Saccule
Pseudoaneurysm
Figure 13.2  (A) Normal lay of the rectus abdominis muscles on either
side. (B) Diastasis recti. (C) Schematic representation of the extent of
subcutaneous dissection with reapproximation at the midline and fascial
plication.
A
C
B

213
Technical pearls
• Wound preparation should excise any non-vital tissues,
indurated and fibrotic tissues likely to become avascular,
and any retained prior foreign-body prosthetics and
mesh.
• Debridement may necessitate removal of the umbilicus
since it is often marginally attached to one of the skin
flaps or may be deemed non-viable at the end of the
operation. The patient should be prepared for this, and
the umbilicus can always be secondarily reconstructed.
• Pre-existing fistulae may be managed by controlling
them with surgical drains, percutaneous drainage and
diversion of collections, surgical washouts and antibiotic
treatment for existing infection or colonization.
• After non-surgical care for a period of 24–72 h,
definitive closure can be scheduled. At the time of
conclusive repair, any intra-abdominal collections and
pathology, such as fistulae and tumors, should be
addressed.
Negative-pressure wound therapy
• If, after debridement, the wound still remains unsuitable
for immediate closure, it can be temporized with topical
antimicrobial creams and dressings to decrease bacterial
colony counts.
• For frank infection or gross contamination not adequately
addressable by bioburden techniques, the wound may be
temporized by using negative-pressure (subatmospheric
pressure) dressings.
• The proposed mechanisms by which NPWT works are:
(1) compression of tissues creating shear and hypoxia
which are signals for angiogenesis/granulation;
(2) hypoxia which releases nitric oxide, causing
vasodilatation; (3) decrease of third-space fluid;
(4) compression of vessel causes, which increases velocity,
leading to decrease in hydrostatic pressure by Bernoulli’s
law and thus less exudate; (5) increased blood velocity,
which “aspirates” exudate back into the second space via
Venturi effect; and (6) splinting of the wound
mechanically.
• Patients with ascites are extremely likely to have a poor
outcome and should be referred to a hepatologist for
management of cirrhosis or hepatic failure prior to
attempt at a repair.
• Metastatic disease (hepatic, abdominal, or distant) is a
relative contraindication.
• Postoperatively, patients may develop weakness in the
abdominal wall and/or donor sites, acute and chronic
pain, respiratory problems, or chronic disability.
• A preoperative discussion of the different implant choices
should be held (synthetic mesh, human and non-human
bioprosthetics).
Technical pearls
• Halsted’s tenets still ring true 100 years later and are
applicable to modern hernia surgery:
■ Aseptic technique.
■ Atraumatic handling of tissues.
■ Sharp anatomic dissection.
■ Meticulous hemostasis.
■ Using non-reactive sutures.
■ Minimizing foreign body.
■ Avoiding non-physiologic tension.
■ Obliterating dead space.
• The specific steps in hernia repair are: (1) preparation of
the wound by reducing bioburden; (2) realignment of
muscles; (3) reinforcing attenuated areas; (4) minimizing
foreign body; and (5) controlling dead space to prevent
seroma which will delay revascularization (Fig. 13.3).
Bioburden reduction
• The first step in adherence to surgical principles.
• The wound should be cleansed mechanically if needed
by pulse lavage or sharp “oncologic” en bloc-type
excision.
Figure 13.3  Modified algorithm for abdominal wall
reconstruction. (After Disa JJ, Goldberg NH, Carlton JM, et al.
Restoring abdominal wall integrity in contaminated tissue
deficient wounds using autologous fascia grafts. Plast Reconstr
Surg. 1998;101:979–986.) The expanding usage of biologics
such as AlloDerm and Strattice has replaced the use of fascial
patches and augments primary fascial closure, and in many
instances synthetic meshes.
Skin intact
Mesh repair
Fascia patch
Fascia patch
<10cm
>10cm
Ventral hernia
>10cm
<10cm
Abdomen open (exposed
mesh or enteric contamination)
AlloDerm
Strattice
>10cm (mesh
contraindicated)
Primary
fascia closure
Local tissue
rearrangement

214
•
• Abdominal wall reconstruction
13
• The segmental neurovascular bundles emanating from
the intercostal vessels and nerves are deep to the internal
oblique, and so the plane of dissection is a safe and
privileged plane.
• Inadvertent dissection below the internal oblique might
damage the innervation, resulting in a patulous and
adynamic rectus abdominis muscle segment (Fig. 13.6).
• The intraperitoneal adhesions of the bowel to the
abdominal wall should be regarded as a “component” as
well, and must be separated.
• Wide adhesiolysis, freeing the viscera from the abdominal
wall undersurface to the bilateral paracolic gutters, is an
important step in mobilizing the abdominal wall.
• To gain additional mobility, should it be required, a
posterior release of the rectus sheath can be performed a
few millimeters lateral to the free edge of the fascia
where the hernia is encountered (Fig. 13.7).
• This posterior release is not always necessary, and it
offers an additional 2–3 cm of mobility on each side.
• It also creates a retrorectus space for placing a mesh or
biologic, should that option be chosen by the surgeon.
• If a stoma (colostomy, ileostomy, ureterostomy) is present,
extra care should be taken in performing component
separation on the involved side.
• Component separation should create musculofascial
flaps, which advance 6 cm at the epigastrium, 10 cm at
the waistline, and 5 cm at the suprapubic region on each
side (Figs 13.8, 13.9).
• Orthopedic-type bone anchors with attached sutures can
be used to suture fascia, mesh, or a biologic matrix to the
pelvis or ribs.
• A tidy alternative to bone anchors, if unavailable
or unfamiliar, is to use a 1 mm wire-passing drill to
create tunnels in the bone, through which to pass the
suture.
• Most surgeons prefer an underlay as opposed to an onlay
mesh reinforcement, but this has not been prospectively
shown to be superior.
• The underlay material can be placed intraperitoneally, in
which case it should span all the way from external
oblique to the contralateral external oblique to reinforce
and secure the entire operative field.
• U-sutures are placed full-thickness from the abdominal
wall down into the peritoneum, into the mesh or biologic,
and back into the abdominal wall.
• The biologic or mesh material used in the underlay
technique should be tensioned so that the mobilized
muscles passively close in the midline, if possible.
• There will be some instances where the muscles will not
come together, and the mesh or biologic will be placed as
a “bridging” material.
• As mentioned above, a bridged material will have greater
risk for bulging and will not be a dynamic or neurotized
portion of the abdominal wall.
• After placement of the underlay, the posterior rectus
sheath and then the anterior rectus sheath can each be
closed with standard technique (Fig. 13.10).
• An underlay, alternatively, may be performed in a
retrorectus position, where it is superficial to the
peritoneal cavity (Rives–Stoppa method).
Operative techniques
Primary suture technique
• The primary suture technique may achieve repair for
small defects by mobilizing the edges and primarily
suturing them together, much like a postpartum
abdomen, when a rectus diastasis is sutured by
imbrication to recentralize the rectus abdominis muscles.
• Large sutures such as number 1 or number 2
monofilament sutures are used.
• They may be slowly absorbable sutures such as PDS
(polydioxanone) or non-absorbable sutures like nylon or
Prolene (polypropylene).
• Faster-absorbing sutures such as chromic (surgical gut) or
polyglactin 910 (Vicryl) are not appropriate for suture
technique.
• Braided sutures are more prone to be a nidus for
infection.
• Permanent sutures provide greater reassurance, but may
form suture granuloma or be palpable or visible in
thinner patients, potentially requiring surgical removal at
a later time.
• The matter of running suture line versus interrupted
suture line remains unadjudicated by prospective peer-
reviewed publications.
Component separation method (Video 13.1)
• Component separation is the mobilization of the rectus
abdominis muscles bilaterally as a musculofascial,
bipedicled, neurotized flap.
• After the initial description by Ramirez et al., several
authors have reported favorable outcomes with this
technique and have offered improvements and variations
which include preservation of peri-umbilical perforators
through lateral minimal access incisions.
• In the original description of this technique, the skin and
subcutaneous tissues are widely degloved to the anterior
or midaxillary line.
• The transition point where the external oblique muscle
becomes tendinous and attaches on to the anterior rectus
sheath aponeurosis is identified as the linea semilunaris.
• Approximately 10–20 mm lateral to that line, a
fasciotomy is made with scissors or electrocautery to
separate the external oblique from the rectus abdominis.
• Maneuvers to identify the linea semilunaris include
palpation of the rectus abdominis muscle bulk and
cautery stimulation can also be used to check the
orientation of muscular fibers (Fig. 13.4).
• Once the fascia is incised, an avascular plane is entered,
between the external oblique and the internal oblique
directly below it.
• Orientation of the fibers can confirm that the correct
plane has been entered since the fibers of the external
oblique run superolateral to inferomedial, and the fibers
of the internal oblique are orthogonal to the external
oblique (Fig. 13.5).
Video
13.1

215
Operative techniques
Figure 13.4  (A) Normal anatomy above and below the arcuate line. (B) Steps in
component separation method: the transition point where the external oblique
muscle becomes tendinous and attaches on to the anterior rectus sheath
aponeurosis is identified as the linea semilunaris. On either side (1, 4), 10–20 mm
lateral to the linea semilunaris, a fasciotomy is made, separating the external
oblique from the rectus abdominis. Cautery stimulation can also be used to check
the orientation of muscular fibers. An avascular plane is entered (between the
external oblique and the internal oblique muscles). Orthogonal orientation of the
fibers can confirm the correct plane. The segmental neurovascular bundles are
protected, coursing deep to the internal oblique muscle. The plane between the
rectus abdominis and the posterior rectus sheath may be developed by incising just
lateral to the linea alba (2) to gain additional length (3). Flap edges are sutured
together. (C) Cross-sectional illustration showing external oblique muscle release.
A
B
C
Rectus sheath, anterior layer
Rectus sheath, anterior layer
Rectus sheath, posterior layer
Linea alba
Rectus abdominis
Rectus abdominis
Rectus abdominis
Bovie to identify
direction of twitch
2
1
1
1
3
3
4
4
2 3
2
Transversalis fascia
Skin
Fat
Transversalis fascia
External oblique
aponeurosis
Internal oblique
aponeurosis
External oblique
aponeurosis
External oblique
Internal oblique
Internal oblique aponeurosis
Transversus abdominis aponeurosis
Transversus
abdominis
Figure 13.5  Schematic representation of the abdominal musculature and fascial
layers above the arcuate line. Note the orthogonal directionality of the oblique
muscles.
■ The peritoneum and posterior rectus sheath are closed,
then a mesh or biologic is placed within the limits of
the rectus sheath.
■ The advantages include having the strength layer
placed in proximity to the muscle sheath and muscle,
and having the implant not in communication with the
bowel.
■ Disadvantages include the fact that it does not
resurface the abdominal wall more broadly, and
may leave the potential for herniation lateral to the
rectus sheath, or through a component separation
release site.
• A frequent criticism of the original separation of parts
technique is the need for elevation of wide skin flaps that
predisposes the skin to edge ischemia and seroma.
<

216
•
• Abdominal wall reconstruction
13
Figure 13.6  Component separation with Strattice underlay. (A) Preoperative photo – ventral hernia. (B) Hernia sac identified. (C) Strattice underlay sutured to one side.
(D) U-stitches through contralateral side. (E) Fascial layers closed above Strattice. (F) Drain placement. (Courtesy of Dr David H. Song.)
A
B
C
D
E
F
Figure 13.7  (A) Cross-sectional diagram demonstrating medial and lateral
incisions to initiate the component separation with development of the posterior
rectus plane. Detachment from the lower rib margins offers additional length in the
upper abdominal region. (B) Incision planes in the upper abdomen. Note the lateral
incision traverses both components of the anterior rectus sheath.
A
B
Displacement of posterior
sheath by stretching
of long muscle attachment
Displacement of
anterior sheath
Site of medial incision
Site of lateral incision
Knife cut opened out
Rib margin
Rib margin
Figure 13.8  As per Shestak et al., maximal unilateral rectus complex mobility in
the upper, middle, and lower abdominal levels, by means of component separation
of the external and internal oblique muscles to the posterior axillary line. The
additional 2 cm of advancement is gained if the rectus abdominis muscle is
separated off the posterior rectus fascia.
4cm + 2cm
8cm + 2cm
3cm + 2cm

217
Operative techniques
Figure 13.9  (A) Preoperative ventral hernia schematic. (B) Postoperative illustration showing midline closure at the linea alba. Note the external oblique fascial release.
(After Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg.
1990;86:519–526.)
A
B
Figure 13.10  Intraperitoneal placement of prosthetic material for ventral hernia repair. (A) Cross-sectional view of prosthetic placement, secured initially to one side. After
initial separation of components, the underlay material is introduced and secured to the lateral musculature with a full-thickness U-suture. (B) If possible, the underlay is
tensioned to bring both muscle complexes to the midline. If midline approximation is impossible, the mesh or biologic will be placed as a “bridging” material. This
inherently poses a greater risk for bulging and will not be a dynamic or neurotized portion of the abdominal wall. After placement of the underlay, the posterior rectus sheath
and then the anterior rectus sheath can each be closed with standard technique. (C) Anterior view of underlay suture postioning.
A
B
C

218
•
• Abdominal wall reconstruction
13
• A graft as large as 28 × 14 cm can be harvested; if needed,
two pieces can be sutured together.
• Drains are routinely placed in the donor site, and
physical therapy for crutch or cane ambulation is
recommended.
• Beyond fascial grafts, a fascial flap can be utilized for
closure.
■ Rectus femoris musculocutaneous pedicled flap is one
option.
■ A pedicled TFL flap based on the transverse branch of
the lateral femoral circumflex vessels, can reach the
lower abdomen, and provide skin, subcutaneous bulk,
and fascia.
■ A free TFL musculocutaneous fascial flap can also be
performed with the anastomoses to intraperitoneal
vessels such as the gastroepiploic artery.
■ Free flaps are more commonly utilized for tumor
resection than for hernia repair.
Tissue expansion
• Some patients not only have fascial deficiencies but also
have skin and soft tissue deficits.
• Tissue expanders can be placed in the subcutaneous
space, on top of the fascia and serially expanded over
several weeks, recruiting additional skin.
• Saulis and Dumanian have championed a perforator-
sparing technique in which the release of the semi-lunar
lines occurs through separate small lateral access incisions
approximately two finger-breadths beneath the costal
margin. Using a lighted retractor or a long electrocautery,
these access incisions allow for release of the external
oblique along its length while sparing several centimeters
of soft tissue and fascial perforators near the midline.
Regional and distant autologous tissue repair
• If the surgeon prefers an autologous reconstruction, and
does not want to use a biologic matrix or a synthetic
mesh, then the established technique of fascia lata
grafting can be employed (Fig. 13.11).
• TFL grafting involves placing a longitudinal incision
along the lateral aspect of one or both thighs.
• After dissecting through skin and subcutaneous tissues,
the broad and dense fascia of the TFL is identified and
mobilized.
• The tensor muscle itself (in the superior portion) is not
harvested, but a broad sheet with a longitudinal “grain”
of fibers is harvested.
• Five to 10 cm should be left above the knee to prevent
lateral knee instability since the fascia lata is part of the
iliotibial tract, which provides stability to the lateral knee.
Figure 13.11  Hernia repair with fascia lata graft. (A) Preoperative image with markings of multiple fascial defects. (B) Intraoperative image of the defects. (C) 20 × 15 cm
fascia lata graft spanning the defects. (D) Postoperative image of abdomen. (E) Donor site. (Courtesy of Dr David H. Song.)
A
B
C
D
E

219
Operative techniques
• Repairs may include reinforcing materials such as
biologic matrices, since synthetics would be more prone
to infection in the setting of stoma.
• Early data suggest a role for the use of a prophylactic
placement of material to prevent late herniation, in
combination with Sugarbaker keyhole or flap valve
technique and/or resiting the ostomy.
Abdominal wall transplantation
Patients undergoing intestinal or multiorgan transplantation
may suffer from loss of abdominal domain, requiring recon­
struction.
In recent years, abdominal wall transplantation has been
described and utilized in the setting of other organ trans­
plants.
The inferior epigastric vasculature is the pedicle typically
used.
Like all transplanted tissues, the immunogenicity of the
transplanted skin requires lifelong immunosuppression, ren­
dering this reconstructive option to be restricted in cases
involving other transplantations.
• After fascial reconstruction, the tissue expanders are
removed, flaps elevated, and closed recruiting the
viscoelastic properties of skin – creep and stress
relaxation (Fig. 13.12).
• Not commonly done, the fascia itself can be expanded via
a technique of placing tissue expanders in the plane
between the internal and external oblique.
• Both subcutaneous and interfascial tissue expander
techniques are partially limited by the fact that the
expander does not rest on a rigid platform (as in the
scalp or on the chest wall for breast reconstruction) and
the expansion process expands both some tissue outward
and some tissue inward, in the path of least resistance.
Parastomal hernia repair
• Parastomal hernias present a notable challenge because
the creation of a stoma is de facto the creation of a defect
in the abdominal wall from which bowel emerges – the
very definition of a hernia.
• Attenuation and enlargement of the fascial defect are
sadly part of the natural history of a sizeable portion of
the stoma-bearing population.
Figure 13.12  Tissue expansion. (A) Preoperative image of a poorly healed abdominal skin defect. (B) After placement of subcutaneous tissue expanders. (C) Expander
removal. (D) Transposition of expanded skin. (E) Postoperative result. (Courtesy of Dr David H. Song.)
A
B
C
D
E

220
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• Abdominal wall reconstruction
13
• Proper pain control includes the use of analgesics, pain
pumps, and regional anesthetic via epidurals.
• Some centers have reported on use of botulinum toxin at
the time of operation into the lateral musculature of the
abdominal wall – the external obliques, internal obliques,
and transversus muscles – which temporarily attenuates
the force of these muscles and decreases spasm and pain,
and diminishes the lateral disruptive forces which might
disrupt a healing repair.
• Botulinum toxin may be administered a week in advance
so that maximal effect is appreciated at the time of
surgery.
• Contraindications include neuromuscular disorders such
as myasthenia gravis and Guillain–Barré syndrome.
• There is broad consensus that only extremely limited
activity should be undertaken for at least the first 6
weeks of convalescence.
• In patients felt to be at higher than average risk,
prohibitions for heavy exertion may be extended for
months, and for the patient undergoing reconstruction of
multiply recurrent hernias, a lifetime of limited physical
activity may be indicated.
• Those in physically demanding vocations may need to be
retrained or reassigned to different occupations.
Complications and outcomes
• Current data estimate the rate of hernia recurrence in a
range from 2% to 54%, depending on the type of repair
(mesh 2–36% versus suture repair 12–54%).
• Suture repair of primary ventral has reported recurrence
rates of 25–52%.
• The number of prior attempts at abdominal wall
herniorrhaphy is predictive of the relative risk of
failure.
• In a population-based study of approximately 10 000
patients, the 5-year reoperative rate was 23.8% after the
first reoperation, 35.3% after the second, and 38.7% after
the third operation.
• Other complications include hematoma, seroma,
infection, pain, bulging, and weakness of the abdominal
wall, in addition to donor site considerations.
• Skin breakdown leading to exposed mesh or biologic
may occur.
• The biologic mesh should be prevented from desiccation
with either moist dressings such as NPWT or topical
antimicrobials such as silver sulfadiazine.
• Granulation is likely to form through a biologic or
lightweight mesh, although the concern for infection is
heightened.
• Alternatively, the patient may be returned to the
operating room for excision of devitalized skin edges and
readvancement closure over drains.
• If synthetic mesh devices are used in the operation, and a
periprosthetic infection develops, it will likely necessitate
its removal.
• Certain macroporous or lightweight meshes may be able
to be treated with local wound care if exposed.
Postoperative considerations
• DVT prophylaxis. At the very least, sequential
compression devices and early ambulation are indicated.
• In the vast majority of cases, chemoprophylaxis is
initiated, including heparin, low-molecular weight
fractionated heparins, and/or coumadinization
postoperatively.
• In many trauma centers or in those patients with an
established history of venous thromboembolism, caval
filters (permanent and reversible) may be utilized.
• Consideration should be made to keeping the patient
intubated on the night of surgery and offering a deeper
extubation on the first postoperative day.
• An agitated extubation may create non-physiologic forces
of bucking against an endotracheal tube and could
disrupt the repair.
• Patients with abdominal wall reconstruction may require
ICU care and monitoring to support their fluid
requirements since they will sequester fluids in the third
space.
• Monitoring for abdominal compartment syndrome via
indwelling bladder pressure transducers may be
indicated.
• Nutritional support can be provided by total parenteral
nutrition (TPN) or early enteral feeds. Enteral feeding is
generally not begun until flatus has occurred. If enteral
feeding is to be avoided for significant time, TPN can be
employed.
• Current state-of-the art data unequivocally indicate that a
dose of antibiotics for prophylaxis should be
administered intravenously 30–60 min before the case
starts and may require redosing depending on the
duration of the case and half-life of the antibiotic.
• For clean cases, only the single preoperative dose may
suffice, but common usage patterns are for 24 h of
antibiotics for prophylaxis.
• A recurrent hernia repair, certainly one with retained
prior synthetic mesh, should be treated not only as
prophylaxis, but also as therapeutic intent for a longer
course.
• Dirty and contaminated cases should be treated with
therapeutic intent.
• Cases with violation of the gastrointestinal tract should
be offered broader coverage for anaerobic as well as
Gram negative bacteria.
• Because of the risk for deep space collections near
anastomoses and areas of contamination, and because of
the risk for hematomas and seromas in the various
dissected layers, the use of drains is essential in
abdominal wall reconstruction.
• Abdominal binders can provide compression in the
postoperative interval which may help with comfort,
minimizing risks for seroma and also supporting the
deeper fascial repair.
• One must consider, however, that in the setting of wide
subcutaneous flaps, a binder may actually compress
marginally perfused tissue and lead to infarction of the
tissue and suture line ischemia.

221
Further reading
Hershey FB, Butcher HR Jr. Repair of defects after partial
resection of the abdominal wall. Am J Surg.
1964;107:586–590.
Luijendijk RW, Hop WC, Van Den Tol MP, et al. A
comparison of suture repair with mesh repair for
incisional hernia. N Engl J Med. 2000;343:392–398.
This landmark prospective multi-institutional European
study evaluated 200 cases of primary hernia repair with
repair reinforced with mesh. The investigators found that
retrofascial preperitoneal repair with polypropylene mesh is
superior to suture repair with regard to the recurrence of
hernia, even in patients with small defects. However, even
with this significant finding, recurrence rates remain high at
10-year follow-up (approximately 30%).
Ramirez OM, Ruas E, Dellon AL. “Components separation”
method for closure of abdominal-wall defects: an
anatomic and clinical study. Plast Reconstr Surg.
1990;86:519–526.
This seminal paper describes 10 cadaver dissections of the
abdominal wall with the purpose of determining the amount
of mobilization possible by dissecting each layer of the
abdominal wall versus the entire complex as a block. The
mobility achieved, allowing for functional transfer of
abdominal wall components, negates the need for distant
muscle flaps. This set the stage for later works by multiple
authors and essentially defining today’s standard of care for
abdominal wall reconstructions applicable in many cases.
Rohrich RJ, Lowe JB, Hackney FL, et al. An algorithm for
abdominal wall reconstruction. Plast Reconstr Surg.
2000;105:202–216; quiz 217.
This continuing medical education article provides a good
overview of abdominal wall anatomy, and provides an
additional perspective to the various techniques of
reconstructing abdominal wall defects and offers a
reconstructive algorithm for partial and complete defects,
addressing location of the defect. Autologous tissue transfer
sources are discussed (cutaneous, local, and distant flaps),
with critique.
Saulis AS, Dumanian GA. Periumbilical rectus abdominis
perforator preservation significantly reduces superficial
wound complications in “separation of parts” hernia
repairs. Plast Reconstr Surg. 2002;109:2275–2280;
discussion 2281–2282.
Acknowledging the strengths of the “component separation”
method, Saulis and Dumanian point out the weaknesses of
the method, particularly regarding wound breakdown
associated with the wide undermining that is part and
parcel of the technique. By preserving the periumbilical
rectus abdominis perforators, the authors have shown
reduction in wound complications while enabling similar
advancement distances and maintaining acceptable hernia
recurrence rates.
• Biologic meshes may be more resilient under infective or
contaminative situations, but they are certainly not
resistant to infection or contamination.
• All surgery incites an inflammatory reaction and this
reaction can cause adhesions of the intra-abdominal
viscera to the abdominal wall.
• During abdominal wall reconstruction, great care should
be exercised to interpose omentum between the bowel
and the abdominal wall.
• When omentum is not available, Seprafilm (composed of
hyaluronic acid and carboxymethylcellulose) may be
useful as a barrier to impede adhesion formation.
• Complications of seroma can be managed with serial
aspiration with sterile technique, introduction of a
sclerosant such as Betadine or tetracycline into the
seroma activity, or placement of a percutaneous drain.
• Seromas refractory to these techniques may require
operative ablation of the seroma cavity by excising the
pseudobursa that has formed, and closing the new space
over drains.
• For the seroma requiring operative intervention,
additional techniques such as quilting sutures or fibrin
glues should be given due consideration.
• Secondary procedures for abdominal wall reconstruction
include scar revision, contour improvement, correction of
stretch or diastasis, reconstruction of the umbilicus, and
amelioration of pain.
• Donor site morbidity must be considered if harvesting
autologous grafts for abdominal wall reconstruction.
Further reading
Disa JJ, Goldberg NH, Carlton JM, et al. Restoring
abdominal wall integrity in contaminated tissue
deficient wounds using autologous fascia grafts. Plast
Reconstr Surg. 1998;101:979–986.
After conducting animal studies, the authors present their
experience with non-vascularized tensor fascia latae
autografts in a series of patients in whom prosthetic mesh
was contraindicated, or components separation impossible.
Recurrence rates, local complications, and donor site
morbidity were within acceptable limits. Several patients
underwent subsequent laparotomy for other purposes, at
which point the transferred fascia was revascularized
(concordant with the authors’ previous findings in animal
experiments). Maximal graft dimension was 28 (14 cm).
Dixon CF. Repair of incisional hernia. Surg Gynecol Obstet.
1929;48:700.
Gibson CL. Post-operative intestinal obstruction. Ann Surg.
1916;63:442–451.

©2014, Elsevier Inc. All rights reserved.
Chapter
14 
Breast augmentation
• Underfilling saline-filled implants may lead to:
■ Increased deflation rates due to folding or friction
subjected to the implant shell, and is not
recommended.
■ Wrinkled appearance or rippling with the breast in
certain positions.
• Aggressive overfilling of saline implants may lead to a
more spherical shape and scalloping along the implant
edge with knuckle-like palpability and unnatural
firmness.
• The first generation silicone gel-filled implant (Cronin–
Gerow implant):
■ Anatomically shaped with Dacron fixation patches,
composed of a thick, smooth silicone elastomer shell
that contained a seam, filled with a moderately viscous
silicone gel.
■ Had high contracture rates.
• The second-generation silicone implants:
■ Round, without fixation patches, composed of a
thinner, seamless shell and filled with a less viscous
silicone gel to promote a natural feel.
■ Had high rates of diffusion or bleed of small silicone
molecules into the periprosthetic intracapsular space.
• The third-generation silicone gel-filled implants:
■ Developed in the 1980s, focused on improving the
strength and integrity of the shell to reduce bleed and
rupture. Despite reducing bleed rates to near zero, the
FDA required temporary removal from the American
market in 1992.
• The fourth-generation gel-filled implants:
■ Manufactured for market re-introduction.
■ Wider variety of surface textures and implant shapes.
• The fifth-generation silicone gel implant:
■ Anatomically-shaped and available with a range of
volumes and any of the twelve combinations of low,
moderate, and full height with low, moderate, full and
extra projection.
This chapter was created using content from
Neligan & Grotting, Plastic Surgery 3rd edition,
Volume 5, Breast, Chapter 2, Breast augmentation,
G. Patrick Maxwell and Allen Gabriel.
SYNOPSIS
■ Breast augmentation is the most common aesthetic procedure
performed in the United States, and perhaps in the world.
■ In preparing for a breast augmentation, one must understand
each patient’s goals and expectations and see if they can be
achieved.
■ Three important variables have to be addressed prior to surgery:
(1) incision length and placement (inframammary, periareolar,
transaxillary, transumbilical); (2) pocket plane (subfascial,
subglandular, submuscular, subpectoral with dual plane 1,2,3);
(3) implant choice: (saline vs silicone, round vs anatomic, smooth
vs textured).
■ Biodimensional planning may be utilized for optimal preoperative
examination.
Brief introduction
• Glandular hypomastia may occur as a developmental or
involutional process and affects a significant number of
women in the United States.
• Developmental hypomastia is often seen as primary
mammary hypoplasia, or as a sequela of thoracic
hypoplasia (Poland syndrome) or other chest wall
deformity.
• Involutional hypomastia may develop in the postpartum
setting and may be exacerbated by breast-feeding or
significant weight loss.

223
Preoperative considerations
Figure 14.1  The aesthetic breast form is composed of measurable parameters.
The resultant breast form desired after surgical augmentation is determined by the
dynamic interaction between the character and compliance of the soft tissue
envelope; the quality, volume, and consistency of the breast parenchyma; and the
dimensions, volume, and characteristics of the breast implant. This form can be
attained by the careful planning and surgical performance of a breast augmentation.
Upper pole
Slope of upper pole
Lower pole
Breast height
Projection
Preoperative considerations
• Preoperative mammography is recommended for patients
over 35 years of age or patients of any age with
significant risk factors for breast cancer.
• The ideal breast should have the nipple-areola complex
(NAC) centered over the most projecting portion of the
breast mound (Fig. 14.1).
• Physical examination should include observation and
documentation of:
■ Chest wall deformity or spinal curvature.
■ Asymmetries.
■ Quantity and compliance of the parenchyma and
soft tissue envelope.
■ Palpation of all quadrants of the breast and axilla to
rule out any dominant masses or suspicious lymph
nodes.
■ The soft tissue pinch test: in general, a pinch test result
of <2 cm will often indicate a need for subpectoral
placement of the implant (Figs 14.2–14.4).
Figure 14.2  Example of hard tissue asymmetry. (A) Patient’s AP view. (B) Patients AP view following automated biodimensional measurements and volume characterization.
(C) Bird’s eye view of patient’s chest. Red line delineating the soft tissue envelope, and blue line the chest wall. (D) Bird’s eye view of patient’s chest with superimposed
soft tissue and chest wall outlines as mirror images with identification of chest wall asymmetry. Even though the volume is identical, the presenting anatomy is very different.
A
B
21.7
3.2
6.0
270 cc
268 cc
3
6.6
3.3
21.7
12.7
12.5
C
D

Figure 14.3  Example of soft tissue asymmetry. (A) Patient’s AP view. (B) Patients AP view following automated biodimensional measurements and volume characterization.
Bird’s eye view of patient’s chest. Red line delineating the soft tissue envelope, and blue line the chest wall. (C,D) Bird’s eye view of patient’s chest with superimposed soft
tissue and chest wall outlines as mirror images with identification of soft tissue asymmetry.
A
80 cc
162 cc
3.2
4.0
20.7
21.0
3.2
6.7
6.7
B
80 cc
162 cc
13.0
13.1
C
D
80 CC
162 CC
Figure 14.4  Example of hard and soft tissue asymmetry. (A) Patient’s AP view. (B) Patients AP view following automated biodimensional measurements and volume
characterization. (C,D) Bird’s eye view.
A
B
2.3
5.7
5.6
18.7
3.8
3.8
18.1
194 cc
271 cc
11.1
11.4
C
D

225
Anatomical/technical pearls
• Should not routinely be used on patients with
an areola diameter <40 mm and may not allow
introduction of larger gel or enhanced cohesive gel
implants.
• The transaxillary approach can be performed either
bluntly or with the aid of an endoscope.
• Disadvantages include difficulty with parenchymal
alterations and the probable need for a second incision on
the breast mound for revisionary surgery, and difficulty
with precise implant placement.
• Transumbilical breast augmentation has the obvious
advantage of a single, well-hidden, remote incision.
■ Only saline implants.
■ Hemostasis can be difficult from the remote access
port.
Pocket position
• The decision of subglandular/subfascial or
subpectoral implant placement depends on implant
selection (fill and texture) and tissue thickness
(Fig. 14.6).
• In patients with a pinch test result of >2 cm,
the implant can safely be placed in the subfascial
plane.
• Textured implants are the preferred implant for
subfascial placement due to lower risk of capsular
contracture when compared to smooth gel implants.
• When using subpectoral pockets, the origin of the
pectoralis major muscle can be divided just above the
inframammary fold to allow better projection in the
lower pole of the augmented breast and to maintain a
natural inframammary fold (Fig. 14.7). This places the
superior portion of the implant in a subpectoral position
while the inferior portion is subglandularly located – the
so-called “dual-plane”.
Implant selection basics
• The base width of the breast is related to the width of the
patient’s chest and is proportional to the overall body
habitus. It is imperative that this dimension is respected
during augmentation in order to maintain the normal
anatomical landmarks such as the lateral breast fold
in the anterior axillary line and the intermammary
distance (IMD).
• Generally, the surgeon should select an implant that is
slightly less wide than the existing breast.
• The choice between textured and smooth-walled implants
is based primarily on minimizing capsular contracture:
■ For subpectoral augmentation, either implant can
probably be used with comparable results. When the
device is placed in the subfascial pocket, a textured
implant is preferred to minimize capsular contracture.
(Fig. 14.8).
• The typical round shaped breast implant has its greatest
projection centrally with the remainder of the volume
distributed evenly along the base of the implant. While
anatomically shaped breast implants have a flatter upper
• Precise measurements must be taken using the
inframammary fold (IMF), the nipple-areola complex,
and the suprasternal notch as key landmarks (Fig. 14.5).
Measurements include:
■ Breast width (BW) , the breast height (BH), the
distance from the nipple-areola complex to the
inframammary fold (N:IMF), the distance from
the suprasternal notch to the nipple areola complex
(SSN:N), and the intermammary distance (IMD).
Anatomical/technical pearls
• The inframammary incision permits complete
visualization of either the prepectoral or subglandular
pocket and allows precise placement of virtually all
implants.
• Smaller incisions (<3 cm) can be used for saline-filled
implants, but silicone gel implants often require incisions
up to 5.0 cm in length.
• Should be placed in the projected inframammary fold
rather than in the existing fold to avoid visibility and
widening of the subsequent scar.
• The periareolar incision is placed at the areolar-cutaneous
juncture and generally heals inconspicuously in light
pigmented patients.
• Disadvantages include limited exposure of the
surgical field, transection of the parenchymal ducts
(which are often colonized with Staphylococcus
epidermidis), potentially increased risk of nipple
sensitivity changes, and visible scarring on the breast
mound.
Figure 14.5  Preoperative measures (taken before breast augmentation) include
SSN:N (suprasternal notch to nipple); N:IMF (nipple to inframammary fold); BW
(breast width); BH (breast height), and IMD (intermammary distance).
SSN:N
SSN:N
N:IMF
IMD
BH
BW

226
•
• Breast augmentation
14
Figure 14.6  (A,B) When ample soft tissue is present, implants may be placed in
the subglandular position or subfascial position. When there is soft tissue
inadequacy, the subpectoral position is generally preferable.
A
Round implant
B
Anatomic implant
pole with the majority of the volume and projection in
the lower pole (Fig. 14.9).
• The anatomically shaped implant of a given base width
and volume will produce less upper pole convexity than
a round implant of the same base width and volume
(Fig. 14.10). This characteristic of anatomically shaped
implants can be extremely useful when the patient
desires a significant volume augmentation but has a
relatively narrow breast width.
Operative techniques
Inframammary incision
• The incision should be placed in the predicted location of
the new inframammary fold which has been determined
and marked preoperatively. It should be designed with
the majority of the incision lateral to the breast midline as
this will place the resulting scar in the deepest portion of
the new IMF.
• The incision is made along the proposed markings, and
the dissection is continued with an insulated
electrocautery instrument through Scarpa fascia.
• If the implant is to be placed in the subfascial pocket, the
dissection proceeds below the pectoralis fascia but above
the pectoralis major fascia.
• For smooth-walled implants, a larger pocket is dissected
to allow mobility of the implant.
• For anatomic implants, the pocket is precisely dissected
to snugly accommodate the implant.
• Care should be taken to preserve the lateral intercostal
cutaneous nerves, especially the fourth intercostal, which
contains the primary sensory innervations of the nipple-
areola complex.
• If a subpectoral pocket is chosen, the dissection is initially
carried out laterally to identify the lateral border of the
pectoralis major muscle. The muscle edge can be lifted by
forceps to allow easy entry into the submusculofascial
plane.
• The inferior origin of the pectoralis major is released from
lateral to medial at the level of the inframammary fold
and continues medially to the sternal border.
• Exact implant “sizers” (gel or saline) are used when
available to evaluate the pockets and resultant breast
form.
• After the sizers are in place, the patient is placed in a 90°
upright position and evaluated from various
perspectives. Any asymmetry or under-dissected areas
are marked, and the patient is placed back in the supine
position.
• Once adequate hemostasis is obtained and pocket
dimensions are finalized, the pocket is irrigated with an
antibiotic-containing solution, and the implants are
carefully placed by a minimal-touch technique.
• The final results are assessed, again with the patient
in a sitting position, and a multilayer closure is
performed.
Periareolar incision
• The periareolar incision is placed along the inferior
portion of the areolar-cutaneous juncture from the
3-o’clock and 9-o’clock positions.
• After the incision is made, the wound edges are elevated
directly up from the chest wall with an opposing pair of
small sharp retractors.
• An insulated electrocautery unit is used to dissect
straight down through the breast parenchyma to the

227
Operative techniques
Figure 14.7  (A–F) Preoperative and postoperative views of a 36-year-old female with Style 20 implants at 12 months: R, 400 cc; L, 400 cc in a subpectoral position.
A
B
C
D
E
F
pectoralis major fascia. The dissection is the same as
described through the inframammary incision.
• If the inferior pole of the breast is constricted (tuberous
breast deformity), radial scoring of the gland in the
inferior pole can allow proper redraping of the soft tissue
over the implant to correct the deformity.
• The gland must be precisely reapproximated and closed
with several layers of interrupted absorbable sutures to
prevent distortion of the nipple-areola complex.
Transaxillary incision (Video 14.1; Video 14.2)
• This procedure can be performed either bluntly using the
Montgomery dissector, or using an endoscope for precise
visualization, and dissection of the implant pocket.
• To locate and mark the incision, the patient’s arm is
placed in complete adduction and the most anterior
aspect of the axilla is marked. The incision should not
extend beyond this line. The arm is then abducted
Video
14.2
Video
14.1

228
•
• Breast augmentation
14
• An incision is made within the umbilicus, large enough
to easily accommodate an index finger.
• An endotube with a blunt obturator is passed just above
the rectus fascia along the line from the umbilicus to the
areola.
• Constantly palpate the progress of the obturator with the
other hand, always keeping the force up and away from
the abdominal and thoracic cavities.
• The endotube is advanced over the costal margin. For
subglandular implant placement, the force applied to the
endotube is directed upward at the inframammary fold
to prevent the obturator from slipping beneath the
pectoralis major. The tunnel ends just cephalad to the
nipple. Subpectoral positioning is possible by careful
technique with use of special instruments to enter the
fascial plane high laterally.
• The obturator is then removed, and an endoscope may be
used to verify correct pocket identification.
• An expander is rolled up and placed within the incision
and “milked” up the tunnel by manual external pressure.
The expander is filled with saline to 150% of the final
volume of the implant. Pocket adjustments can be made
manually during filling.
• When the expansion is complete, the expander is drained
and removed from the pocket by traction on the fill tube.
The implant is placed and filled in exactly the same
manner as the expander.
• The incision is closed with a single layer of absorbable
suture. An abdominal binder is used for compression on
the abdominal tunnels.
Postoperative considerations
• If smooth (non-textured) implants were used, initiation of
implant mobility exercises is recommended at first
follow-up visit.
• If the patient is at risk for superior implant displacement,
a circumferential elastic strap may be used to apply
continuous downward pressure during the early
postoperative period.
• Patients are usually able to return to work a few days
after surgery, but are not permitted to resume rigorous
exercise for 2–3 weeks. Additional follow-up visits are
scheduled at 4–6 weeks, 3 months, and 1 year.
Complications and outcomes
• Alterations of nipple sensitivity after augmentation are
thought to result from traction injury, bruising, or
transection of the lateral intercostal cutaneous nerves.
• Periprosthetic seroma fluid is usually resorbed by the soft
tissues within the first week of surgery, and use of topical
antibiotics intraoperatively has been shown to decrease
the rates.
• Hematoma after breast augmentation has several
deleterious effects in both the early and late postoperative
period including pain, blood loss, disfigurement, and
capsular contracture.
approximately 45°, and a prominent axillary crease is
identified. Any fold may be used, but preference is given
to one high in the axilla, which aids in instrumentation
during the procedure. For saline-filled implants, the
incision should generally be 2.5–3.5 cm. Silicone implants
require larger incisions.
• The incision is made, and small sharp retractors are used
to elevate the medial aspect of the incision. Superficial
subcutaneous dissection to the lateral border of the
pectoralis major prevents injury to the intercostobrachial
nerve.
• The fascia of the pectoralis major muscle is visualized at
the lateral edge of the muscle, and the dissection is
carried deep to this for a subfascial placement or deep to
the muscle for subpectoral placement.
• For an endoscopically assisted augmentation, the
endoscope is passed into the transaxillary tunnel, and the
subpectoral space is seen under direct vision. This allows
a more controlled release of the pectoralis major origin
with a long insulated electrocautery instrument.
• The remaining steps follow those above. On closure, the
pectoralis muscle fascia is repaired with a single
absorbable suture, and the incision is closed in one or
two layers.
Transumbilical
• While the markings are similar to those for a standard
inframammary fold approach, an additional mark is
made with the patient supine: a line is drawn from the
umbilicus to the medial border of the areola bilaterally.
Figure 14.8  Large pocket for smooth-surfaced implants to allow tissue redraping
and encourage implant mobility to minimize capsule contracture which is different
for textured devices (including anatomic), where a precise pocket is created that is
either the same or slightly larger than the base and height of the implant to help
maintain implant position.
Mobile implant moving
within larger capsule

229
Complications and outcomes
Figure 14.9  (A–F) Preoperative and postoperative views of a 29-year-old female with CPG 332 implants at 12 months: R, 350 cc; L, 350 cc in a subpectoral position.
A
B
C
D
E
F

A
B
C
D
Figure 14.10  (A–F) Preoperative and postoperative views of a 33-year-old female with Style 410 MM implants at 12 months: R, 280 cc; L, 245 cc in a subpectoral
position.
E
F

231
Further reading
particles such as glove powder, lint, or dust, and
infectious etiologies (subclinical infection and biofilm).
• Strategies to prevent capsular contracture: the creation of
a large implant pocket, and maintenance of this oversized
pocket with implant displacement exercises; the use of
textured implants; meticulous hemostasis and sterility.
• Treatment of established capsular contractures usually
requires operative intervention.
• Very thick fibrous capsules, or those heavily calcified
containing silicone granulomas often require either a
partial or complete capsulectomy
• Any defect in the silicone elastomer shell of a saline-filled
breast implant will ultimately result in deflation of the
implant. The saline filling material leaks out of the
implant and is harmlessly absorbed by the surrounding
tissues.
• Magnetic resonance imaging (MRI) of the breast is
considered the state-of-the-art technique for evaluating
breast implant integrity.
• For gel-filled implants, the recommendation is initial MRI
3 years after the augmentation, followed by imaging
every 2 years.
• Modern fourth generation silicone gel is substantially
more cohesive than the second- and third-generation gel,
and less likely to leak into the surrounding tissues, even
when the implant shell is ruptured.
Further reading
Adams WP Jr, Rios JL, Smith SJ. Enhancing patient
outcomes in aesthetic and reconstructive breast surgery
using triple antibiotic breast irrigation: six-year
prospective clinical study. Plast Reconstr Surg.
2006;117(1):30–36.
The authors show the clinical importance of the use of triple
antibiotic breast irrigation. This study shows the lower
incidence of capsular contracture compared with other
published reports, and its clinical efficacy supports
previously published in vitro studies. Application of triple
antibiotic irrigation is recommended for all aesthetic and
reconstructive breast procedures and is cost-effective.
Bengtson BP, Van Natta BW, Murphy DK, et al. Style 410
highly cohesive silicone breast implant core study
results at 3 years. Plast Reconstr Surg. 2007;120
(7 Suppl 1):40S–48S.
Cunningham B. The Mentor study on contour profile gel
silicone MemoryGel breast implants. Plast Reconstr
Surg. 2007;120(7 Suppl 1):33S–39S.
Cunningham B, McCue J. Safety and effectiveness of
Mentor’s MemoryGel implants at 6 years. Aesthet Plast
Surg. 2009;33(3):440–444.
The authors update on the post-approval study for the
Mentor Corporation. The study shows that Mentor
MemoryGel silicone breast implants represent a safe and
effective choice for women seeking breast augmentation or
breast reconstruction following mastectomy.
Gabriel SE, O’Fallon WM, Kurland LT, et al. Risk of
connective-tissue diseases and other disorders after
Table 14.1  The grades of capsular contracture are divided into
the following four types
Grade
Description
I
Capsular contracture of the augmented breast feels
as soft as an unoperated breast
II
Capsular contracture is minimal. The breast is less
soft than an unoperated breast. The implant can be
palpated but is not visible
III
Capsular contracture is moderate. The breast is firmer.
The implant can be palpated easily and may be
distorted or visible
IV
Capsular contracture is severe. The breast is hard,
tender, and painful, with significant distortion present.
The capsule thickness is not directly proportional to
palpable firmness, although some relationship may
exist
Reproduced with permission from Spear SL, Baker JL Jr. Classification of
capsular contracture after prosthetic breast reconstruction. Plast Reconstr Surg.
1995;96(5):1119–1124.
• Immediate evacuation of all hematomas is recommended.
• Postoperative wound infection may present with a
spectrum of severity ranging from a mild cellulitis of the
breast skin to a purulent periprosthetic space infection.
Staphylococcus epidermidis is the most frequently identified
pathogen in postoperative wound infections.
• Most infections will respond to oral or intravenous
antibiotics if therapy is initiated very early in the course
of the infection.
• If the infection persists or progresses, then the implant
should be removed and the wound should be allowed to
heal over a drain or in severe cases by secondary
intention.
• Once the infection has totally cleared, a secondary
augmentation and scar revision should be planned in
6–12 months.
• Mondor’s disease is a superficial thrombophlebitis of the
breast that may occur in up to 1–2% of augmentation
patients.
• Usually affects the veins along the inferior aspect of the
breast and occurs most frequently with the
inframammary approach.
• Self-limiting process that usually resolves with warm
compresses over a period of several weeks.
• Clinically significant periprosthetic capsular contracture
is characterized by excessive scar formation that leads to
firmness, distortion, and displacement of the breast
implant.
• Histological examination reveals circumferential linear
fibrosis, which is especially severe when formed in
response to smooth shell implants.
• In 1975, Baker proposed a clinical classification system of
capsular contracture after augmentation that is still
commonly used to describe periprosthetic contractures
(Table 14.1).
• Risk factors for capsular contracture: periprosthetic
hematoma, seroma, silicone gel bleed, other foreign body

232
•
• Breast augmentation
14
breast implantation. N Engl J Med.
1994;330(24):1697–1702.
The authors conducted a population-based, retrospective
study to examine the risk of a variety of connective-tissue
diseases and other disorders after breast implantation. No
association between breast implants and the connective-
tissue diseases and other disorders that were studied was
found.
Magnusson M, Hoglund P, Johansson K, et al. Pentoxifylline
and vitamin E treatment for prevention of radiation-
induced side-effects in women with breast cancer: a
phase two, double-blind, placebo-controlled
randomised clinical trial (Ptx-5). Eur J Cancer.
2009;45(14):2488–2495.
Nelson N. Institute of Medicine finds no link between breast
implants and disease. J Natl Cancer Inst.
1999;91(14):1191.
Spear SL, Baker JL Jr. Classification of capsular contracture
after prosthetic breast reconstruction. Plast Reconstr
Surg. 1995;96(5):1119–1124.
Spear SL, Murphy DK, Slicton A, et al. Inamed silicone
breast implant core study results at 6 years. Plast
Reconstr Surg. 2007;120(7 Suppl 1):8S–18S.
The authors update on the post-approval study for Allergan
Corporation. The study demonstrates the safety and
effectiveness of Natrelle (formerly Inamed) silicone-filled
breast implants through 6 years, including a low rupture
rate and high satisfaction rate.
Tebbetts JB. Dual plane breast augmentation: optimizing
implant-soft-tissue relationships in a wide range of
breast types. Plast Reconstr Surg. 2001;107(5):1255–1272.
This article describes specific indications and techniques for
a dual plane approach to breast augmentation. Indications,
operative techniques, results, and complications for this
series of patients are presented. Dual plane augmentation
mammaplasty adjusts implant and tissue relationships to
ensure adequate soft tissue coverage, while optimizing
implant soft tissue dynamics to offer increased benefits and
fewer tradeoffs compared with a single pocket location in a
wide range of breast types.

©2014, Elsevier Inc. All rights reserved.
Chapter
15 
Mastopexy
seen in cases of macromastia and gigantomastia is a
predominance of parenchyma without skin excess.
• The pathophysiology of breast ptosis is the result of the
combination of expansion and aging, or separately as a
result of a congenital deformity.
• Breast ptosis in its various degrees is defined by
its anatomic relationship to the inframammary fold
(IMF). In 1976, Regnault described degrees of breast
ptosis (Fig. 15.1).
■ Grade I ptosis (mild): the nipple is within 1 cm of the
IMF, and above the lower pole of the breast.
■ Grade II (moderate): the nipple is 1–3 cm below the
IMF, but still above the lower pole of the breast.
■ Grade III (severe): the nipple is more than
3 cm below the IMF and is below the lower
breast contour.
■ Grade IV (psuedoptosis): the nipple rests above the
IMF but the majority of breast parenchyma is below it,
giving the appearance of ptosis.
• An additional caveat to the Regnault classification was
submitted by Brink, which takes into account other
causes of the ptotic breast, such as parenchymal
maldistribution, and posits an algorithm by which they
can be surgically addressed (Table 15.1, Fig. 15.2).
Preoperative considerations
• One of the most helpful questions that can be posed to a
patient is “can you make your breasts look the way you
want them to in a bra?”
■ If the answer is yes, then perhaps a mastopexy alone is
the best recommendation.
■ If the answer is no, and the patient relies on adding
volume by stuffing or padding, then adding an
implant may be necessary.
This chapter was created using content from
Neligan & Grotting, Plastic Surgery 3rd edition,
Volume 5, Breast, Chapter 1, Anatomy for plastic
surgery of the breast, Jorge I. de la Torre and
Michael R. Davis, Chapter 7, Mastopexy, Kent K.
Higdon and James C. Grotting.
Brief introduction
• Mastopexy is a parenchymal reshaping that may or may
not require a small parenchymal reduction, whereas
reduction mammaplasties always require parenchymal
reduction.
• The difference between mastopexy and reduction
mammoplasty, is whether the patient truly exhibits
symptoms of macromastia.
• Typically, the ptotic breast has a paucity of breast
parenchyma in relation to a lax, excessive skin envelope
while the cardinal finding of the hypertrophic breasts
SYNOPSIS
■ Breast ptosis is a common problem caused by several different
factors: pregnancy, weight changes, aging, delayed effect of breast
implants and developmental deformities.
■ Mastopexy and augmentation-mastopexy techniques are varied and
can be applied to different breast shape deformities.
■ Mastopexy techniques can be periareolar, vertical or based on the
inverted-T techniques, as well as being performed in some
instances by liposuction alone.
■ Preoperative deflation prior to mastopexy or augmentation-
mastopexy is a safe and effective technique that offers the patient
and surgeon many benefits.

234
•
• Mastopexy
15
• The plastic surgeon must take into account the degree of
skin laxity, the excess amount of skin in relation to the
parenchyma, the position or malposition of the
parenchyma, and degree of nipple-areolar complex
elevation anticipated.
• Measurements are a key component to the diagnosis and
treatment of the patient with breast ptosis. These
measurements offer guidelines for altering the breast,
which must be individualized, based on proportionality,
variances in chest wall anatomy, posture and patient
A
B
C
Figure 15.1  Breast ptosis classification as described by Regnault. (A) Minimal
ptosis: the nipple is at the level of or just inferior to the inframammary crease. (B)
Moderate ptosis: the nipple is 1–3 cm below the inframammary crease. (C) Severe
ptosis: the nipple is >3 cm below the inframammary crease. (Redrawn from
Georgiade GS, Georgiade NG, Riefkohl R. Esthetic breast surgery: In: McCarthy JG,
ed. Plastic surgery. Philadelphia: WB Saunders; 1991:3839.)
Table 15.1  Procedural specifics for forms of breast ptosis
Inframammary
fold position
Parenchymal
position
Nipple–areola
position
Nipple to fold
distance
Clavicle to
nipple distance
Clavicle to
fold distance
True ptosis
Fixed normal
Fixed rotated
Low downward
pointing
Unchanged
normal
Elongated
Unchanged
normal
Glandular ptosis
  Common
Mobile
descended
Mobile
descended
Low forward
pointing
Elongated
Elongated
Elongated
  Uncommon
Fixed normal
Mobile
descended
Low relative to
fold
Elongated
Normal to
elongated
Unchanged
Normal
Normal
Parenchymal
maldistribution
Fixed high
Fixed high
Normal downward
pointing
Short
Normal
Short
Pseudoptosisa
Variable, usually
lowa
Mobile
re-descended
Surgically fixed
Elongated
Surgically fixed
Variable, usually
elongateda
aPseudoptosis is most common after corrective procedures for glandular ptosis where the fold has descended preoperatively. (From Brink RR. Management of true ptosis
of the breast. Plast Reconstr Surg. 1993;91:657–662.)
preference. Important measurements and their reported
statistical standards (Fig. 15.3) include:
■ The sternal notch to nipple distance: 19–21 cm.
■ The nipple to IMF distance: 5–7 cm.
■ Nipple to midline distance: 9–11 cm.
■ The breast base diameter.
■ The degree of ptosis: based on Regnault Classification.
• The majority of patients presenting for mastopexy
procedures typically fall into three categories. The
analysis of the quality and amount of skin in relation to
the mass and anatomic distribution of the breast
parenchyma usually dictates which procedure is
necessary.
■ Patients who indeed would benefit from mastopexy.
Normal volume of breast parenchyma and a minimal-
to-moderate excess of skin that is of good quality.
■ Patients who need an augmentation with mastopexy.
Minimal glandular mass and breast ptosis.
■ Patients who need a formal reduction mammaplasty.
Overabundance of parenchyma and ptosis.
• Any history of breast changes/masses, nipple-areolar
changes or discharge, mammography, previous breast
surgery, pregnancies and breast-feeding, radiation
therapy to the chest or breast, and personal or family
history of breast cancer must be explored with the patient
in detail.
• Most agree that patients over 35 years of age should
obtain a recent mammogram, unless a normal one has
been documented in the year prior, before proceeding
with surgery.
Anatomical/technical pearls
• Knowledge of the breast anatomy is critical
for optimizing outcomes following mastopexy.
(Figs 15.4–15.11).

235
Anatomical/technical pearls
A
B
C
D
Glandular ptosis
True ptosis
Parenchymal maldistribution
(high IMF)
Pseudoptosis
Figure 15.2  (A–D) Different types of breast ptosis. IMF, inframammary fold. (Redrawn after Brink RR. Management of true ptosis of the breast. Plast Reconstr Surg.
1993;91:657–662.)
Figure 15.4  AP image: ideal breast dimensions demonstrating symmetry and
projection.
19 to 21 cm
19 to 21 cm
19 to 21 cm
5 to 6 cm
5 to 6 cm
9 to 11 cm
2cm
Figure 15.3  Statistical standards for the dimensions of the breast.

236
•
• Mastopexy
15
Figure 15.5  The milk lines. (Reproduced with permission from Standring S, ed.
Gray’s anatomy. 40th ed. London: Churchill Livingstone; 2008.)
Figure 15.6  Stages in breast development. Pre-and post-pubertal development and structure of the female breast, demonstrating changes in the contour of the breast.
(Reproduced with permission from Standring S, ed. Gray’s anatomy. 40th ed. London: Churchill Livingstone; 2008.)
• The vascular supply to the breast and nipple-areolar
complex is rich and redundant and includes contributions
from the internal mammary perforator, lateral thoracic
perforators, and the intercostal perforators from both the
anterolateral and anteromedial origins.
• Branches of the lateral division of the fourth intercostal
nerve provide the primary innervation of the nipple.
Contributions from the third and fifth anterior cutaneous
intercostals, as well as the fifth lateral cutaneous
intercostals, may also provide some sensation of the
nipple.
• Cooper’s ligaments run from the pectoralis muscular
fascia, through breast parenchyma, and insert into the
dermis (Fig. 15.12). Parenchymal changes with aging,
weight changes in the obese, and pregnancy, are
accompanied by specific alterations in the integrity of
Cooper’s ligaments, as well as the breast’s fascial
components, and the overlying skin. The breast
parenchyma, once held in place on the chest wall by and
within these structures, becomes mobile and descends
with the constant pull of gravity.
• Mastopexy techniques are often described by the scar
pattern from the skin reduction: periareolar, vertical, J or
L, and inverted-T.
• Periareolar techniques are best suited for patients with
mild to moderate breast ptosis and in whom the
parenchyma is adequate from a volume standpoint.
Incisions range from a superior crescent of excised skin to
a complete donut.
• Patients who present with mild to moderate breast ptosis,
but with inadequate parenchymal volume can be treated
with an implant via the periareolar technique.
• The greatest advantage of the periareolar technique is
that the incision is camouflaged in the aesthetic transition
from breast skin to the skin of the nipple-areola.
• Disadvantages of periareolar techniques include:
■ A limited degree of cephalic nipple-areolar complex
movement.
■ Possible scar widening.
■ Possible decreased breast projection.
• Small, mildly ptotic breasts with adequate parenchyma
respond best to these techniques.
• Excising skin around the nipple-areola at the same
operative setting elevates the nipple-areolar complex to a
more aesthetic location and completes the periareolar
mastopexy. Usually, the amount of lift obtained is limited
to 1–2 cm.
• In an effort to limit complications associated with
periareolar mastopexy techniques, Spear et al. designed a
series of rules to follow.
■ Rule 1: Doutside ≤ Doriginal + (Doriginal − Dinside). The amount
of non-pigmented skin excised should be less than the
amount of pigmented skin excised. In doing so, there
will be no undue tension on the new areola that could
cause subsequent widening. The distance from the
edge of the areola to the outer diameter located on the
normal breast skin should roughly equal the distance
to the inner diameter, which should be located within
the areola.
■ Rule 2: Doutside < 2 × Dinside. The design of the outside
diameter should be no more than two times the inside

237
Anatomical/technical pearls
Figure 15.7  (A) Structure of the breast. (B) Changes in the breast during lactation. (C) Section of the nipple. (D) Cross-section of the nipple. There is a corrugated layer of
stratified squamous keratinized epithelium over the nipple surface; 20 or more lactiferous ducts (L) open onto the surface; sebaceous glands (S) are deep to the epidermis.
(A–C, Reproduced with permission from Standring S, ed. Gray’s anatomy. 40th ed. London: Churchill Livingstone; 2008; D, from Kerr JB. Atlas of functional histology.
London: Mosby; 1999, with permission from Dr JB Kerr, Monash University.)
S
S
L
L
S
Nonlactating
breast
Breast during
lactation
Rib
Pectoralis minor
Pectoralis major
Pectoral fascia
Suspensory
ligament
Submammary space
Deep
Superficial
layers
of
fascia
Adipose tissue
Secretory lobule
containing alveoli
Sebaceous gland
Circular smooth muscle
Accessory gland
(of Montgomery)
Areola
Lactiferous duct
Axillary tail
Edge of
pectoralis major
deep to breast
Areola
Nipple
Possible
extensions of
mammary tissue
(posterior and
medial)
A
B
C
D
diameter in order to minimize the discrepancy in circle
sizes, thereby reducing tension on the closure.
■ Rule 3: Dfinal = 12 (Doutside + Dinside). This final rule
helps predict the final areolar size, which is
particularly useful in asymmetry cases, as well as
those in whom no round block suture is employed
(Fig. 15.13).
• As the degree of the breast ptosis increases, so does the
total length of the incision necessary to correct it. The
logical extension of the periareolar scar is the addition of
a vertical component.
• Lassus and other vertical mastopexy techniques combine
four principles:
■ (1) a central wedge resection to reduce the size of the
breast, if needed; (2) transposition of the areola on a
superiorly-based flap; (3) no undermining of the skin;
(4) addition of a vertical scar component.
• Vertical mastopexy techniques are best for young women
with good skin elasticity, a firm, glandular breast, and
breasts that are not excessively large or ptotic.
• Advantages of vertical techniques: almost no risk of skin,
nipple, or glandular necrosis; preservation of most of the