Chẩn Đoán Và Điều Trị Phẫu Thuật Tái Tạo Hiện Đại (CURRENT Reconstructive Surgery)

BREAST CANCER • 483
Non–high-grade DCIS retains the risk of subsequent
invasive carcinoma; however, the time course for disease
progression is variable and for practical purposes non-
quantifi able for an individual patient.
The management of DCIS focuses on local surgical
excision of the diseased breast segment with attention to
obtaining a surrounding margin of histologically normal
breast tissue. Regional lymph node staging is not indicated
for the majority of patients with DCIS, as the disease is
confi ned to the duct lumen and does not have access to
the lymphatic space. Lymph node staging with sentinel
node biopsy should be considered in patients undergoing
mastectomy for extensive DCIS, patients who present
with a palpable mass where there is a suspicion of under-
lying invasive carcinoma, and large volume partial breast
resections of high-grade DCIS. Approximately 20% of
these patients will be found to have invasive ductal car-
cinoma on fi nal pathology and the fi nding of a negative
sentinel node obviates the need for a second operative
procedure for axillary staging.
Most patients require mammographically guided wire
localization of the microcalcifi cations immediately prior
to surgery to direct excision of this nonpalpable lesion.
Patients need to be advised that mammography frequently
underestimates the extent of DCIS, particularly when
there is extensive noncalcifi ed disease. Meticulous
pathology assessment of the specimen with attention to
the extent of DCIS found in the specimen and proxim-
ity to inked margins will guide the need for additional
therapy. There is no standard defi nition for what con-
stitutes a negative surgical margin; however, DCIS less
than 1 mm from the inked specimen edge is generally
felt to represent a positive fi nding. Patients with close or
positive surgical margins are advised to have additional
surgery to exclude residual disease in the breast. Most
patients can be managed with a margin-directed re-exci-
sion to achieve clear margins. A postexcision mammo-
gram is recommended to document complete excision of
all calcifi cations prior to initiating radiation therapy.
Adjuvant whole breast radiation is recommended fol-
lowing local excision of DCIS to reduce the risk of local
recurrence. Excision alone is associated with 10-year
recurrence rates of 25% to 30%, 12 , 13 and approximately
50% of patients who recur after breast-conserving treat-
ment for DCIS will have invasive carcinoma at the time
of recurrence. Whole breast radiation decreases the risk of
local recurrence by 40% to 50%. 14 To date, no subset of
women with DCIS has been identifi ed for which radiation
is not benefi cial, although the absolute benefi t is high-
est in patients with the highest risk of local failure. The
Van Nuys Prognostic Index incorporates age at diagnosis,
extent of DCIS, proximity of DCIS to the closest surgical
margin, and DCIS grade and necrosis to classify patients
as at low, intermediate, or high risk for local recurrence. 15
The index was developed at a single institution based on
retrospective analysis of selected patients and has not been
validated prospectively. However, it can be useful in coun-
seling patients about their individual recurrence risk.
Clinical trials are in progress to determine if there is a
subset of low-risk DCIS for which radiation therapy can
be omitted. A recent prospective study of local excision
alone with protocol mandated margins of less than 1 cm
met early stopping rules due to ipsilateral recurrence
rates of 2.4% per year corresponding to a 12% 5-year
recurrence rate. 16 Although DCIS is a nonlethal breast
cancer, up to 50% of recurrences are associated with
invasive breast cancer with the associated risk of axillary
or systemic metastasis. At present, radiation therapy is
recommended for the majority of women following local
excision for DCIS.
Total mastectomy with immediate reconstruction
remains an alternative to breast-conserving therapy for
DCIS. Indications for mastectomy include diffuse malig-
nant microcalcifi cations not amenable to surgical exci-
sion with an acceptable cosmetic deformity, failure to
achieve negative resection margins after attempts at
breast conservation, and patient preference. Scleroderma
remains a contraindication to radiation therapy and
mastectomy may be the most reasonable option for this
special population. Inability to achieve clear margins fol-
lowing multiple attempts at local excision occurs infre-
quently; however, depending on breast size and patient
expectations, mastectomy with reconstruction may result
in a superior long-term cosmetic result than continued
attempts at re-excision.
Skin-sparing mastectomy via a periareola incision per-
mits dissection of all glandular tissue with preservation
of the natural skin envelope and inframammary crease.
The boundaries of dissection of the breast glandular tis-
sue are identical to those for standard total or modifi ed
radical mastectomy. Rates of local recurrence following
skin-sparing mastectomy are comparable with conven-
tional mastectomy procedures. 17 In rare circumstances, a
clear plane of dissection cannot be developed due to the
presence of DCIS in the most anterior breast tissue, and
skin excision overlying the breast parenchyma is neces-
sary. Preservation of the natural skin envelope provides a
template for reconstruction, achieving remarkable sym-
metry to the normal contralateral breast. Sentinel lymph
node biopsy can be performed via the periareola incision
or, if necessary, via a separate axillary incision. Nipple-
sparing and areola-sparing mastectomies are gaining in
popularity and selection criteria and long-term outcomes
for these procedures are emerging. 18 , 19
Oncoplastic breast conserving surgery refers to local
tissue rearrangement following the wide segmental exci-
sion of breast cancer to improve the cosmetic outcome. 20
In women with large invasive carcinomas, neoadjuvant
chemotherapy can be used to locally down-stage the
primary tumor to improve the likelihood of successful
breast-conserving surgery. At present, there are no sys-
temic treatments to reduce the volume of DCIS to make
breast preservation more feasible for patients with exten-
sive disease. As an alternative to mastectomy, large vol-
ume full thickness segmental excisions combined with
local breast fl ap advancement can increase the options for

484 • CHAPTER 41
breast conservation in patients with extensive segmental
DCIS ( Figure 41-2 ). These procedures include use of a
parallelogram skin incision ( Figure 41-3 ), batwing mas-
topexy ( Figure 41-4 ), donut mastopexy, and reduction
mammoplasty.
Preoperative consultation with radiology to plan tumor
localization with multiple localizing wires for extensive
areas of calcifi cation will increase the chances for nega-
tive surgical margins. Patients benefi t from consultation
with plastic surgery to discuss contralateral symmetry
FIGURE 41-2. (A) Full-thickness parenchymal resection from skin to pectoralis
fascis. (B) Fibroglandular tissue mobilized off the pectoralis fascia to permit
advancement over chest wall. (C) Closue of defect. (Reproduced with permission
of Benjamin O. Anderson, MD.)
A
B
C
FIGURE 41-3. Standard lumpectomy with resulting deformity (top row).
Parallelogram mastopexy lumpectomy (bottom row). (Reproduced with permission of
Benjamin O. Anderson, MD.)

BREAST CANCER • 485
procedures. It is advisable to await fi nal pathology results
to determine margin status before proceeding with any
contralateral procedures. Positive resection margins fol-
lowing large-volume oncoplastic resection are generally
an indication for mastectomy.
The selective estrogen receptor modulator, tamoxifen,
has been shown to reduce the risk of ipsilateral DCIS
recurrence and contralateral breast cancer events fol-
lowing breast-conserving surgery. 21 Tamoxifen reduces
the occurrence of both DCIS and invasive carcinomas,
although this benefi t is limited to patients with ER1
DCIS. Patients treated with breast-conserving therapy
for ER1 DCIS should be counseled about the use of
tamoxifen. Trials are in progress evaluating the effi cacy
of aromatase inhibitors for the management of DCIS
in postmenopausal women. Taken together, breast can-
cer specifi c survival following local therapy for DCIS
approaches 100%.
LOBULAR CARCINOMA IN SITU
LCIS is characterized by a monotonous proliferation of
neoplastic cells within the acini of lobules with disten-
tion of these structures ( Figure 41-5 ). Loss of cellular
cohesion can be observed. There are no clear mammo-
graphic, ultrasound, or physical fi ndings associated with
LCIS and typically it is discovered on examination of
biopsy specimens obtained for other indications. LCIS
has traditionally been viewed as a marker of increased
risk of breast cancer in both the index and contralateral
breast and not as a precursor lesion to invasive breast
FIGURE 41-4. Batwing mastopexy lumpectomy. Permits partial- or full-thickness
parenchymal resection of centrally located tumors. (Reproduced with permission of Benjamin
O. Anderson, MD.)
FIGURE 41-5. LCIS high power view. Monotonous
proliferation of neoplastic cells with lobular distention.
(Courtesy of Mammath Chivakula, MD, Department of Pathology,
Magee-Womens Hospital of UPMC.)
cancer. LCIS identifi ed following a core-needle biopsy
performed for a mammographic abnormality should be
further evaluated with surgical excisional biopsy due
to the small but measurable risk of associated carci-
noma. 22 Attempts to achieve clear surgical margins are
not warranted, as it is accepted that LCIS is often mul-
ticentric and bilateral. LCIS is almost uniformly ER1,
and patients benefi t from tamoxifen for breast cancer
chemoprevention.

486 • CHAPTER 41
There is growing evidence that LCIS represents a
spectrum of lobular intraepithelial neoplasia, similar
to the heterogeneity observed in DCIS. A more appro-
priate classifi cation suggested is a three-tiered system
with lobular intraepithelial neoplasia 3 associated with
the highest level of subsequent breast cancer risk. 23
Pleomorphic LCIS, which may represent a nonobligate
precursor of invasive LCIS, may be best managed simi-
larly to DCIS. 24 , 25 Close communication between the
surgical oncologist and pathologist is warranted for cases
of LCIS to determine whether additional excision may
be warranted. 23
INVASIVE CARCINOMA
The identifi cation of mammary stromal invasion differ-
entiates in situ from invasive carcinoma ( Figure 41-6 ).
Invasive carcinoma has the potential to metastasize to
regional lymph nodes or to distant sites, most commonly
bone, lung, liver, and brain. Comprehensive treatment
involves multimodality therapy, including surgery and
radiation, for local and regional disease and systemic
therapy. The majority of invasive carcinomas are ductal
in origin and include the special histologic variants: tubu-
lar, mucinous, papillary, and medullary. Invasive lobular
carcinomas represent approximately 20% of invasive car-
cinomas. It is recognized that the histologic variants of
invasive carcinoma have different metastatic potential;
however, local and adjuvant therapy are not primarily
infl uenced by histologic classifi cation.
Patients may present with a screening detected lesion
or a palpable mass. The diagnostic evaluation should
include a diagnostic mammogram with magnifi ed and
spot compression views of the abnormality. The pres-
ence of associated calcifi cations should be noted as this
is often an indication of concomitant in situ carcinoma.
Ultrasound is a useful complementary diagnostic study
to confi rm the size and position of the mass within the
breast and is essential in patients with dense breasts
and a palpable lesion not visualized on mammography.
Ultrasound can be useful for evaluation of the regional
axillary lymph nodes prior to surgery. Metastatic axillary
nodes will appear abnormally rounded with a thickened
cortex and loss of the normal fatty hilum. Ultrasound
directed fi ne-needle aspiration or core-needle biopsy
of abnormal nodes is useful to determine whether the
patient is a candidate for sentinel node biopsy or if an
axillary node dissection is indicated.
Percutaneous image directed core-needle biopsy
with stereotactic or ultrasound guidance is the pre-
ferred approach to the diagnostic evaluation of a sus-
picious screening detected or palpable mass. The large,
bore core needles currently in use (typically 14-, 11-, or
9-gauge) permit accurate preoperative diagnosis of the
lesion to guide patient counseling and surgical planning.
Appropriate radiologic-pathologic correlation is indi-
cated following core-needle biopsy. A fi nding of benign
histology with a suspicious lesion mandates further eval-
uation with surgical excision.
Dynamic contrast-enhanced breast MRI is used with
increasing frequency to locally stage primary breast cancer
and assist with operative planning. MRI relies on the acqui-
sition of breast images before and after the administration
of intravenous gadolinium contrast. Malignant lesions will
demonstrate rapid contrast enhancement due to neovas-
cularity and abnormal permeability of the neoplastic ves-
sels ( Figure 41-7 ). Benign breast fi ndings may also show
enhancement on MRI and there can be considerable over-
lap in the pattern of enhancement between benign and
malignant lesions. MRI has a high false-positive rate and
FIGURE 41-6. (A,B) Invasive ductal carcinoma low-power (A) and high-power
(B) views. (Courtesy of Mammath Chivakula, MD, Department of Pathology, Magee-Womens
Hospital of UPMC.)
A
B

BREAST CANCER • 487
FIGURE 41-7. Contrast-enhanced breast MRI
demonstrating diffuse regional enhancement consistent
with extensive carcinoma.
biopsy of abnormal MRI detected lesions is essential to
avoid unnecessary surgery. 26
It is accepted that MRI is more sensitive than mam-
mography for detecting cancer in women with heteroge-
neously and homogeneously dense breasts and may help
to delineate the extent of disease in this patient popula-
tion. MRI may also demonstrate occult foci of multifo-
cal or multicentric disease that could alter the planned
operative procedure. 26 MRI is more sensitive than mam-
mography in screening high-risk patients, particularly
documented BRCA1/2 mutation carriers. 27 MRI has also
proven to be effective for identifi cation of a primary
tumor in patients presenting with axillary lymph node
metastases, and in monitoring response to neoadjuvant
chemotherapy. 28 Breast-conserving therapy consisting of
partial mastectomy followed by adjuvant whole breast
radiation is the preferred approach for the local manage-
ment of early-stage breast cancer. Nonpalpable lesions
may require imaged-guided, preoperative wire localiza-
tion to guide local resection. Intraoperative ultrasound
can effectively be used to locate a nonpalpable mass and
plan the surgical incision and resection and is a patient-
friendly alternative to wire localization. Axillary senti-
nel node dissection is the preferred staging procedure
for patients presenting with a clinically negative axilla.
The sentinel node(s) represents the fi rst node to receive
lymphatic drainage from the breast and can be identifi ed
with the injection of radiolabeled tracer and/or vital blue
dye into the breast prior to the planned procedure. The
patient receives an injection of technetium-99 labeled
sulfur colloid into the breast, usually in the department
of nuclear medicine, prior to surgery. Lymphazurin blue
dye in injected intraoperatively. The dual technique of
radioisotope and blue dye yields the highest sentinel
node localization rates with the fewest false-negative
sentinel nodes. Through a minimal axillary incision, the
sentinel node can be localized with the use of a hand-held
gamma probe and the direct visualization of blue-stained
lymphatics or node(s). The sentinel node accurately
refl ects the status of the axilla with a false-negative rate
of less than 5% in experienced centers. 29 Patients with
a negative sentinel node can be spared complete axil-
lary node dissection with a lower risk of upper extremity
lymphedema. 30 The risk of axillary recurrence following
a negative sentinel node procedure is less than expected,
based on published false-negative rates. 31
Breast cancer staging is based on the American Joint
Committee on Cancer (AJCC) TNM (tumor, node,
metastasis) system. 32 The sixth edition of the AJCC
breast cancer staging manual introduced substantial mod-
ifi cations to incorporate the detailed lymph node infor-
mation obtained from sentinel node sectioning. Isolated
tumor deposits identifi ed with immunohistochemical
stains for cytokeratin can be identifi ed and remain of
uncertain clinical signifi cance. The current staging clas-
sifi cation standardizes the reporting of these fi ndings to
permit prospective evaluation of the impact of isolated
tumor cells on relapse-free and overall survival.
Patients found to have axillary sentinel node metas-
tases are recommended to have a complete levels I and
II axillary lymph node dissection. Approximately 50%
of patients will have no additional metastases identifi ed
in the remaining axillary nodes (non-sentinel nodes) on
completion dissection. Intense efforts have been applied
to identify factors that predict nonsentinel node metas-
tases. In general, the risk of nonsentinel node metastasis
increases with the size of the primary tumor, size of the
metastasis in the sentinel node, and the number of posi-
tive sentinel nodes. A Web-based nomogram is available
to provide an estimate of the probability of nonsenti-
nel node metastasis. 33 The predicted probability of addi-
tional positive nodes can be used to guide discussions
regarding further axillary surgery or alternatives such
as axillary radiation. Attempts to identify a subset of
patients who can omit axillary dissection with the fi nding
of a positive sentinel node have failed to identify a subset
with no risk of additional disease. Adjuvant whole breast
radiation is routinely recommended following partial
mastectomy to decrease the risk of local recurrence. A
total dose of 50 Gy delivered in 25 fractions to the entire
breast often with a local boost to the surgical site is stan-
dard. Although all patients with invasive breast cancer
have lower rates of local recurrence following breast
radiation, the magnitude of benefi t is proportional to

488 • CHAPTER 41
the level of risk. The risk of local recurrence in patients
older than 70 years old with small, histologically favor-
able, node-negative, ER1 tumors may be suffi ciently low
to omit adjuvant radiation. 34 It is important to evaluate
comorbidities and life expectancy in elderly breast can-
cer patients to compare their risk of breast cancer recur-
rence with competing causes of mortality. 35
Accelerated partial breast radiation is an alternative to
whole breast radiation, and is increasingly being utilized.
Partial breast radiation can be delivered using multiple
interstitial catheters, a balloon-based catheter, or with
conformal external beam approaches. 36 The advantages
of partial breast radiation include the ability to target
the radiation dose directly to the primary tumor bed,
which represents the area at highest risk for true local
recurrence as well as the ability to complete treatment
over a 5-day period. Most series of partial breast radia-
tion are single institution phase I/II studies and include
highly selected patients with limited follow-up. 37 – 39 The
long-term local recurrence risk for patients managed fol-
lowing partial breast radiation is unknown and patients
are encouraged to participate in available clinical trials
comparing partial breast radiation to standard external
beam radiation. Total mastectomy remains an alternative
to breast conservation therapy for surgical management
of invasive carcinoma. The liberal use of neoadjuvant or
primary chemotherapy in patients with large or locally
advanced breast cancer has enabled more women to
undergo breast conservation. Patients presenting with
large primary tumors, unfavorable tumor to breast size
ratio, localized skin involvement, or metastatic axillary
adenopathy may potentially undergo breast preserving
surgery following response to neoadjuvant chemother-
apy. Administration of chemotherapy prior to surgery
also provides important information about the response
of the tumor to the agents utilized. Anthracycline-based
chemotherapy is recommended in tumors that overex-
press HER2/neu or simultaneously overexpress topoi-
somerase II. 40 Tumors with p53 mutations generally have
lower response rates. 41 High-grade, ER2 tumors with
high proliferative rates are more likely to have a com-
plete pathologic response than low-grade ER1 lesions.
Although tumor response to chemotherapy is high for
ER2 tumors, disease-free survival is signifi cantly higher
in ER1 disease.
Patients with large tumors that respond poorly to
systemic therapy, infl ammatory carcinomas, and tumors
associated with extensive malignant microcalcifi ca-
tions are best managed with mastectomy and lymph
node staging. When a mastectomy is the recommended
surgical management, there are often still indications
to proceed with chemotherapy initially. Patients with
infl ammatory breast cancer present with skin thicken-
ing, erythema, and edema or peau d’orange skin changes.
This clinical presentation is due to the presence of tumor
in the dermal lymphatic system and/or the result of sig-
nifi cant lymphatic obstruction in the breast from tumor
or axillary lymph node involvement. Infl ammatory can-
cer is viewed as inoperable disease due to the extensive
skin involvement with tumor and these patients are best
managed with primary systemic chemotherapy. The vast
majority of cases will have resolution of the underlying
skin changes although there may be residual microscopic
or macroscopic disease in the breast. Due to the exten-
sive skin involvement at presentation, mastectomy and
axillary node staging is the recommended surgical man-
agement. These patients are advised to forego immediate
breast reconstruction due to the indication for post-
mastectomy radiation to minimize the risk of local or
regional recurrence.
Patients presenting with tumors fi xed to the chest wall
or with fi xed axillary adenopathy are felt to have locally
advanced breast cancer (LABC) and also benefi t from
primary systemic therapy before operative intervention.
The success of breast conservation surgery in this popu-
lation is not established although could be entertained in
patients who experience a complete clinical response to
chemotherapy. Most patients who present with LABC
will ultimately require a mastectomy for defi nitive sur-
gical management. Like infl ammatory carcinoma, the
decision for postmastectomy radiation is based on dis-
ease stage at presentation. For this reason, patients with
LABC who undergo mastectomy are advised to delay
breast reconstruction.
The accepted indications for postmastectomy radia-
tion include pathologic tumor size larger than 5 cm, four
or more pathologically positive lymph nodes, and positive
surgical margins. 42 Relative indications include patients
with multicentric disease with total tumor volume
approaching 5 cm and close surgical margins. In addi-
tion, there is evidence that postmastectomy radiation in
women with one to three positive nodes reduces local-
regional recurrence and improves overall breast cancer
survival. 42 As the indications for postmastectomy radia-
tion expand, it is increasingly diffi cult to advise patients
undergoing mastectomy whether to have an immediate
reconstruction. The long-term cosmetic and functional
outcome for the reconstructed breast following radiation
is generally inferior to the nonradiated reconstruction.
Although autologous tissue fl aps may tolerate radia-
tion therapy better than implant-based reconstructions,
achieving good symmetry and minimizing fi brosis in the
reconstruction cannot be guaranteed. Planning targeted
radiation therapy to the chest wall is complicated by the
presence of a reconstructed breast mound, and higher
doses of radiation may be administered to the underly-
ing lungs or heart. Preoperative consultation with radia-
tion oncology and a thorough evaluation of the axillary
lymph nodes will help guide the decision for immediate
or delayed reconstruction.
There is increasing interest in the use of delayed-
immediate reconstruction techniques. 43 This strategy
refers to the placement of a tissue expander at the time
of mastectomy as a temporizing device in order to offer a

BREAST CANCER • 489
skin-sparing procedure. Once the fi nal pathology results
are available, a determination can be made as to the indi-
cations for postmastectomy radiation. In patients who do
not require radiation, reconstruction can proceed with
tissue expansion and implant placement or autologous
tissue fl ap based on patient preferences. If radiation is
recommended, the tissue expander can be removed, or
left in place expanded throughout treatment. Once radi-
ation is complete, a decision regarding the most suitable
reconstruction can be made.
ADJUVANT THERAPY
The majority of patients with invasive breast cancer are
offered adjuvant systemic treatment to reduce their risk
of relapse. Patients with a 10% or greater risk of systemic
relapse are recommended to receive adjuvant treatment.
Decisions for systemic therapy are based on prognos-
tic and predictive factors including age, lymph node
status, tumor size and grade, hormone receptor status
and, HER2/neu overexpression. The clinical challenge
is to identify the individual patients with the highest
risk of relapse who have the most to benefi t from cyto-
toxic treatment. Based on evidence from randomized
clinical trials, patients with node-positive breast cancer
benefi t from receiving adjuvant chemotherapy, even in
the setting of ER1 disease. Adjuvant hormonal therapy
is recommended for patients with ER1 or PR1 breast
cancer.
Patients with small, node-negative, ER1 breast cancer
represent a subset of patients with an overall low-risk
of systemic failure. However, some ER1 breast cancer
patients will experience systemic relapse and ultimately
die of their disease. Molecular profi ling of the primary
tumor can identify low-, intermediate-, and high-risk
patients for systemic relapse. A multimarker gene assay
has been validated to predict risk of relapse as well as
response to therapy. 44 Gene expression profi ling has dem-
onstrated that differential expression of certain genes is a
more powerful prognostic indicator than traditional fac-
tors such as tumor size and lymph node status. Currently,
this panel is in use for women with node-negative ER1
breast cancer and can provide meaningful information
that may infl uence treatment decisions.
The Early Breast Cancer Trialists’ Collaborative Group
reported in their recent overview analysis that anthracy-
cline-based polychemotherapy results in a 38% reduction
in the risk of death for patients older than age 50 years
and a 20% reduction in the risk of death for 50 to 69 years
olds. 45 These benefi ts of chemotherapy are independent
of the use of endocrine therapy (tamoxifen), estrogen
receptor status, nodal status, or other tumor characteris-
tics. For ER1 patients, the use of tamoxifen for 5 years
reduced the annual breast cancer death rate by 31%,
independent of age, use of chemotherapy, PR status, or
other tumor characteristics. Five years of tamoxifen is
superior to 2 years and the survival benefi t persists after
treatment is discontinued. This overview underscores
the importance of systemic therapy in the multimodality
approach to breast cancer treatment.
For years, tamoxifen was the endocrine therapy of
choice for patients with ER1 invasive breast cancer.
Recently, the aromatase inhibitors, including anastrazole
and letrozole, have been shown to be superior to tamox-
ifen in disease-free survival and in reducing the num-
ber of contralateral breast cancer events. 46 Aromatase
inhibitors block the peripheral conversion of estrogen
precursors to estrogen but do not block ovarian estro-
gen production. They are, therefore, only effective and
recommended for postmenopausal women. Aromatase
inhibitors are associated with fewer adverse events com-
pared with tamoxifen, including fewer endometrial can-
cers, thromboembolic events, vaginal discharge, and hot
fl ashes, although fracture risk is slightly increased.
The era of targeted therapies for breast cancer is rap-
idly emerging and the drug trastuzumab (Herceptin) has
emerged as major advance in the systemic treatment of
breast cancer. Trastuzumab, a humanized mouse mono-
clonal antibody, targets the HER2/neu protein which is
overexpressed in 25% to 30% of breast cancers. Initially
used for the treatment of metastatic breast cancer, recent
studies have confi rmed the effi cacy of this drug in the
adjuvant setting. With short-term follow-up, 1 year of tras-
tuzumab (combined with conventional chemotherapy)
reduces the risk of local, regional, or systemic relapse by
50% in patients with HER2/neu positive breast cancer. 47 , 48
For high-risk HER2/neu–positive breast cancer patients,
the addition of trastuzumab is now a standard option.
CONCLUSION
Care of the breast cancer patient is genuinely multidisci-
plinary and close communication and integration of the
treatment plan across disciplines will maximize outcomes
for the patient. Improvements in screening have contrib-
uted to earlier detection, allowing many patients to have
minimal surgery. There is a growing trend toward targeted
therapies, including partial radiation and more selective
systemic agents. Further advances in treatment will rely
on an improved understanding of the biology of individual
tumors and the further development of tailored agents
directed at unique targets.

490 • CHAPTER 41
REFERENCES
1. Ries LAG, Harkins D, Krapcho M, et al., eds. SEER Cancer
Statistics Review, 1975–2003 . Bethesda, MD: National Can-
cer Institute. .
2. Chlebowski RT, Chen Z, Anderson GL, et al. Ethnicity and
breast cancer: factors infl uencing differences in incidence
and outcome. J Natl Cancer Inst . 2005;97(6):439–448.
3. Chlebowski RT, Hendrix SL, Langer RD, et al. Infl uence
of estrogen plus progestin on breast cancer and mammog-
raphy in healthy postmenopausal women: the Women’s
Health Initiative Randomized Trial. JAMA . 2003;289(24):
3243–3253.
4. Suzuki R, Rylander-Rudqvist T, Ye W, et al. Body weight
and postmenopausal breast cancer risk defi ned by estrogen
and progesterone receptor status among Swedish women:
A prospective cohort study. Int J Cancer . 2006;119(7):
1683–1689.
5. Cho E, Spiegelman D, Hunter DJ, et al. Premenopaus-
al fat intake and risk of breast cancer. J Natl Cancer Inst .
2003;95(14):1079–1085.
6. Suzuki R, Ye W, Rylander-Rudqvist T, et al. Alcohol and
postmenopausal breast cancer risk defi ned by estrogen and
progesterone receptor status: a prospective cohort study.
J Natl Cancer Inst . 2005;97(21):1601–1608.
7. Metcalfe KA, Narod SA. Breast Cancer risk perception
among women who have undergone prophylactic bilateral
mastectomy. J Natl Cancer Inst . 2002;94(20):1564–1569.
8. Kramer JL, Velazquez IA, Chen BE, et al. Prophylactic oo-
phorectomy reduces breast cancer penetrance during pro-
spective, long-term follow-up of BRCA1 mutation carriers.
J Clin Oncol . 2005;23(34):8629–8635.
9. Rebbeck TR, Friebel T, Lynch HT, et al. Bilateral prophylac-
tic mastectomy reduces breast cancer risk in BRCA1 and
BRCA2 mutation carriers: The PROSE Study Group. J Clin
Oncol . 2004;22(6):1055–1062.
10. Rebbeck TR, Lynch HT, Neuhausen SL, et al. Prophylactic
oophorectomy in carriers of BRCA1 or BRCA2 mutations.
N Engl J Med. 2002;346(21):1616–1622.
11. Domchek SM, Eisen A, Calzone K, et al. Application of
breast cancer risk prediction models in clinical practice.
J Clin Oncol . 2003;21(4):593–601.
12. Silverstein MJ, ed. Ductal Carcinoma In Situ of the Breast .
2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2002:
303–321.
13. MacDonald HR, Silverstein MJ, Mabry H, et al. Local con-
trol in ductal carcinoma in situ treated by excision alone:
incremental benefi t of larger margins. Am J Surg . 2005;
190(4):521–525.
14. Fisher B, Costantino J, Redmond C, et al. Lumpectomy
compared with lumpectomy and radiation therapy for
the treatment of intraductal breast cancer. N Engl J Med .
1993;328(22):1581–1586.
15. Boland GP, Chan KC, Knox WF, et al. Value of the Van
Nuys Prognostic Index in prediction of recurrence of ductal
carcinoma in situ after breast-conserving surgery. Br J Surg .
2003;90(4):426–432.
16. Wong JS, Kaelin CM, Troyan SL, et al. Prospective study
of wide excision alone for ductal carcinoma in situ of the
breast. J Clin Oncol. 2006;24(7):1031–1036.
17. Singletary SE, Robb GL. Oncologic safety of skin-sparing
mastectomy. Ann Surg Oncol . 2003;10(2):95–97.
18. Simmons RM, Hollenbeck ST, Latrenta GS. Two-year
follow-up of areola-sparing mastectomy with immediate
reconstruction. Am J Surg . 2004;188(4):403–406.
19. Petit JY, Veronesi U, Orecchia R, et al. Nipple-sparing mas-
tectomy in association with intra operative radiotherapy
(ELIOT): a new type of mastectomy for breast cancer treat-
ment. Breast Cancer Res Treat . 2006;96(1):47–51.
20. Anderson BO, Masetti R, Silverstein MJ. Oncoplastic
approaches to partial mastectomy: an overview of volume-
displacement techniques. Lancet Oncol . 2005;6(3):145–157.
21. Fisher B, Dignam J, Wolmark N, et al. Tamoxifen in treat-
ment of intraductal breast cancer: National Surgical Adju-
vant Breast and Bowel Project B-24 randomised controlled
trial. Lancet . 1999;353(9169):1993–2000.
22. Arpino G, Allred DC, Mohsin SK, et al. Lobular neopla-
sia on core-needle biopsy–clinical signifi cance. Cancer .
2004;101(2):242–250.
23. Bratthauer GL, Tavassoli FA. Lobular intraepithelial neo-
plasia: previously unexplored aspects assessed in 775 cases
and their clinical implications. Virchows Arch. 2002;440(2):
134–138.
24. Hwang ES, Nyante SJ, Chen YY, et al. Clonality of lobular
carcinoma in situ and synchronous invasive lobular carcino-
ma. Cancer . 2004;100:2562–2572.
25. Reis-Filho J, Simpson P, Jones C, et al. Pleomorphic lobular
carcinoma of the breast: role of comprehensive molecular
pathology in characterization of an entity. J Pathol .
2005;207(1):1–13.
26. Bedrosian I, Mick R, Orel SG, et al. Changes in the surgi-
cal management of patients with breast carcinoma based
on preoperative magnetic resonance imaging. Cancer .
2003;98(3):468–473.
27. Kuhl CK, Schrading S, Leutner CC, et al. Mammography,
breast ultrasound, and magnetic resonance imaging for sur-
veillance of women at high familial risk for breast cancer.
J Clin Oncol . 2005;23(33):8469–8476.
28. Yeh E, Slanetz P, Kopans DB, et al. Prospective comparison
of mammography, sonography, and MRI in patients under-
going neoadjuvant chemotherapy for palpable breast cancer.
AJR Am J Roentgenol . 2005;184(3):868–877.
29. Lyman GH, Giuliano AE, Somerfi eld MR, et al. American
Society of Clinical Oncology guideline recommendations
for sentinel lymph node biopsy in early-stage breast can-
cer. J Clin Oncol. 2005;23(30):7703–7720.
30. Mansel RE, Fallowfi eld L, Kissin M, et al. Randomized mul-
ticenter trial of sentinel node biopsy versus standard axillary
treatment in operable breast cancer: the ALMANAC Trial.
J Natl Cancer Inst . 2006;98(9):599–609.
31. Veronesi U, Galimberti V, Mariani L, et al. Sentinel node
biopsy in breast cancer: early results in 953 patients with

BREAST CANCER • 491
negative sentinel node biopsy and no axillary dissection. Eur
J Cancer . 2005;41(2):231–237.
32. National Cancer Institute. Stage information for breast can-
cer. Breast Cancer Treatment (PDQ ® ) .
gov/cancertopics/pdq/treatment/breast/HealthProfessional/
page3 .
33. Van Zee KJ, Manasseh DM, Bevilacqua JL, et al. A nomo-
gram for predicting the likelihood of additional nodal metas-
tases in breast cancer patients with a positive sentinel node
biopsy. Ann Surg Oncol . 2003;10(10):1140–1151.
34. Hughes KS, Schnaper LA, Berry D, et al. Lumpectomy plus
tamoxifen with or without irradiation in women 70 years
of age or older with early breast cancer. N Engl J Med .
2004;351(10):971–977.
35. Smith BD, Gross CP, Smith GL, et al. Effectiveness of radia-
tion therapy for older women with early breast cancer. J Natl
Cancer Inst . 2006;98(10):681–690.
36. Vicini F, Winter K, Straube W, Wong J, et al. A phase I/II trial
to evaluate three-dimensional conformal radiation therapy
confi ned to the region of the lumpectomy cavity for Stage
I/II breast carcinoma: initial report of feasibility and repro-
ducibility of Radiation Therapy Oncology Group (RTOG)
Study 0319. Int J Radiat Oncol Biol Phys . 2005;63(5):
1531–1537.
37. Jeruss JS, Vicini FA, Beitsch PD, et al. Initial outcomes for
patients treated on the American Society of Breast Surgeons
MammoSite clinical trial for ductal carcinoma-in-situ of the
breast. Ann Surg Oncol . 2006;13(7):967–976.
38. Zannis V, Beitsch P, Vicini F, et al. Descriptions and out-
comes of insertion techniques of a breast brachytherapy
balloon catheter in 1403 patients enrolled in the American
Society of Breast Surgeons MammoSite breast brachythera-
py registry trial. Am J Surg . 2005;190(4):530–538.
39. Kuske RR, Winter K, Arthur DW, et al. Phase II trial of
brachytherapy alone after lumpectomy for select breast can-
cer: toxicity analysis of RTOG 95–17. Int J Radiat Oncol Biol
Phys . 2006;65(1):45–51.
40. Scandinavian Breast Group Trial 9401, Tanner M, Isola J,
Wiklund T, et al. Topoisomerase IIalpha gene amplifi cation
predicts favorable treatment response to tailored and dose-
escalated anthracycline-based adjuvant chemotherapy in
HER-2/neu-amplifi ed breast cancer: Scandinavian Breast
Group Trial 9401. J Clin Oncol . 2006;24(16):2428–2436.
41. Xu Y, Yao L, Ouyang T, et al. p53 Codon 72 polymorphism
predicts the pathologic response to neoadjuvant chemo-
therapy in patients with breast cancer. Clin Cancer Res .
2005;11(20):7328–7333.
42. Nielsen HM, Overgaard M, Grau C, et al. Loco-regional
recurrence after mastectomy in high-risk breast cancer–
risk and prognosis. An analysis of patients from the DBCG
82 b&c randomization trials. Radiother Oncol . 2006;79(2):
147–155.
43. Kronowitz SJ, Hunt KK, Kuerer HM, et al. Title delayed-
immediate breast reconstruction. Plast Reconstr Surg .
2004;113(6):1617–1628.
44. Paik S, Tang G, Shak S, et al. Gene expression and benefi t
of chemotherapy in women with node-negative, estrogen
receptor-positive breast cancer. J Clin Oncol . 2006;24(23):
3726–3734.
45. Early
Breast
Cancer Trialists’
Collaborative
Group
(EBCTCG). Effects of chemotherapy and hormonal therapy
for early breast cancer on recurrence and 15-year survival:
an overview of the randomised trials. Lancet . 2005;365:
1687–1717.
46. Baum M, Buzdar A, Cuzick J, et al. Anastrozole alone or
in combination with tamoxifen versus tamoxifen alone for
adjuvant treatment of postmenopausal women with early-
stage breast cancer: results of the ATAC (Arimidex, Tamox-
ifen Alone or in Combination) trial effi cacy and safety up-
date analyses. Cancer . 2003;98(9):1802–1810.
47. Romond EH, Perez EA, Bryant J, et al. Trastuzumab plus
adjuvant chemotherapy for operable HER2-positive breast
cancer. N Engl J Med . 2005;353(16):1673–1684.
48. Piccart-Gebhart MJ, Procter M, Leyland-Jones B, et al. Tras-
tuzumab after adjuvant chemotherapy in HER2-positive
breast cancer. N Engl J Med . 2005;353(16):1659–1672.

This page intentionally left blank

42
Alloplastic Breast Reconstruction
Louis P. Bucky, MD, FACS / Alexander J. Gougoutas, MD
INTRODUCTION
With the exception of nonmelanoma skin cancers, breast
cancer is the most common cancer seen in women in
the United States, with an incidence of 1 in 8 (13%). In
this same population, it is succeeded only by lung cancer
as the second most common cause of cancer deaths. In
2010, there were more than 200,000 new cases of breast
cancer in the United States alone. 1 Breast reconstruction
will play an integral role in the increasing number of
these patients who will require mastectomy for defi ni-
tive treatment. This demand, in combination with the
well-described psychosocial benefi ts of reconstruction,
has led to the development of numerous reconstructive
techniques, all in pursuit of a reproducible and aestheti-
cally pleasing result.
To date, breast reconstruction is accomplished with
either rotational or free autologous tissue transfer, pros-
thetic tissue expanders and implants, or a combination
of both. Despite the diversity of available reconstruc-
tive techniques, it is evident from a review of the 2010
American Society of Plastic Surgeons statistics that
alloplastic expander/implant reconstruction is by far
the most common technique employed, accounting for
nearly 70% of all reconstructions. 2
Alloplastic reconstruction accomplishes the recre-
ation of the absent breast mound and can be performed
either in the immediate postmastectomy setting or in
a delayed fashion. Immediate reconstructions typically
are accomplished in one or two stages. In the case of
single-stage, immediate reconstruction, a permanent sili-
cone or saline implant is placed following completion
of the mastectomy, frequently with the addition on an
acellular dermal matrix (ADM). In two-stage, immedi-
ate reconstruction, a temporary tissue expander is placed
at the time of mastectomy. A second-stage procedure is
typically performed at least 3 months after mastectomy,
at which time the tissue expander is replaced with a
permanent silicone or saline implant. Delayed recon-
structions are usually performed at least 6 to 8 months
postmastectomy, almost invariably in two stages. Though
immediate and delayed reconstructions each have their
own advantages and disadvantages, two-stage, immediate
reconstruction with tissue expander/implant exchange is
by far the most common reconstruction performed and
will be the focus of the discussion to follow.
Alloplastic reconstruction confers several unique
advantages over autologous reconstruction. These include
less scaring; the use of local, texture, and color-matched
skin; avoidance of donor site morbidity; as well as a
shorter operative time, hospital stay, and overall recovery. 3
Furthermore, advances in expander/implant technology
as well as refi nements in mastectomy and reconstructive
techniques have increased the predictability, reproducibil-
ity, and aesthetics of implant reconstruction.
Textured anatomic expanders offer several advantages
over their original, smooth, round design. The poten-
tial advantages of these devices include a reduction in
both capsular contracture and lateral subluxation of the
expander. Shaped or anatomic devices can preferentially
expand the breast’s lower pole, giving it a more natu-
ral appearance. Use of the nipple-sparing mastectomy
not only may eliminate the need for future nipple-are-
ola reconstruction but also preserves the breast’s skin
envelope in its entirety, obviating the need for any skin
recruitment. The selective addition of an ADM to the
reconstruction can create greater defi nition of the infra-
mammary fold, conceal implant wrinkling or folding,
reduce muscle dissection, and potentially decrease the
rate of capsular contracture—all of which may provide a
better aesthetic appearance. Finally, the selective transfer
of autologous fat may serve to blunt contour abnormali-
ties and improve the periprosthetic soft tissue envelope.
c h a p t e r

494 • CHAPTER 42
All the aforementioned advances have greatly improved
the aesthetics of implant-based breast reconstruction.
This is particularly true in patients undergoing bilateral
reconstructions where achieving symmetry, often the
most formidable challenge of unilateral reconstruction,
is simplifi ed. This point warrants some discussion as
the incidence of contralateral prophylactic mastectomy
(CPM) and bilateral prophylactic mastectomy (BPM) has
increased dramatically over the past decade. 4 , 5
The increased incidence of CPM and BPM likely stems
from a multitude of factors. The relatively recent discov-
ery of the BRCA1 and BRCA2 genes has allowed physi-
cians to identify a subpopulation of patients at high risk
for developing breast cancer. These high-risk patients
may derive a signifi cant psychological benefi t from elec-
tive BPM. Similarly, patients with unilateral disease may
elect to undergo CPM to reduce the anxiety associated
with the possibility of developing contralateral breast
cancer in the future. Finally, there is an abundance of
evidence demonstrating improved outcomes, namely a
decreased risk of contralateral cancer development, in
high-risk patients with unilateral disease who elect to
undergo CPM. 6 – 9 This same decreased risk has also been
demonstrated in high-risk, disease-free patients who
elect to undergo BPM. 10 , 11
The benefi ts of prophylactic mastectomy have led to
a growing population of patients seeking bilateral mas-
tectomies, many of whom are ideally suited for implant-
based reconstructions. Furthermore, many of these
patients, including, but not limited to, those undergo-
ing prophylactic mastectomy or with small, peripherally
located tumors, are candidates for nipple-sparing mas-
tectomy. This technique confers many potential benefi ts
to the ultimate reconstruction, including preservation of
the nipple-areola complex and limited skin resection. As
a result, many nipple-sparing mastectomies and subse-
quent reconstructions can be performed in one stage.
PATIENT EVALUATION
AND SELECTION
Patient evaluation and selection begins during the initial
consultation, a forum in which patients can voice their
expectations and be informed of the goals of reconstruc-
tion. These goals are: (1) to give the patient an aestheti-
cally pleasing appearance when either fully clothed or
when wearing a revealing brassiere or bathing suite; and
(2) to allow the patient to get dressed normally every
day, free of the potential psychological burden that
either the absence of a breast or usage of a cumber-
some, unnatural prosthesis may impart. Selection of
appropriate candidates for alloplastic reconstruction is
based largely on the likelihood of accomplishing these
two fundamental goals.
Multiple factors impact the ultimate aesthetic out-
come of breast reconstruction, all of which must be
taken into consideration. The key to appropriate patient
evaluation and selection is understanding those factors
that are within the surgeon’s control and those that
are not. Factors generally beyond the surgeon’s control
include body habitus, previous radiation therapy, adju-
vant chemotherapy, future radiation therapy, previous
breast surgeries and scar patterns, unilateral versus bilat-
eral reconstruction, past medical history, general healing
capabilities, and a patient’s reconstructive preferences.
Factors generally within the surgeon’s control include
selection of mastectomy and reconstructive techniques
employed and timing of the reconstruction.
Physical evaluation of potential candidates for allo-
plastic reconstruction begins and ends with the breasts
themselves. In cosmetic breast augmentation, the base
width of the breast is the keystone for implant selection.
Alloplastic reconstruction, however, must take into con-
sideration not only the base width of the breast but also
chest wall dimensions. This stems from the fact that the
base of the reconstructed breast parenchyma, namely the
expander/implant, will be strictly limited to the muscular
confi nes of the chest wall.
Patients ideally suited for implant-based reconstruc-
tions are those with symmetric, small to moderate-sized
breasts who seek bilateral reconstruction. A unique
group of patients are those seeking reconstructions who
have undergone prior breast augmentation. In the case of
patients with prior subpectoral breast implants, alloplas-
tic reconstruction is typically far easier as the subpectoral
pocket has been previously dissected and expanded. The
opposite is true for those patients who have undergone
prior subglandular augmentation. In these cases, subpec-
toral dissection can be more challenging, as the muscle
has been compressed against the chest wall by the over-
lying capsule.
While there are no absolute contraindications to allo-
plastic breast reconstruction, successful outcomes are
predicated on appropriate patient selection. It should
be stressed that not all patients are candidates for
implant/expander reconstructions. The most fundamen-
tal require ment for successful prosthetic reconstruction
is adequate soft tissue coverage of the implant/expander.
In the case of infl ammatory breast cancers, resection of
large volumes of skin at the time of mastectomy are often
required in addition to frequent adjuvant radiation. This
results in a paucity of skin available for prosthesis cover-
age and thus expander/implant reconstruction alone in
these cases is ill advised.
Historically speaking, prior radiation or the need for
adjuvant radiation therapy was considered a contraindi-
cation to alloplastic breast reconstruction. This stemmed
from the higher incidence of both postoperative com-
plications and suboptimal aesthetic outcomes in irradi-
ated patients. Recent data, however, suggests that patient
satisfaction and aesthetic results in those undergoing
expander/implant reconstruction and adjuvant radio-
therapy do not differ signifi cantly from those who do
not require radiation. 12 – 14 While the debate is still ongo-
ing, many believe that adjuvant radiotherapy is at most a
relative contraindication to alloplastic reconstruction.

ALLOPLASTIC BREAST RECONSTRUCTION • 495
A
B
FIGURE 42-1. Preoperative markings. The patient’s midline is marked from sternal
notch to xiphoid (A) and all anatomic boundaries of the breast are marked with particular
attention to the inframammary crease (B).
PATIENT PREPARATION
Tissue expander breast reconstruction is performed under
general anesthesia, and in bilateral cases, will typically
require 1 to 3 hours to complete. If performed in the
immediate setting, this is in addition to time required by
the oncologic surgery team and thus a 4 to 5 hours total
operative time should be anticipated. Patient-specifi c pre-
operative evaluation should be critically reviewed with
both the oncologic surgeon and anesthesiologist prior to
the day surgery.
Marking of the patient is performed in the preopera-
tive holding area. In the cases of immediate reconstruc-
tion, mastectomy technique and incisions are coordinated
with the oncologic surgery team. The patient is marked
while standing up with arms at their sides. After marking
the midline from sternal notch to xiphoid, all anatomic
boundaries of the breast are marked with particular atten-
tion to the inframammary crease ( Figure 42-1 ). Preexisting
differences in breast morphology and position should be
carefully noted.
The availability of all necessary expander/implants
should be confi rmed prior to surgery. If use of an ADM is
anticipated, ordering of the product should be done well
in advance, as many institutions do not have stock supplies.
In addition to a lighted retractor and light source, a basic
plastics instrument tray is typically all that is required.
Patients are positioned supine. In the case of immedi-
ate, single-stage reconstruction or second-stage expander/
implant exchanges, arms should be positioned at 90 degrees
to allow upright positioning of the patient to evaluate
symmetry. In the cases of fi rst-stage expander placement,
arms may be positioned at 90 degrees in order to facilitate
lymph node access during dissection.
TECHNIQUE
As immediate, two-stage expander/implant reconstruc-
tions are by far the most common type of reconstruction
performed both at our institution and in the commu-
nity at large, we will focus on this technique. Though
there are many variations on creation of the submuscular
pocket, as a rule, we opt for total muscle coverage using
the pectoralis major and serratus anterior muscles. We
take exception to this rule in those patients who have
a high riding pectoralis, that is, where the inferior most
insertion of the pectoralis on the chest wall is superior
to the inframammary fold. In these cases, we will fre-
quently employ the use of an ADM sling.
At the completion of the mastectomy, the junction of
the pectoralis major and serratus anterior muscles is well
exposed. This is the anatomic starting point for creation of
the submuscular pocket. Elevation of the pectoralis major
begins laterally at its junction with the serratus anterior
( Figure 42-2 ). Using electrocautery, dissection is carried
down to the chest wall between these two muscles, creat-
ing a window just large enough to facilitate exposure and
accommodate the tissue expander (typically the inferior
third to half of the pectoralis major is separated from
the serratus anterior). Elevation of the pectoralis off of
FIGURE 42-2. Elevation of the pectoralis major.
Elevation of the pectoralis major begins laterally at the
junction with the serratus anterior.

496 • CHAPTER 42
the chest wall proceeds from lateral to medial with aid
of a lighted retractor for visualization ( Figure 42-3 ). All
intercostal perforating vessels are carefully identifi ed and
coagulated as the dissection proceeds. Medial elevation
of the pectoralis is carried to the midline with minimal
elevation off the sternum. Inferiorly, elevation of the pec-
toralis proceeds to the level of the inframammary crease.
In those patients with an inframammary crease that
sits below the inferior most insertion of the pectoralis,
extended subcutaneous dissection over the rectus fascia
is required. Once elevation of the pectoralis is complete,
attention is turned to elevating the serratus anterior.
Elevation of the serratus begins at the window cre-
ated between the lateral pectoralis and serratus muscle
itself. Dissection is started immediately superfi cial to an
underlying rib to prevent inadvertent penetration of the
pleural space. Once again, dissection is carried straight
down to chest wall. Elevation of the serratus then pro-
ceeds medial to lateral. Care must be taken to follow the
curvature of the chest wall as the subserratus plane is
often poorly defi ned and dissection in the wrong plane
may lead to penetration of the thorax. Just enough ser-
ratus is elevated to provide coverage of the portion of
the expander extending beyond the lateral border of the
pectoralis ( Figure 42-4 ).
After air is evacuated from the expander, it is placed
in the submuscular pocket with the valve facing ante-
riorly ( Figure 42-5 ). The edges of the pectoralis and
serratus anterior muscles are then approximated with
absorbable suture to provide complete muscular cover-
age of the expander ( Figure 42-6 ). It is our practice to
select an expander that is smaller than the base width
of the breast if it extends beyond the chest wall—a fre-
quently encountered scenario in women with larger
breasts. This practice generally errs on the creation of
a constricted soft tissue pocket that may require lateral
capsulectomy at the time of implant exchange. This situ-
ation is, however, aesthetically preferable to an expanded
FIGURE 42-3. Continued elevation of the pectoralis
major. Elevation of the pectoralis major proceeds from lateral
to medial with the aid of a lighted retractor (not pictured).
FIGURE 42-4. Elevation of the serratus anterior. Just
enough serratus is elevated to provide lateral muscular
coverage of the tissue expander.
FIGURE 42-5. Placement of the tissue expander.
The tissue expander is placed beneath the pectoralis major
muscle with the valve facing anteriorly (pictured at the tip of
the surgeon’s forceps).
FIGURE 42-6. Approximation of the serratus anterior
and pectoralis major. The pectoralis and serratus muscles are
approximated with a running, absorbable suture to provide
complete muscular coverage of the expander.

ALLOPLASTIC BREAST RECONSTRUCTION • 497
soft tissue pocket requiring capsuloraphy at the time of
implant exchange, the ultimate results of which are far
less predictable.
In the cases of a high-riding pectoralis muscle, we
employ the use of an ADM. In these cases, elevation of
the pectoralis and serratus muscles proceeds as previously
described; however, the inferior border of the pectoralis
is released from the chest wall. The ADM, once reconsti-
tuted in sterile saline, is sewn between the inferior border
of the window shaded pectoralis and the projection of the
inframammary crease along the chest wall. We frequently
will also employ the use of an ADM as an overlay to rein-
force an attenuated pectoralis muscle or as lateral sling to
limit lateral serratus dissection.
Depending on the appearance and redundancy of
the mastectomy skin fl aps the expander is then infl ated
with a variable volume of sterile saline. This is accom-
plished by fi rst locating the fi ll valve with the locating
magnet provided with the expander ( Figure 42-7 ). Once
the valve is accessed, 50 to 200 cc of sterile saline are
injected with a sterile fi lling system composed of a 60-cc
syringe attached via a T-connector to a reservoir of sterile
saline and small-bore needle ( Figure 42-8 ). Partial fi lling
of the expander at the time of its placement serves to
expand the overlying musculature while preventing skin
contracture. Initial overexpansion, however, may cause
undo tension on skin fl aps already compromised by the
mastectomy and thus initial fi ll volumes should be tai-
lored to each patient.
Following placement of a 10-Fr round JP, the mastec-
tomy skin fl aps are closed with interrupted, absorbable,
deep dermal sutures followed by a running subcuticular
suture ( Figure 42-9 ). Excessive tension on the mastec-
tomy skin fl aps following closure should prompt removal
of saline from the expander, as this may increase the likeli-
hood of skin fl ap necrosis.
Expansion is usually begun 2 to 3 weeks postopera-
tively when the skin fl aps have healed and the patient is
comfortable. Roughly 60 cc of sterile saline is injected into
FIGURE 42-7. Locating the fi ll port. The fi ll port is
localized with a surface magnet.
FIGURE 42-8. Filling of the expander. The tissue
expander is fi lled using a 60-cc syringe connected via a two-
way valve (not pictured) to a small-bore needle inserted into
the expander fi ll port.
FIGURE 42-9. Skin closure and drain placement.
the integrated valve of the expander at biweekly intervals.
This interval may be increased depending on patient toler-
ance. Blanching of the skin or excessive pain at the time of
expansion indicates overfi lling and should prompt removal
of volume to prevent potential skin necrosis. The second
stage of the reconstruction should occur approximately
4 to 6 weeks from the time of the fi nal expansion or com-
pletion of adjuvant chemotherapy.
At the second stage of reconstruction, the skin and sub-
cutaneous tissue is elevated off the underlying pectoralis
muscle. The pectoralis is then incised along the direction
of its fi bers and the expander is removed. Necessary dis-
section and capsulotomies are completed to facilitate cor-
rect positioning of the permanent implant. Selection of
the permanent implant is based on the base width of the
expander and the appearance of the chest wall with the
expander in place. Typically high profi le, permanent gel
implants with base widths similar to those of the expander

498 • CHAPTER 42
are utilized. Once the permanent implant is placed, the
overlying musculature is approximated with interrupted,
absorbable sutures followed once again by a two-layered
closure of the skin fl aps. The patient is then positioned
upright to evaluate symmetry.
Achieving symmetry, particularly in patients undergo-
ing unilateral breast reconstruction, remains a formidable
challenge and frequently requires a contralateral balanc-
ing procedure. In those patients with large, ptotic breasts
this may include a reduction, mastopexy, or mastopexy
with an implant. In those patients with smaller breasts,
a contralateral augmentation is often required. We typi-
cally perform any required balancing procedure at the
second stage of reconstruction. This practice avoids any
potential contralateral complications at the time of mas-
tectomy and expander placement. Additionally, delay
of any necessary balancing procedure until the second
stage of reconstruction assures healthy mastectomy
skin fl aps and, most importantly, allows settling of the
reconstructed breast, thus conferring the best chance of
achieving acceptable symmetry. Even with this proto-
col, however, patients who require a contralateral bal-
ancing procedure rarely achieve the symmetry of those
who undergo bilateral reconstruction, where long-term
symmetry is typically far easier to achieve regardless of
native breast size and shape.
The use of autologous fat grafting with implant recon-
struction has signifi cant potential benefi ts. These include
blunting of any intrinsic irregularities, such as rippling,
tapering of the interface between the implant, and the
patient’s chest wall (the so-called “step-off deformity”),
and improved periprosthetic soft tissue coverage. ADMs
can similarly be utilized in selective cases to help improve
the soft tissue envelope surrounding an implant.
COMPLICATIONS
As with any surgical procedure, alloplastic breast recon-
struction is not without its own set of potential compli-
cations, some of which may result in signifi cant patient
morbidity. A recent review found a 15.2% postoperative
complication rate in all patients undergoing expander/
implant reconstruction. 15 These complications include,
but are not limited to, mastectomy skin fl ap necrosis,
seroma/hematoma, capsular contracture, implant infec-
tion, migration, exposure, and defl ation.
Several patient risk factors have been identifi ed which
increase the likelihood of developing one or more post-
operative complications, and thus appropriate candi-
date selection for alloplastic reconstruction requires a
detailed knowledge of a potential patient’s medical and
social history. Both smoking and diabetes have repeatedly
been demonstrated to be independent risk factors for
postoperative complications most notably mastectomy
skin fl ap necrosis and delayed wound healing. Though
the data is less clear, other patient factors, including obe-
sity, age older than 65 years, hypertension, laterality of
reconstruction (unilateral versus bilateral), and adjuvant
chemotherapy may also independently increase the like-
lihood of developing postoperative complications.
With reported rates as high as 24%, 16 perhaps no com-
plication has been the source of more study in alloplastic
breast reconstruction than infection. Infection may be lim-
ited to superfi cial skin and subcutaneous tissues or may
extend deeper to involve the mastectomy pocket muscu-
lature and underlying prosthesis. Infection manifests as a
spectrum of signs and symptoms ranging from asymptom-
atic peri-incisional erythema to frank sepsis with hemo-
dynamic compromise. Regardless of how it manifests, an
infected prosthesis may, if left untreated, have devastating
effects on both the ultimate aesthetic result of the recon-
struction and the patient’s general health and therefore
requires urgent attention.
Limited peri-incisional cellulitis without systemic
symptoms may be managed initially with oral antibiotics.
Failure to respond should prompt hospital admission for
intravenous antibiotics and infectious disease consultation.
Radiographic imaging with either ultrasound or CT may
help identify periprosthetic collections requiring drain-
age. Persistent local and or systemic signs/symptoms of
infection despite intravenous antibiotics or periprosthetic
fl uid collections suggest an infected prosthesis.
Traditionally speaking, a presumed expander/implant
infection mandated removal of the prosthesis followed
by a minimum healing period of 6 months prior to any
attempt at implant replacement. The last decade, however,
has seen an increasing trend toward attempted implant
salvage rather than explantation. Salvage procedures are
surgeon specifi c and entail implant removal, copious irri-
gation, varying degrees and methods of capsulectomy, and
reinsertion of either the original or new implant.
If successful, salvage procedures may spare the patient
additional future surgeries as well as the psychologi-
cal burden of being without a breast during the healing
phase. Not all patients are, however, candidates for salvage
and such procedures should generally be avoided in those
with frank exposure, advanced local infections or signs/
symptoms of systemic infection.
Mastectomy skin fl ap necrosis is another relatively
common complication of alloplastic breast reconstruc-
tion with reported rates as high as 20%. 17 Flap necrosis,
depending on area and thickness, may have profound
implications for the ultimate aesthetic outcome of the
reconstruction as it results in a loss of soft tissue domain.
Furthermore, a breach in the skin’s immunoprotective
barrier places the underlying prosthesis at risk for expo-
sure and subsequent infection, particularly in cases where
the prosthesis has not been placed completely submuscu-
larly. Avoiding both over aggressive thinning of the skin
fl aps and excessive tension on skin closure can decrease
the likelihood of skin fl ap necrosis. While new technolo-
gies are being developed to help determine skin fl ap
viability and guide skin resection, fl ap necrosis remains
a source of signifi cant morbidity in expander/implant

ALLOPLASTIC BREAST RECONSTRUCTION • 499
reconstructions. In light of this fact, management of skin
fl ap necrosis continues to be the source of much study.
Recent reports suggest that in the absence of infection,
skin fl ap necrosis with eschar formation need not neces-
sarily hinder the expansion process. Eschar excision can be
performed 4 weeks post operatively at which time volume
is removed from the expander to facilitate a tension-free
closure. Once fully healed expansion is resumed, typically
6 to 8 weeks postoperatively. 17
Capsular contracture is an additional source of poten-
tial morbidity in patients undergoing implant-based
reconstruction. The etiology and biology of capsular con-
tracture are poorly understood and treatment options are
limited. While grade 1 or 2 capsular contracture can often
be managed nonoperatively, symptomatic, grade 4 con-
tracture almost universally requires extensive capsulec-
tomies or complete capsulotomy in addition to implant
exchange. The incidence of capsular contracture in non-
radiated patients who have undergone expander/implant
reconstruction is estimated at 15% to 20%. 12 This number
increases dramatically in patients who require postopera-
tive radiation therapy.
It is well established that radiation therapy increases
the likelihood of postoperative complications in those
who undergo expander/implant breast reconstruction.
Depending on the study, complications including pain,
capsular contracture, implant exposure, infection, migra-
tion, and failure are seen in between 17% to 80% of irradi-
ated patients. 3 It is for this reason that radiation therapy
has, historically speaking, been considered a contraindica-
tion to alloplastic reconstruction. As previously mentioned
however, an increased complication rate in irradiated
patients does not necessarily translate to less patient sat-
isfaction when compared with nonradiated patients.
Therefore, alloplastic reconstruction in patients requiring
radiation therapy may, in select cases, be acceptable.
As the use of radiation therapy in breast cancer patients
is increasing, 18 so too is the number of irradiated patients
seeking alloplastic reconstruction. The decision to offer
expander/implant reconstruction to those patients who
will require radiation should not be taken lightly, as these
cases are among the most challenging a reconstructive
surgeon will encounter. Expander selection, timing of and
incision utilized for expander exchange, as well as selec-
tion of the permanent prosthesis may need to be modifi ed
in this unique population. Patients should be made aware
during the initial consultation that failure of alloplas-
tic reconstruction may require the pursuit of autologous
alternatives.
OUTCOMES
Two-stage expander/implant reconstruction remains the
most popular method of postmastectomy breast recon-
struction and, in the hands of experienced surgeons, can
yield consistently pleasing aesthetic results with high over-
all patient satisfaction. Successful reconstruction hinges
not only on meticulous surgical planning, technique, and
proper device selection but also on appropriate candidate
selection and patient education. Patients need to under-
stand the realistic alternatives to and potential conse-
quences of alloplastic reconstruction. Additionally, they
need to understand that expander/implant reconstruc-
tion represents a long-term commitment, often requiring
multiple stages and many months to complete. It should
also be stressed that implants may fail and require replace-
ment, though typically not before 10 to 15 years following
placement.
Understanding a prospective patient’s expectations is
crucial to a reconstructive success as the defi nition of such
may differ between surgeon and patient. For example, a
multiple-stage reconstruction requiring numerous revi-
sions to achieve ideal symmetry, while a success in the eyes
of the surgeon, may be less of a success in the eyes of a
patient willing to sacrifi ce a degree of symmetry for less
operations and an easier overall convalescence.
A recent review of 410 expander/implant reconstruc-
tions over a 12-year period demonstrated that 95% of
patients were satisfi ed with the aesthetics of their recon-
struction. 12 This same review demonstrated that an aesthet-
ically pleasing result can be achieved in the vast majority
of patients requiring postoperative radiation, despite an
overall high complication rate in this subgroup. While
alloplastic reconstruction traditionally yields the best aes-
thetic results in small-breasted patients with minimal pto-
sis, satisfying outcomes can also be achieved in heavier-set
patients with larger, ptotic breasts. 12 And while autologous
reconstruction may arguably yield better overall aesthet-
ics when compared with alloplastic reconstruction, studies
indicate that overall patient satisfaction may still be greater
in the latter group. 19
As reconstructive techniques continue to be refi ned
and expander/implant technology continues to improve,
so too will the aesthetics of expander/implant reconstruc-
tions. Improved aesthetic outcomes, while only part of
overall reconstructive success, will undoubtedly lead to an
increase in overall patient satisfaction and ensure the con-
tinued popularity of alloplastic breast reconstruction.
REFERENCES
1. National Cancer Institute. Defi nition of breast cancer. Breast
Cancer. .
2. American Society of Plastic Surgeons. Report of the 2010
Plastic Surgery Statistics . ASPS National Clearinghouse of
Plastic Surgery Procedural Statistics; 2011.
3. Agha-Mohammadi S, De La Cruz C, Hurwitz DJ. Breast
reconstruction with alloplastic implants. J Surg Oncol.
2006;94(6):471–478 .
4. Tuttle TM, Habermann EB, Grund EH, et al. Increasing use
of contralateral prophylactic mastectomy for breast cancer

500 • CHAPTER 42
patients: a trend towards more aggressive surgical treatment.
J Clin Oncol . 2007;25(33):5203–5209.
5. Jones NB, Wilson J, Kotur L, et al. Contralateral prophy-
lactic mastectomy for unilateral breast cancer: an increas-
ing trend at a single institution. Ann Surg Oncol . 2009;
16(10):2691–2696.
6. Herrinton LJ, Barlow WE, Yu O, et al. Effi cacy of pro-
phylactic mastectomy in women with unilateral breast
cancer: a cancer research network project. J Clin Oncol.
2005;23(19):4275–4286.
7. Van Sprundel TC, Schmidt MK, Rookus MA, et al. Risk
reduction of contralateral breast cancer and survival after
contralateral breast cancer and survival after contralateral
prophylactic mastectomy in BRCA1 or BRCA2 mutation
carriers. Br J Cancer . 2005;93(3):287–292.
8. Guiliano AE, Boolbol S, Degnim A, et al. Society of surgical
oncology: position statement on prophylactic mastectomy.
Ann Surg Oncol. 2007;14(9):2425–2427.
9. Goldfl am K, Hunt KK, Gershenwald JE, et al. Contralateral
prophylactic mastectomy. Predictors of signifi cant histologic
fi ndings. Cancer . 2004;101(9):1977–1986.
10. Rebbeck TR, Freibel T, Lynch HT, et al. Bilateral prophylac-
tic mastectomy reduces breast cancer risk in BRCA1 and
BRCA2 mutation carriers: the PROSE study group. J Clin
Oncol. 2004;22(6):1055–1062.
11. Lostumbo L, Carbine N, Wallace J, et al. Prophylactic mas-
tectomy for the prevention of breast cancer. Cochrane Data-
base Syst Rev. 2004;4CD002748.
12. Cordeiro PG, McCarthy CM. A single surgeon’s 12-year
experience with tissue expander/implant breast recon-
struction: part II. an analysis of long-term complications,
aesthetic outcomes, and patient satisfaction. Plast Reconstr
Surg. 2006;118(4):832–839.
13. Krueger EA, Wilkins EG, Strawderman M, et al. Complica-
tions and patient satisfaction following expander/implant
breast reconstruction with and without radiotherapy.
Int J Radiation Oncology Biol Phys. 2001;49(3):713–721.
14. Percec I, Bucky LP. Successful prosthetic breast recon-
struction after radiation therapy. Ann Plast Surg. 2008;
60(5):527–531.
15. McCarthy CM, Mehrara BJ, Riedel E, et al. Predicting com-
plications following expander/implant breast reconstruc-
tion: an outcomes analysis based on preoperative clinical
risk. Plast Reconstr Surg. 2008;121(6):1886–1892.
16. Nahabedian MY, Tsangaris T, Momen B, et al. Infec-
tious complications following breast reconstruction with
expanders and implants. Plast Reconstr Surg. 2003;112(2):
467–476.
17. Antony AK, Mehrara BM, McCarthy CM, et al. Sal-
vage of tissue expander in the setting of mastectomy fl ap
necrosis: a 13-year experience using timed excision with
continued expansion. Plast Reconstr Surg. 2009;124(2):
356–363.
18. Frassica DA, Zellars R. Radiation oncology: the year in
review. Curr Opin Oncol. 2002;14(6):594–599.
19. Spear SL, Majidian A. Immediate breast reconstruction in
two stages using textured, integrated-valve tissue expanders
and breast implants: a retrospective review of 171 consecu-
tive breast reconstructions from 1989 to 1996. Plast Reconstr
Surg. 1998;101(1):53–63.

43
Autologous Breast Reconstruction
Joshua Fosnot, MD / Joseph M. Serletti, MD, FACS
INTRODUCTION
Breast cancer is a devastating disease which will affect
one out of every eight women in their lifetime, some-
times at a young age. Although frequent, the disease is
often curable; thus, most women live many years follow-
ing treatment for their breast cancer. To avoid the debili-
tating psychosocial and aesthetic effects of mastectomy,
an increasing number of women elect for reconstruction
of a breast mound either at the time of mastectomy or
in a delayed fashion. There are many options for breast
reconstruction, utilizing either alloplastic materials or
autologous tissue. Expander/implant reconstruction by
far remains the most common method for reconstruc-
tion; however, autologous reconstruction has increased
as methods for transferring the tissue evolve to reduce
donor site morbidity and improve outcomes. In this
chapter, we explore the various methods of autologous
tissue reconstruction and discuss the relative risks and
benefi ts of each in an effort to present the breadth of
options to restore a woman’s sense of self following treat-
ment for breast cancer.
PATIENT EVALUATION AND SELECTION
A breast cancer patient may seek information regarding
reconstruction from a plastic surgeon at different stages in
the treatment of her disease with varying levels of under-
standing of the types of reconstruction available. Breast
reconstruction demands an open dialogue with regard
to all of the patient’s options with associated risks and
benefi ts regardless of what the surgeon is most capable
of or what his or her preferred method of reconstruction
is. It is important to listen to the patient’s wishes and
expectations and formulate a plan for moving forward.
This is paramount to avoiding untoward outcomes and
disappointment with the fi nal result.
Three types of reconstruction are available to the
majority of patients: an implant-based reconstruction,
autologous tissue reconstruction, or a combination of
the two methods. Implant reconstruction has the advan-
tage of being a quicker procedure, shorter recovery, and
avoids an additional surgical site. For the right patient,
it can offer an excellent result with minimal morbidity.
Implant-based reconstructions, however, have risks asso-
ciated with implant malfunction, such as infection, cap-
sular contracture, and rupture. In addition, it can be risky
in patients who have a history of or will require postmas-
tectomy radiation.
Autologous tissue reconstruction, on the other hand,
avoids the complications of implants and offers the
unique ability to replace “like with like.” This may lead
to improved overall patient satisfaction in many patients.
In addition, autologous reconstruction may be particu-
larly benefi cial in unilateral reconstruction in which the
reconstructed breast will behave much more like the
contralateral native breast over an implant-based recon-
struction. The reconstruction has the potential to be
lifelong. Despite these benefi ts, there are risks associated
with tissue reconstruction.
Risk Factors for Poor Outcomes
Patient comorbidities play a critical role in the likelihood
of complications postoperatively and should be recog-
nized prior to undertaking any operation. Most notably,
smoking and obesity have repetitively been implicated as
independent risk factors for wound complications, such
as wound infection, mastectomy fl ap necrosis, abdomi-
nal fl ap necrosis, and fat necrosis. 1 , 2 These risk factors
are particularly detrimental in pedicled transverse rectus
abdominis myocutaneous (TRAM) fl ap reconstruction
and are generally considered relative contraindications
to this procedure.
c h a p t e r

502 • CHAPTER 43
While not necessarily an absolute contraindication,
a hypercoagulable state places a patient at higher risk
for thrombosis during free or pedicled fl ap autologous
reconstruction. Patients should be asked specifi cally
about a history of deep venous thrombosis, pulmonary
embolism, or genetic diseases such as factor V Leiden.
Although no studies defi nitively support the practice, if
patients are willing to accept an increased risk of fl ap
failure and wish to proceed, more aggressive anticoagula-
tion should be considered postoperatively.
Prior surgical history is important to ensure the pedi-
cle of interest or recipient site has not been sacrifi ced.
This is particularly true for abdominal incisions, which
may have transected the epigastric artery or vein. A pre-
vious subcostal incision almost certainly transected the
superior epigastric vessels, making this an absolute con-
traindication for a pedicled TRAM, whereas an inguinal
hernia or paramedian incision may have transected the
inferior vessels making a free TRAM based on the pedicle
on that side impossible. A prior coronary artery bypass
graft (CABG) may make the internal mammary vessels
unavailable for recipients of a free fl ap. In addition, a
common CABG conduit is the internal mammary artery,
in which case a pedicled TRAM is contraindicated.
As with any major operation, patients should be coun-
seled on the risks of medical complications, including, but
not limited to, heart attack, stroke, and pulmonary embo-
lism. Proper patient selection plays a role in minimizing
these risks.
Adjuvant Therapy
Although many women with breast cancer undergo che-
motherapy, it does not appear to play a signifi cant role in
increasing complications in breast reconstruction. 1 It is
prudent, however, to avoid operations while on chemo-
therapy to allow for normal wound healing. Radiation
therapy, on the other hand, can have a signifi cant del-
eterious effect on autologous reconstruction. The use of
radiation therapy for the treatment of breast cancer is
increasing and while plastic surgeons have no control over
its utilization, they do have control over the timing of
reconstruction in relation to radiation therapy. Whether
administered before or after reconstruction, radiation
therapy leads to decreased overall aesthetic outcomes. 3
Fat necrosis, volume loss, and asymmetry are also more
likely in fl aps that are subsequently irradiated. Although
there is some literature to suggest that radiation fi eld
design may be compromised by breast reconstruction,
to date there are no reports of higher recurrence rates
or worse oncologic outcomes in women who receive
adjuvant radiation therapy after breast reconstruction. 3
Although aesthetically patients may benefi t from delay-
ing reconstruction until after any radiation therapy is
complete, this must be balanced with the ability to forgo
a second major operation with immediate reconstruc-
tion. Ultimately, this is only accomplished between open
dialogue between patient and surgeon.
PATIENT PREPARATION
Imaging
Little in the way of preoperative imaging is necessary
prior to proceeding for reconstruction, although this
statement is admittedly controversial in perforator fl aps.
Some authors conclude that preoperative Doppler or CT
angiogram is important to identify the perforator ves-
sels when performing a deep inferior epigastric perfora-
tor (DIEP) fl ap. 4 While imaging may make the surgeon
more comfortable that a large perforator is available
and in the end may shorten operating room time, it is
unclear whether the added risk and expense of a contrast
enhanced CT has any signifi cant impact on patient out-
come or overall expenditure.
Timing
Breast reconstruction may be performed at the same
time as mastectomy, or at a later date in delayed fashion.
While delayed reconstruction generally should not be
performed until several months following mastectomy,
there is no temporal limit. In fact, many patients opt for
reconstruction 10 or 15 years following cancer treatment.
The benefi t of immediate reconstruction is multifacto-
rial. First, the native skin envelope can be preserved if the
oncologic surgeon is comfortable performing a skin-spar-
ing mastectomy. As a result, the fl ap skin needed is often
only a small, natural-appearing circle used to replace
the lost nipple-areola complex. Second, the native skin
tends to be more pliable and predictable than that used
in delayed reconstruction where new skin fl aps are raised
from a previously operated, often irradiated fi eld. Due to
the resultant discrepancy of skin quality between sides in
a unilateral delayed reconstruction, there is a tendency
for asymmetry in the long term. Third, symmetry is easier
to obtain due to the unaltered native inframammary fold
position in immediate reconstruction. In delayed recon-
struction, the new inframammary fold must be approxi-
mated either by comparison to the contralateral breast,
or by the impression left by a well-fi tting brassiere. While
usually this does not result in any noticeable problems, this
does introduce more unpredictability. Lastly, immediate
reconstruction allows for completion of two major opera-
tions at one time. This effi ciency should not be minimized
as breast cancer patients often navigate a long journey to
complete their treatment. In the end, whether immediate
or delayed, long-term outcomes remain excellent.
Operative Planning
Regardless of type of autologous reconstruction per-
formed, several general principles apply. Anatomical
landmarks are more easily recognized when a patient is
awake and mobile (rather than under drapes). For this
reason, marking of the patient for fl ap design should be
done in the preoperative holding area prior to induction
of general anesthesia. The width of the fl ap should be

AUTOLOGOUS BREAST RECONSTRUCTION • 503
estimated to allow for tension-free donor site closure, yet
provide adequate volume.
When asleep, the patient should receive a Foley cath-
eter for monitoring of adequate urine output during these
sometimes long procedures. Preoperative antibiotics should
be administered within one hour of incision, and may
require repeat dosing intraoperatively if the case is pro-
longed. Antibiotics have been shown to decrease wound
infections when used in this manner.
TECHNIQUE
Latissimus Dorsi Myocutaneous Flap
The latissimus fl ap was one of the autologous fl aps origi-
nally described for breast reconstruction. Although it has
largely been replaced by lower abdominal island-based
fl aps for routine reconstruction, it remains an excellent
option for breast reconstruction. In particular, in salvage
situations where a previous fl ap was lost, it serves as a
reliable and hardy alternative. Due to lack of volume,
this fl ap is often paired with an implant whereby the
fl ap provides a skin envelope and the implant provides
the volume. This approach also serves well in delayed
reconstruction to an irradiated fi eld in which skin area is
needed for coverage.
A skin island can be designed over almost any portion
of the muscle; however, skin overlying the most inferior
portions of the muscle may be problematic due to com-
promised blood supply. For breast reconstruction, the
skin island is usually placed in a transverse orientation
over the superior aspect of the muscle. This allows for the
donor scar to be potentially hidden by an overlying back
of a brassiere or by the back of a two-piece bathing suit.
In both immediate and delayed reconstruction, sur-
gery may begin with the patient in either the supine or
decubitus position. In delayed reconstruction, the chest
wall skin is elevated off of the pectoralis muscle to rede-
fi ne the perimeter of the breast pocket. The fl ap’s skin
island is incised, and skin fl aps are elevated to expose the
needed boundaries of the latissimus muscle. The lateral
thoracic skin is elevated so as to create a subcutaneous
tunnel between the latissimus dissection and the mas-
tectomy defect ( Figure 43-1 ). In most patients, the tho-
racodorsal vessels do not need to be dissected, and the
insertion of the muscle is left intact. Some surgeons prefer
to divide the motor nerve so as to avoid potential motion
of the breast reconstruction with shoulder movement. In
delayed reconstructions, the thoracodorsal vessels may
have been previously injured from the axillary dissection.
Despite division of these vessels, the latissimus dorsi is
believed to remain reliable through retrograde fl ow by
its serratus branches. In cases of delayed reconstruction,
the latissimus muscle should be examined preoperatively.
Absence of motor activity within the muscle should raise
suspicion about the patency of the thoracodorsal vessels.
Flap viability in these patients should be ensured during
surgery; questionable viability may require microsurgical
intervention to establish a more profound blood supply.
When an implant is used, it is placed underneath the pec-
toralis and latissimus muscles.
Pedicled Transverse Rectus
Abdominis Myocutaneous Flap
The transfer of a lower abdominal skin island is the most
common method of autologous breast reconstruction,
whether as a pedicled TRAM, free TRAM, DIEP, or super-
fi cial inferior epigastric artery (SIEA) fl ap. Considering all
alloplastic and autologous methods, most surgeons agree
that the abdominal tissue is unmatched in its ability to cre-
ate a soft, pliable, and natural breast mound with excellent
potential for symmetry to an intact opposite breast.
The superior rectus blood supply is provided by the
superior epigastric vessels, which are terminal branches
of the internal mammary vessels. The inferior muscle is
supplied by the inferior epigastric vessels, which originate
from the external iliacs. These two systems anastomose
with each other through choke vessels within the center of
the muscle. The entire muscle can, therefore, be elevated
on either blood supply. The overlying skin and adipose
tissue within the transverse skin island of the TRAM fl ap
receives its blood supply from perforating vessels through
the rectus abdominis muscle. The skin island in the pedi-
cled TRAM fl ap is based on the superior epigastric vessels
as it is transferred to the chest defect.
For a standard lower transverse abdominal based
fl ap, the upper border of the fl ap is typically 1 to 2 cm
above the umbilicus, the lower border close to the
pubic hairline, but no lower than what will allow easy
closure. Typically, the resultant fl ap is a standard ellipse
( Figure 43-2 ). The midline should be marked from ster-
num to pubis to aid in symmetrical closure. The skin
island is viewed as four separate zones or quadrants
based on its attachment to one vascular pedicle. Zone 1,
directly overlying the rectus muscle and vascular pedicle,
is the area of greatest perfusion; however, the adjacent
zones 2 and 3 are generally reliable for adequate perfu-
sion and subsequent survival. The zone furthest from the
muscle (zone 4) is usually unreliable and is discarded
before insetting a pedicled TRAM fl ap.
The pedicled TRAM fl ap begins with the elevation of
the skin superior to the TRAM skin island. A subcutane-
ous tunnel is created between the abdominal dissection
and the mastectomy defect. This tunnel is kept as medial
as possible to maintain a signifi cant portion of the infra-
mammary fold, but large enough to allow passage of the
TRAM skin island. The skin island can be pedicled on
one rectus abdominis muscle or two. A vertical anterior
sheath fasciotomy allows for expose of the upper rec-
tus muscle of interest. In preparing the skin island for
transfer, all attachments except those of the skin island
to the rectus muscle(s) are divided. Whether designed as
a unipedicled fl ap or as a bipedicled fl ap, some surgeons
harvest the entire muscle(s); whereas, others preserve a
lateral and medial band of muscle, harvesting only central

504 • CHAPTER 43
or medial portions of the rectus muscle ( Figure 43-3 ). By
defi nition, a section of the anterior rectus fascia is taken
as part of the specimen. In high-risk patients, alterations
to technique for the pedicled TRAM fl ap can be used to
augment the blood supply to the skin island. These alter-
ations include a bipedicle blood supply whereby both
rectus muscles are harvested. Alternatively, the pedicled
TRAM fl ap can be “supercharged” by dissecting lengths
of the inferior epigastric vessels and anastomosing them
to the thoracodorsal vessels. To improve abdominal
donor site results, muscle-sparing techniques have been
used to preserve some muscle and fascia. Once the fl ap
is transferred to the chest, the abdominal wall defect is
closed. Onlay and inlay mesh can be used to reinforce
the abdominal wall closure. The lower abdominal skin
defect is closed by mobilizing the upper abdominal skin
fl ap inferiorly. The previously separated umbilicus is re-
inset into the anterior abdominal skin of the superior
skin fl ap. After closure of the abdominal site is complete,
the patient is placed in the sitting position, and the
TRAM skin island is trimmed and contoured to match
the opposite breast.
Free Transverse Rectus
Abdominis Myocutaneous Flap
Although pedicled TRAM reconstruction is still
quite common, free fl ap reconstruction has become
C
D
A
B
FIGURE 43-1. This patient underwent bilateral mastectomy with tissue expander/
implant reconstruction. On the left, she had been previously irradiated requiring excision
of a larger island of skin, thus a latissimus fl ap was used to cover the prosthesis. (A) The
fl ap is elevated on oblique angle and brought through a lateral subcutaneous tunnel into
(B) the mastectomy defect. (C, D) Postoperative result following exchange to implants.

AUTOLOGOUS BREAST RECONSTRUCTION • 505
increasingly popular. Whereas the pedicled TRAM fl ap is
based on the superior epigastric vessels, the free TRAM
fl ap is based on the deep inferior epigastric vessels. In a
pedicled TRAM, the primary portion of the skin island
is in the second angiosome, receiving blood via “choke”
vessels in the muscle. The TRAM fl ap island is in the
primary angiosome of the inferior epigastric blood sup-
ply giving the free TRAM a more robust blood supply.
Patients with a history of smoking, hypertension, obe-
sity, chronic obstructive pulmonary disease, previous
abdominal surgery, and even diabetes have been consid-
ered high-risk patients in regard to the pedicled TRAM
fl ap. The improved blood supply and more limited donor
site defect achieved with the free TRAM fl ap technique
has allowed TRAM fl ap breast reconstruction in these
higher-risk patients with acceptable complication rates. 5 , 6
Insetting of the free TRAM fl ap is easier and less restric-
tive as compared to the pedicled fl ap.
The upper edge of the TRAM skin island is incised, and
an upper abdominal fl ap is raised to the xiphoid and the
costal margins in similar fashion to the pedicled TRAM;
however, the upper abdominal fascia is not incised. The
lower portion of the skin island is then incised. The lat-
eral portion of the skin island closest to the selected
muscle is elevated to the fi rst row of lateral perforators,
and the fascia is incised. A muscle-splitting dissection is
performed, and the inferior epigastric vessels are identi-
fi ed and dissected to the external iliac vessels. There is
usually a single inferior epigastric vein at this level or a
large vein with a smaller counterpart entering the exter-
nal iliac vein. A decision as to whether to use an ipsi-
lateral or contralateral free fl ap has usually been made
preoperatively, based on the shape of the contralateral
breast and the choice of recipient vessels.
The opposite side of the skin island is elevated to the
fi rst row of medial perforators exiting from the selected
FIGURE 43-2. (A) The typical design of a TRAM fl ap is elliptical in shape and
includes around the umbilicus although the height is dependent on the relative skin and
soft tissue laxity of the abdomen. Sometimes a more elliptical design is used (shown by
the dotted line). (B) The TRAM fl ap is broken into four vascular zones of perfusion. Zone 1
is the most reliable, lying directly over the vascular pedicle.
A
B

506 • CHAPTER 43
muscle. This maneuver separates the skin island from the
vasculature of the opposite rectus. The anterior rectus
fascia is incised here, and a medial muscle-splitting dis-
section is performed. The fl ap is now ready for division
and transfer ( Figure 43-4 ). The vascular anastomosis and
inset of the fl ap is discussed later in this chapter. After the
tissue is harvested, a fascial defect remains in the lower
abdominal wall. This is typically repaired by primary clo-
sure and either onlay or inlay mesh. The abdominal donor
site is closed in a manner similar to that of an aesthetic
abdominoplasty.
Deep Inferior Epigastric Perforator Flap
The DIEP fl ap uses the same skin island as described
above, but does not sacrifi ce any of the rectus muscle
or anterior rectus fascia. The muscle fi bers are tempo-
rarily splayed apart to allow for removal of the inferior
epigastric vessels and selected perforators. Criticisms of
both pedicled and free TRAM fl aps have mostly centered
on the abdominal wall donor site. The DIEP offers one
technical variation that minimizes donor site morbidity. 7
Proponents of this technique suggest that it results in
less postoperative pain, a shorter hospitalization, a more
prompt recovery with little or no functional defi cit in
the abdominal donor site. Because this fl ap relies on one
or two perforators, it may be less suitable for high-risk
patients.
Upon selecting the right or left side, the lateral edge of
the ipsilateral part of the skin island is elevated off of the
fascia. Using loupe magnifi cation and atraumatic tech-
nique, the surgeon identifi es an acceptably large perfora-
tor (or perforators). The anterior rectus fascia is incised
above the perforator for a short distance and below it to
just above the inguinal region. The fascia is refl ected off
of the muscle in a lateral direction. The muscle is splayed
for a short distance around the perforator, identifying its
connection to the inferior epigastric system. The lateral
edge of the muscle is elevated off of the posterior rec-
tus sheath for further identifi cation and dissection of the
inferior epigastric vessels. Care is taken to maintain all of
the intercostal motor nerve supply to the rectus muscle.
After completion of the fl ap dissection, the inferior epi-
gastric vessels are divided proximally and passed through
the opening in the muscle at the level of the perforator.
The fl ap is separated from its remaining attachments to
the abdominal wall and passed to the chest for anasto-
mosis and inset. The incision in the anterior rectus fascia
FIGURE 43-3. This patient underwent a
bilateral pedicle TRAM breast reconstruction.
(A) Dissection of each hemi fl ap and the
corresponding superior pedicle. (B) Note that
this is a muscle sparing procedure in which
neither rectus muscle is completely sacrifi ced.
(C) The fl aps are transferred up to the chest via
subcutaneous tunnels medially. (Photos courtesy
of M. Nahabedian, MD.)
C
A
B

AUTOLOGOUS BREAST RECONSTRUCTION • 507
A
B
C
D
E
F
FIGURE 43-4. In a standard free TRAM (A) the superior abdominal fl ap is raised
starting from the superior aspect of the TRAM fl ap. This will eventually allow for closure
of the donor site defect. (B) The lateral aspects of the TRAM fl ap are raised up until the
lateral row of perforators. (C) A fasciotomy is made above and below the perforators.
(D) The inferior epigastric pedicle is identifi ed and the rectus muscle is sacrifi ced in a
manner which allows for inclusion of the perforators and vascular pedicle. In most cases,
some of the muscle is spared. (E) The resultant fl ap is shown with muscle and pedicle
included. (F) The donor site fascial defect is closed in this case with mesh for added
strength. The fl ap is then ready for anastomosis and inset.

508 • CHAPTER 43
is closed directly, without the need for mesh, and the
entire muscle with its nerve supply has been preserved
( Figure 43-5 ).
Superfi cial Inferior Epigastric Artery Flap
In a small percentage of patients, the superfi cial inferior
epigastric vessels are suffi cient in caliber to support half
of the transverse lower abdominal fl ap. The benefi t lies in
the very nature of the size and location of these extrafas-
cial vessels. The dissection does not violate the fascia or
muscle of the abdominal wall, leading to decreased donor
site morbidity. 8 The downsides include increased vascu-
lar complications such as thrombosis and fat necrosis, as
well as limited fl ap size. 9 Generally, a hemifl ap is all that
is available for inset given the angiosome distribution of
the superfi cial inferior epigastric vasculature. In addition,
the angiosome distribution of the SIEA appears to be
highly variable such that simple inspection of the cali-
ber of the vessel may be inadequate to reliably predict a
dependable outcome. 10
The patient is marked and the case started in the
same fashion as the free TRAM or DIEP. The superfi cial
vessels, if present, are encountered via the inferior fl ap
incision at the midpoint between the anterior superior
iliac spine and pubic tubercle in the subcutaneous tis-
sue ( Figure 43-6 ). If it appears that these vessels will be
large enough, the dissection is carried inferiorly to their
origin at the superfi cial femoral vessels roughly 2 to 3 cm
below the inguinal ligament. The fl ap dissection is then
carried out by harvesting the typical lower abdominal
ellipse of tissue without violating the fascia. The vessel
origins are then taken and the fl ap is ready for anastomo-
sis and insetting.
Superior Gluteal Flap
Many patients either do not have suffi cient abdomi-
nal tissue or have had prior abdominal surgery such
as an abdominoplasty or previous TRAM, effectively
eliminating the option of a subsequent TRAM for recon-
struction. In these circumstances, a gluteal fl ap is an
excellent choice. A signifi cant advantage of this tech-
nique is the more rapid recovery and decreased postop-
erative discomfort in comparison with the TRAM fl ap.
Unfortunately, the adipose tissue in the gluteal fl ap is
more septate and less pliable than in both the native
breast and the TRAM fl ap which makes insetting more
challenging, and the fi nal result is somewhat fi rmer than
most natural breasts.
The free superior gluteal myocutaneous fl ap is based
on the superior gluteal vasculature to the gluteus maxi-
mus muscle and its overlying skin. With the patient in
the decubitus or prone position, a line is drawn from the
C
B
FIGURE 43-5. (A) In a DIEP fl ap, the
perforators are identifi ed individually to assess
the adequacy of their caliber for reliable perfusion.
(B) The fasciotomy is made above and below the
perforator(s) of interest. The perforators are followed
down through the muscle to the deep inferior
epigastric vessels without sacrifi cing any muscle.
(C) The resultant fl ap carries with it no attached
muscle and the patient is left with an intact
functional rectus muscle.
A

AUTOLOGOUS BREAST RECONSTRUCTION • 509
A
B
C
D
E
FIGURE 43-6. (A) The superfi cial inferior epigastric
vessels are encountered with minimal dissection in the
subcutaneous fat of the inferior fl ap margin. (B) In this left
hemifl ap, either the DIEP perforators or the superfi cial
inferior epigastric vessels could be used to support the free
fl ap. Note that the superfi cial inferior epigastric vessels stay
extrafascial, whereas the DIEPs perforate the fascia. The
DIEP vessels can be temporarily clamped to ensure the
fl ap is viable via the SIEA. (C) The fl ap is taken as an SIEA
with excellent pedicle length. (D) This patient ultimately
underwent bilateral reconstruction with a muscle-sparing
free TRAM on the contralateral side. Note the difference
between the left and right sides upon completion of fl ap
harvest. (E) The right TRAM requires fascial closure, the left
SIEA does not.
posterior superior iliac spine to the top of the greater
trochanter. Dividing that line into thirds, the superior glu-
teal pedicle is located near the junction of the superior and
middle thirds. The skin island can be centered along this
oblique line or may be rotated to a more horizontal posi-
tion overlying the upper portion of the gluteus maximus
muscle. As patient positioning generally does not allow
access to the contralateral breast during fl ap harvest, the
dimensions of the contralateral breast should be appreci-
ated prior to positioning to help guide the size of the fl ap
needed for symmetry. The superior and inferior edges of
the skin island are incised and skin fl aps are subsequently

510 • CHAPTER 43
raised, leaving an appropriate amount of adipose tissue
attached to the muscle for volume. The superior edge
of the gluteus maximus is identifi ed and elevated off of
the gluteus medius. Dissection then follows to the lateral
margin of the muscle as it heads toward the greater tro-
chanter. The lateral muscle here is divided. The superior
gluteal vessels are identifi ed on the undersurface of the
gluteus maximus and are followed to their origin off of
the internal iliacs. This origin is approximately 5 cm lat-
eral to the sacral edge between the gluteus medius and
the piriformis muscle. Because the vessels here are fragile,
it is imperative that they are dissected carefully. A pedicle
length of 2 to 3 cm is typically obtained. The lower edge
of the fl ap with its attached muscle is incised and the
gluteus maximus muscle is divided at that level. The ves-
sels are divided, as are the remaining soft tissue attach-
ments to the fl ap. While the donor site is being closed,
the fl ap is taken to the side table for further dissection
to gain pedicle length. The patient is returned to the full
supine position for fl ap anastomosis and inset. Due to the
short pedicle length, the internal mammary vessels are
preferred, allowing for medial placement of this tissue.
Some surgeons regularly use vein grafts with this fl ap to
overcome the diffi culties with the short pedicle.
The superior gluteal fl ap can also be harvested as a
perforator fl ap. Analogous to muscle preservation in the
DIEP fl ap, all of the gluteus maximus muscle is pre-
served in the superior gluteal artery perforator fl ap. One
or more perforators from this system to the skin can be
identifi ed just lateral to the origin of the superior gluteal
vessels. The upper and lower edges of the skin paddle are
prepared just as in the gluteal fl ap. Beginning at the lat-
eral edge of the skin island, a subfascial dissection is per-
formed until an acceptable perforator is identifi ed. The
muscle fi bers are splayed, and the perforator is dissected
away from its muscle attachments to where it joins a
major muscle branch of the superior gluteal vessels. This
major muscle branch is followed proximally to the main
gluteal vessels which are then divided as close to the ori-
gin as possible. All other attachments of the skin island
to the muscle are divided, and the fl ap is passed to the
chest for anastomosis and inset.
The perforator fl ap leads to a considerably longer
pedicle length, upward of 6 cm. This makes perform-
ing the anastomosis more straightforward than the stan-
dard free gluteal fl ap procedure. Without the bulk of the
muscle, insetting the fl ap is easier and the intraoperative
result more closely mimics the matured postoperative
result of a standard gluteal fl ap procedure. Preserving all
of the gluteus maximus muscle has signifi cant functional
considerations and leaves a less depressed contour defor-
mity in comparison to the gluteal fl ap.
Inferior Gluteal Flap
The inferior gluteal fl ap is a myocutaneous fl ap based on
the inferior gluteal blood supply to the gluteus maximus
muscle. The skin island is transversely positioned over
the lower half of the gluteus maximus muscle, ending
just above the gluteal crease. The skin and muscle are
elevated to expose the inferior gluteal vessels, which are
the terminal branches of the internal iliacs. This infe-
riorly designed fl ap has the advantage of a somewhat
longer vascular pedicle but the disadvantage of a more
conspicuous donor deformity and scar. Harvesting this
fl ap also usually divides the posterior femoral cutane-
ous nerve, leaving an area of numbness on the posterior
aspect of the thigh. Although there are varying opinions,
the majority of surgeons choose the superior gluteal fl ap
over the inferior design as their fi rst choice when a free
TRAM fl ap cannot be used. The inferior gluteal fl ap can
be achieved as a perforator fl ap as well ( Figure 43-7 ).
Lateral Thigh Flap
The lateral thigh fl ap is a laterally oriented modifi cation
of the free tensor fascia lata myocutaneous fl ap. This fl ap
is specifi cally designed to take advantage of excess tis-
sue in the upper lateral thigh for breast reconstruction.
A transverse skin island is harvested with the underlying
tensor fascia lata. The pedicle to this fl ap is composed of
the lateral femoral circumfl ex vessels, which can be dis-
sected back to the profundus for a pedicle length of 6 to
8 cm. Patients selected for this technique must have suf-
fi cient soft tissue in the upper thigh and generally speak-
ing, this method is considered only if a TRAM or gluteal
fl ap is not available.
Rubens Flap
The Rubens fl ap, or deep circumfl ex iliac soft tissue fl ap,
is a variation of the deep circumfl ex iliac artery or iliac
crest fl ap but without the bone. There can be signifi cant
redundant skin and adipose tissue overlying the iliac crest.
This soft tissue is supplied by perforating branches of
the deep circumfl ex iliac vessel. A transverse skin island
overlying the iliac crest is designed and the circumfl ex
iliac vessels are approached as in the free iliac crest fl ap.
Instead of bone being taken, a subperiosteal dissection is
performed, capturing the perforating vessels to the skin.
This fl ap provides a moderate amount of soft tissue with
a reliable vascular pedicle. This fl ap has particular useful-
ness when the TRAM fl ap has already been used, since
this lateral tissue is often preserved.
Transverse Upper Gracilis Flap
In addition to the lateral thigh and Rubens fl aps, the
TUG fl ap is an excellent option for autologous breast
reconstruction in patients who are not candidates for
transverse lower abdominal based fl aps. Here, an upper
inner thigh fl ap based upon the medial femoral cir-
cumfl ex vessels is oriented transversely, with the wid-
est portion directly over the gracilis muscle. The patient
is placed in the supine position with legs abducted and
knees slightly bent. The anterior portion of the fl ap is dis-
sected fi rst, superfi cial to the fascia of the thigh muscles.

AUTOLOGOUS BREAST RECONSTRUCTION • 511
FIGURE 43-7. (A) Depicted are the standard landmarks in a gluteal fl ap. The
superior gluteal artery (SGA) is dopplerable roughly one third the distance between the
posterior superior iliac spine (PSIS) and the greater tuberosity (GT). Depicted here is the
typical transverse fl ap design of an inferior gluteal artery perforator fl ap which is more
inferiorly positioned, closer to the ischeal tuberosity (IT). (B) Several perforators are visible
entering this inferior gluteal artery perforator fl ap. (C) The fl ap is taken with two large
perforators, converging to the inferior gluteal artery pedicle. (D) The IGAP fl ap is shown
following anastomosis and inset.
A
B
D
C

512 • CHAPTER 43
FIGURE 43-8. (A, B) Postoperative photos of a woman who underwent bilateral
autologous breast reconstruction using transverse upper gracilis fl aps. In this photo, this
patient had also undergone recent bilateral nipple-areola reconstruction, but has yet to
undergo tattooing. (C, D) The donor site is fairly inconspicuous and offers the benefi t of a
bilateral medial thigh lift. (Photos courtesy of Liza C. Wu, MD.)
A
B
C
D
Upon reaching the adductor longus, the fascia is incised
allowing for exposure of the gracilis pedicle under the
adductor longus muscle. At this point, the posterior end
of the fl ap can be elevated and the gracilis can be divided
proximally and distally. The vascular pedicle can be fur-
ther dissected if needed for length. The pedicle is gener-
ally 5 to 6 cm and insetting of the fl ap provides excellent
contour due to the crescent shape of the fl ap. In addi-
tion, this fl ap offers a simultaneous inner thigh lift as the
donor site is closed ( Figure 43-8 ) .
Recipient Site and Insetting
The axilla is fairly well exposed during a modifi ed radical
mastectomy making the thoracodorsal system useful as a
recipient site; however, in most circumstances, the inter-
nal mammary vessels have become the primary recipi-
ent site for free fl ap breast reconstruction. Outcomes
between the two recipient sites have proven to be similar
and the internal mammary site allows for more medial
positioning of the fl ap, leading to improved symmetry and

AUTOLOGOUS BREAST RECONSTRUCTION • 513
aesthetics. 11 In addition, using the internal mammary site
avoids having to access the axilla in a simple mastectomy
and avoids the risk of injury in cases where reoperating in
the axilla for further nodal resection is possible at a later
date. The internal mammary system also requires less
pedicle length compared to the thoracodorsal, which is
particularly helpful in short pedicles such as those found
in either the superior or inferior gluteal fl aps.
The internal mammary vessels can be approached
through a rib-sparing or rib-harvesting procedure. For
a rib-sparing procedure, the intercostal space, typically
between the third and fourth, is identifi ed. The overlying
pectoralis major muscle is split and the intercostal mus-
cle is removed. The internal mammary vessels are found
immediately under the intercostal muscles overlying the
pleura. In a rib harvesting procedure, the pectoralis muscle
overlying the third or fourth costal cartilage is split and
the rib is exposed. The perichondrium is incised along the
midanterior surface from the junction of the sternum to
the costochondral junction. The perichondrium is sepa-
rated off of the cartilage anteriorly and 2 to 3 cm of costal
cartilage is removed with a rongeur. Next, the posterior
perichondrium is incised lateral to the internal mammary
vessel and refl ected lateral to medial. The vessels are found
immediately posterior to the perichondrium above the
pleura. In both techniques, care must be taken to avoid
transection of the small intercostal vessel branches com-
ing off of the internal mammary system. Once the vessels
are identifi ed and separated from the internal mammary
lymphatics, the length of dissection is increased by har-
vesting additional rib or intercostal muscles superiorly or
inferiorly. Compared with most other recipient vessels
throughout the body, the internal mammary artery is more
susceptible to injury and thrombosis during its dissection.
Minimal use of vascular forceps is recommended. The
internal mammary vein tends to be larger on the right side
than on the left side. The free fl ap is temporarily positioned
to allow easy performance of the anastomoses. The artery
and vein are typically handsewn with 8-0 or 9-0 nylon. The
coupler device can be used on the vein as an alternative
( Figure 43-9 ). Following completion of the vascular anas-
tomoses, the fl ap is inset by closing in multiple layers.
Nipple-Areola Reconstruction
Following re-creation of the breast mound with autolo-
gous breast reconstruction, many women opt to undergo
re-creation of the nipple-areola complex as a fi nal step in
restoring body image. Techniques employed in the past
have included grafting from skin, buccal mucosa, labia
minora or majora, thigh, buttocks, groin, upper eyelids,
or earlobes. Although the technique varies, the principles
remain the same: to provide color, texture, size, and pro-
jection which are all in line with the patient’s aesthetic
wishes. The most common method used today consists of
local skin fl ap rearrangement to create texture and pro-
jection followed by tattooing for color ( Figure 43-10 ). 12
Nipple-areola reconstruction in most cases is performed
more than 3 to 4 months following mound reconstruc-
tion or after adjuvant therapy is completed. This allows
for complete healing of the fl ap and ensures stable mound
symmetry which is a key prerequisite prior to recreating
a nipple-areola complex. Immediate nipple-areola re-cre-
ation at the time of fl ap has been reported but is by far less
common. It should also be noted that although mastec-
tomy has classically included excision of the native nipple-
areola, there has been an increasing interest and study of
the safety and effi cacy of nipple-sparing mastectomy.
COMPLICATIONS
A broad category of wound complications may arise,
including seroma, delayed wound healing, hematoma,
and mastectomy skin fl ap necrosis. As a whole, the nonin-
fectious wound complications may be as high as 28% to
43%; however, the vast majority of time, these heal with-
out intervention or long term sequelae. 6 Wound infection
occurs 3.5% to 9.5% of the time but is usually limited to
simple cellulitis easily treated with antibiotics. Vascular
complications such as thrombosis or ischemia may lead to
fl ap loss or fat necrosis; however, complete fl ap loss is rare.
Close observation of these fl aps is paramount in the imme-
diate postoperative period as arterial or venous thrombo-
sis can be salvaged with rapid surgical intervention.
Donor site morbidity is an unfortunate downside
of autologous reconstruction not seen with expander/
implant reconstruction. Hernias may require reopera-
tion for repair. In addition, following manipulation of the
abdominal wall, many patients may experience a perma-
nent decrease in abdominal wall strength.
OUTCOMES ASSESSMENT
The mastectomy defect can be devastating both physi-
cally and psychologically. Numerous studies have doc-
umented signifi cant improvement in self-confi dence
and mental health following breast reconstruction. 13
Although not routinely done, efforts to reestablish inner-
vation to free fl aps has been shown to improve patient
satisfaction overall. 14 No one procedure outshines
another in all circumstances; however, certain patients
clearly benefi t from careful procedural selection. In the
end, the overall plan for reconstruction must be an open
dialogue between surgeon and patient, one which ulti-
mately involves listening and education.
Aesthetic complications should be discussed with
the patient preoperatively. These include breast mound
asymmetry, contour irregularities, contracture and vol-
ume loss related to radiation or fat necrosis, poor wound
healing, and scaring. With proper planning, these set-
backs can be ameliorated with revision surgery, reduc-
tion, implant augmentation and newer techniques such
as fat grafting for contour irregularities. Proper counsel-
ing of patients preoperatively once again is imperative, as
accurate expectations will most often yield the greatest
patient satisfaction.

514 • CHAPTER 43
FIGURE 43-9. (A) Shown here is the dissection of
the third rib in preparation for exposure of the internal
mammary vessels for a recipient site. The overlying
pectoralis muscles are splayed apart to allow adequate
exposure (B). (C) The perichondrium is incised to allow
for removal of the costochondral junction. (D) Following
removal, the internal mammary vessels are exposed.
Further proximal and distal dissection is generally needed.
(E) The fl ap is anastomosed in standard fashion.
A
B
D
E
C

AUTOLOGOUS BREAST RECONSTRUCTION • 515
FIGURE 43-10. (A, a–d) Schematic representation of the modifi ed skate fl ap for
nipple-areola reconstruction. The lateral “V” shaped fl aps become the walls of the nipple
projection, whereas the “C” shaped fl ap becomes the top. The dissection plane is deeper
in the center to add bulk. The blood supply comes from the uncut superior pedicle. (B–D)
The same skate fl ap shown on a typical patient. This is followed by tattooing for color.
B
C
D
A
a
b
c
d

516 • CHAPTER 43
REFERENCES
1. Selber JC, Kurichi JE, Vega SJ, Sonnad SS, Serletti JM. Risk
factors and complications in free TRAM fl ap breast recon-
struction. Ann Plast Surg . 2006;56(5):492–497.
2. Vyas RM, Dickinson BP, Fastekjian JH, Watson JP, Dalio
AL, Crisera CA. Risk factors for abdominal donor-site
morbidity in free fl ap breast reconstruction. Plast Reconstr
Surg. 2008;121(5):1519–1526.
3. Kronowitz SJ, Robb GL. Radiation therapy and breast
reconstruction: a critical review of the literature. Plast
Reconstr Surg . 2009;124(2):395–408.
4. Masia J, Kosutic D, Clavero JA, Larranaga J, Vives L, Pons G.
Preoperative computed tomographic angiogram for deep in-
ferior epigastric artery perforator fl ap breast reconstruction.
J Reconstr Microsurg. 2010;26(1):21–28.
5. Andrades P, Fix RJ, Danilla S, et al. Ischemic complications
in pedicle, free, and muscle sparing transverse rectus abdo-
minis myocutaneous fl aps for breast reconstruction. Ann
Plast Surg . 2008;60(5):562–567.
6. Mehrara BJ, Santoro TD, Arcilla E, Watson JP, Shaw WW,
Da Lio AL. Complications after microvascular breast recon-
struction: experience with 1195 fl aps. Plast Reconstr Surg .
2006;118(5):1100–1109; discussion 1110–1111.
7. Man L-X, Selber JC, Serletti JM. Abdominal wall following
free TRAM or DIEP fl ap reconstruction: a meta- analysis
and critical review. Plast Reconstr Surg . 2009;124(3):
752–764.
8. Wu LC, Bajaj A, Chang DW, Chevray PM. Comparison of
donor-site morbidity of SIEA, DIEP, and muscle-sparing
TRAM fl aps for breast reconstruction. Plast Reconstr Surg .
2008;122(3):702–709.
9. Selber JC, Samra F, Bristol M, et al. A head-to-head compari-
son between the muscle-sparing free TRAM and the SIEA
fl aps: is the rate of fl ap loss worth the gain in abdominal wall
function? Plast Reconstr Surg . 2008;122(2):348–355.
10. Holm C, Mayr M, Hofter E, Raab N, Ninkovic M. Interindi-
vidual variability of the SIEA angiosome: effects on opera-
tive strategies in breast reconstruction. Plast Reconstr Surg .
2008;122(16):1612–1620.
11. Saint-Cyr M, Youssef A, Bae HW, Robb GL, Chang DW.
Changing trends in recipient vessel selection for micro-
vascular autologous breast reconstruction: an analysis of
1483 consecutive cases. Plast Reconstr Surg . 2007;119(7):
1993–2000.
12. Farhadi J, Maksvytyte GK, Schaefer DJ, Pierer G, Scheufl er
O. Reconstruction of the nipple-areola complex: an update.
J Plast Reconstr Aesthet Surg. 2006;59(1):40–53.
13. Alderman AK, Kuhn LE, Lowery JC, Wilkins EG. Does pa-
tient satisfaction with breast reconstruction change over
time? Two-year results of the Michigan Breast Reconstruction
Outcomes Study. J Am Coll Surg . 2007;204(1):7–12.
14. Temple CL, Ross DC, Kim S, et al. Sensibility following
innervated free TRAM fl ap for breast reconstruction: Part
II. Innervation improves patient-rated quality of life. Plast
Reconstr Surg . 2009;124(5):1419–1425.
CONCLUSION
Autologous breast reconstruction can be performed
using a wide variety of fl aps which all offer the ability to
reliably recreate a breast mound following mastectomy.
This has the unique ability to replace “like with like” and
although it is not free of complications, can be performed
in a variety of settings with the expectation of excellent
patient satisfaction.

44
Reduction Mammaplasty
Michael N. Mirzabeigi, MD / Liza C. Wu, MD, FACS
INTRODUCTION
Macromastia, or breast hypertrophy, can prove to be a
troublesome condition for many women. Plastic sur-
geons are frequently called upon to provide the only
known defi nitive treatment of macromastia, which is
direct excision of tissue. Reduction mammaplasty (mam-
moplasty), otherwise known as breast reduction, serves
to improve the aesthetics of the breast as well as alleviate
functional sequelae that can result from excessive breast
enlargement. This is achieved by generally targeting three
goals for the patient: (1) reduce breast size, (2) improve
breast shape, and (3) improve nipple-areola position. In
order to safely achieve these goals, surgeons must care-
fully select patients who are appropriate candidates for
surgery, and in a manner fi tting for each patient, surgeons
must select a suitable technique for reduction.
PATIENT EVALUATION AND SELECTION
Symptoms
The etiology of this condition is believed to be secondary
to an exaggerated response to circulating estrogen, pro-
gesterone, and/or prolactin. The resultant breast hyper-
trophy can lead to a litany of well documented problems.
Patients often complain of musculoskeletal pain of the
neck, shoulders, and back. Many patients may also present
with intertriginous rash (eg, dermatitis or fungal growth)
at the inframammary sulcus, painful shoulder groov-
ing (secondary to pressure from the brassiere overlying
the distribution of the trapezius muscle), and kyphosis.
Furthermore, psychosocial issues can be prevalent in this
patient population with concerns for self-image, confi -
dence, ability to fi nd properly fi tting clothes, and sexual
dysfunction.
Patient Selection
Reduction mammaplasty is ultimately elective surgery;
therefore, patients should not have signifi cant comor-
bidities which would place them at high risk for anes-
thetic complications. Otherwise, there are some more
specifi c issues to be considered during the preoperative
evaluation. First, patients should be strongly counseled
to discontinue smoking for at least 1 month (some would
suggest 3 months) prior to undergoing surgery or risk a
higher rate of wound complications. Also, patients should
be at an age in which the decision can be made autono-
mously and with full knowledge and understanding of
the risks and benefi ts. Unless there is a compelling or pro-
found disturbance caused by the macromastia, patients
should wait until at least 18 years of age to ensure some
level of stability in breast size, and moreover, to promote
a properly informed decision by the patient.
Once it has been determined that a patient is an
appropriate candidate for surgery, a concerted effort
should be made in an attempt to assist the patient with
the precertifi cation of insurance coverage. This pro-
cess varies depending on the insurance carrier; how-
ever, insurance companies have relatively predictable
requests. First, the patient must demonstrate clinical
macromastia via some estimation of resection volume or
relative breast size as a function of body surface area.
Many insurance carriers require documentation of symp-
toms, which is noted to be persistent over more than
one offi ce visit (eg, 6 months of documented symptoms).
Oftentimes there is also a request to document a non-
surgical attempt to alleviate symptoms via weight loss
programs and/or physical therapy. Among other reasons,
these attempts often fail as macromastia can be largely
independent of weight loss and pendulous breasts make
exercise diffi cult.
c h a p t e r

518 • CHAPTER 44
Interestingly, it has recently been established that
increased BMI and amount of tissue resection are risk fac-
tors for postoperative wound complications. As reduction
mammaplasty can be an impetus for weight loss, these
patients do not need to be discouraged from surgery;
however, a higher rate of wound complications can be
expected.
PATIENT PREPARATION
Patients should undergo a thorough preoperative evalua-
tion, in which it is important to ascertain as well as guide
patient expectations. The preoperative evaluation con-
sists of a comprehensive exploration of breast sympto-
mology. Any personal or family history of breast cancer
should be investigated. A thorough breast examination
should also be performed. Any breast masses, nipple dis-
charge, and skin changes should be noted. The shape, size,
and consistency of the breast tissue should be examined.
The most relevant measurements, such as the nipple to
notch distance, should be recorded at this time.
Although preoperative brassiere size is often used as a
measurement, it is unadvisable to make any strong pre-
diction or speak in defi nitive terms regarding a fi nal bras-
siere size. Manufacturers do not utilize a universal system,
and even still, there is a variation of brassiere size choice
amongst women with a similar breast size. Furthermore,
the postoperative scarring that is to be expected of the
procedure must be thoroughly discussed. For patients
older than 40 years old, or those younger with a positive
family history of breast cancer, a recent mammogram
should be provided prior to surgery. Breast asymmetries
are not uncommon, and can also be related to spinal cur-
vature. Preoperative asymmetry, and the potential for a
reasonable level of postoperative asymmetry, should be
thoroughly explained.
The potential for loss of nipple sensation, one of
the more concerning complications following reduc-
tion mammoplasty, should be discussed as well. Patients
should be counseled that a minority of patients lose
nipple sensation. It should also be stated there is a time-
dependent component for a return to nipple sensitivity.
TECHNIQUE
Anatomy
The redundant and multivector nature of the blood sup-
ply to the breast parenchyma and nipple-areola com-
plex affords a diverse array of technique designs. Before
choosing a technique for reduction, it is essential to have
an understanding of the blood supply to the breast.
The dominant blood supply to the breast is supplied
by perforating branches of the internal mammary artery
(also known as the internal thoracic artery). In addition
to the internal mammary perforators, there is a vascu-
lar supply from the pectoral branch of the thoracoacro-
mial artery, lateral thoracic artery, and inferior mammary
arteries (branches of the anterior intercostals arteries).
There is variation, particularly in the ancillary blood
supply, and anatomic studies have demonstrated that the
internal mammary system is the most reliable vascular
supply.
Sensory innervation to the nipple-areola is provided
primarily from the anterior and lateral rami of the 4th
intercostal nerve. Additional innervation can be provided
by 3rd and 5th intercostal nerves as well. In more recent
literature, important fi brous and ligamentous structures
of the breast have been described by Wuringer. These
suspensions have been increasingly discussed in the liter-
ature as they can be used to locate important neurovas-
culature to the breast. Wuringer horizontal septum, arises
from the pectoral fascia at the 4th and 5th rib, traveling
perpendicular from the chest wall to the nipple-areola
complex. This fi brous septum runs horizontally through
the breast parenchyma dividing it into superior and infe-
rior segments. The septum carries the perforators from
the anterior intercostal arteries as well as the main sen-
sory supply to the nipple-areola, namely the 4th inter-
costal nerve which runs with 4th intercostal artery. Also
of anatomical importance, Wuringer described a medial
vertical ligament which contains the perforators of the
internal mammary system, again, typically the dominant
supply to the breast.
Pedicle Design
There are multiple pedicle designs which are possible
given the aforementioned robust blood supply. These
named pedicle types include superior, superomedial,
medial, inferior, and central. Traditionally, surveying of the
plastic surgery community has demonstrated that the infe-
rior pedicle approach is the most prevalent technique. The
inferior dermoglandular pedicle relies primarily on the
lower anterior intercostals perforators, consisting of one or
more perforators from intercostals spaces 4 through 6. The
central pedicle relies on same blood supply as the inferior
pedicle; however, it has been described as solely relying on
the glandular rather than dermoglandular blood supply. In
other words, it relies on the glandular blood supply via the
named supply of Wuringer horizontal septum.
The medial pedicle relies on perforators from the inter-
nal mammary system as the dominant pedicle source.
Oftentimes, the superomedial pedicle can also incorporate
perforator vessels from the lateral thoracic artery, lateral
intercostals artery, or thoracoacromial artery.
Skin Resection Pattern
Essentially pedicle design and skin resection pattern are
independent of one another. Nonetheless, repeated asso-
ciation of a pedicle with a particular skin resection pattern
in the literature gives them, in a sense, some degree of asso-
ciation. Skin resection patterns can be largely divided into
three categories: (1) Wise or inverted T pattern, (2) vertical
reduction pattern, and (3) minimal scarring techniques.

REDUCTION MAMMAPLASTY • 519
Wise Pattern. The Wise or inverted T pattern remains
the most widely utilized skin resection pattern. Typically
this is performed via keyhole pattern in which the supe-
rior aspect of the keyhole is placed a few centimeters
above the nipple-areola complex. The nipple-areola is
then transposed cephalad into the keyhole ( Figure 44-1 ).
Vertical Scar Pattern . The vertical reduction method has
gained traction and is increasingly more prevalent. These
methods eliminate the horizontal inframammary scar
that is typical of inverted T or Wise pattern reductions
( Figure 44-2 ).
Miscellaneous Skin Resection Patterns. While verti-
cal reductions have been described to eliminate the infra-
mammary scar, other authors have described efforts to
eliminate the vertical scar (see operative technique section
below). Additionally, Hammond described a short scar
periareola reduction. 1 A Y-scar vertical mammplasty has
also been described for grade I ptosis and resections less
than 400 g. 2
Skin Markings
Prior to anesthesia administration, the patient is placed
in a standing or upright seated position. The midline of
the chest is marked from the sternal notch inferiorly to
the umbilicus. Next, the breast meridian is marked by
drawing a line from the midclavicle through the nipple-
areola complex, extending onto the upper abdomen.
Attention should then be turned to marking the new
nipple-areola complex, which should be approximately
at the midhumeral point. Critical to the placement of
the future nipple-areola is the utilization of Pitanguy
point, and this landmark can be located by transpos-
ing the inframammary fold onto the anterior portion of
the breast at the midclavicular line. This can be done by
placing one hand in the inframammary fold and palpat-
ing with the examiner’s opposite hand from the anterior
aspect of the breast. The new nipple can be marked at
this point 62 cm above or below this point, depending
on the patient and technique ( Figure 44-3 ).
Vertical pattern reductions often result in the infra-
mammary fold traveling cephalad, and therefore, it is rea-
sonable to mark the new nipple 1 to 2 cm lower than
one would for a Wise pattern. The superior aspect of the
future areola can be marked approximately 2 cm above
the future nipple. A cookie-cutter template is used to
mark the new nipple-areola diameter. Cookie-cutter tem-
plates typically range from 38 to 45 mm in diameter.
The lateral limbs can be marked by rotating the breast
medially and laterally, then marking for the limb when
the tissue is in line with the meridian. From this point
skin markings are dependent on pedicle/skin resection
design, and these will be briefl y mentioned for each
respective technique.
FIGURE 44-1. Inferior pedicle reduction mammaplasty. (A) Markings for Wise
pattern reduction. (B) T-shaped incision on fi nal closure. (Reprinted with permission from
Brunicardi F, Andersen D, Billiar T. Schwartz’s Principles of Surgery . 9th ed. New York:
McGraw-Hill, 2009. )
B
A

520 • CHAPTER 44
Operative Technique
It is preferred that the patient undergoes general anes-
thesia; however, this procedure can be performed under
conscious sedation. Approximately 60 minutes prior the
initial skin incision, intravenous prophylactic antibiot-
ics are administered. Typically a fi rst generation cepha-
losporin is utilized (eg, cefazolin). Compression devices
are placed on the lower extremity for deep vein thrombo-
sis prophylaxis. The patient is then prepped and sterilely
Midsternal mark
Breast meridian marked
IMF
Hatch mark—new NAC location
at approximately 22–23 cm
from the sternal notch
Marking mid-inframammary
fold continuous with central
breast axis and
bilaterally symmetrical
FIGURE 44-3. Commonly utilized landmarks and reference points for skin
markings. (From Shermak MA. Body Contouring . New York: McGraw-Hill; 2010. )
FIGURE 44-2. Vertical reduction mammaplasty, Lejour technique. (A) Markings
for vertical reduction. (B) Closure of the vertical mammaplasty. There is bunching up of
skin and tissue along the vertical limb that will resolve over time; in addition, the new
inframammary fold will declare itself superior to the original one. (Reprinted with permission
from Brunicardi F, Andersen D, Billiar T. Schwartz’s Principles of Surgery . 9th ed. New York:
McGraw-Hill, 2009. )
A
B

REDUCTION MAMMAPLASTY • 521
draped. The skin markings and underlying parenchyma
can be infi ltrated with 0.25% lidocaine and 1:400,000
epinephrine solution. A Penrose drain can be used as a
tourniquet around the base of the breast in order to help
control blood loss as well as ease in the de-epithelization
and incision of periareola skin markings. The following
will describe any skin markings or intraoperative steps
unique to each respective technique listed. Following
parenchymal resection and glanduloplasty, regardless
of technique, the skin edges are closed with buried 3-0
intradermal monofi lament suture and running 4-0 sub-
cuticular monofi lament suture.
Inferior Pedicle and Wise Pattern. A keyhole pattern
is planned using the marking for the new nipple-areola
placement. An inferior dermal pedicle is then planned
started at the inframmary fold (caudal to the nipple-are-
ola complex) then ascending vertically, stopping approx-
imately 1 cm above the current nipple-areola complex.
The dermoglandular pedicle is marked as a vertical strip
(8 cm width 62 cm, widest at the base). This dermoglan-
dular pedicle is then de-epithialized with a 10-blade knife
and bleeding is controlled with Bovie electrocautery. The
skin and parenchyma are then excised en bloc laterally
and superiorly into the keyhole pattern. Vascularized
glandular parenchyma under the dermal fl ap is preserved
with tapering of the dermoglandular fl ap superiorly
toward the nipple-areola. The nipple-areola complexis
then transposed superior into the “empty keyhole,” and
the lateral limbs of the keyhole are reapproximated .
The inferior pedicle can be enhanced by augmenting
the blood supply with medial vasculature. The medial
vertical ligament of Wuringer is incorporated, which
preserves the perforators from the internal mammary
system. This is done by locating the internal mammary
perforators in the medial vertical ligament and creating
a 1 cm thick medial fl ap in conjunction with an inferior
pedicle design.
Inferior pedicle-based reductions have been previ-
ously criticized as creating a wide, fl at, and boxy breast.
This phenomenon of “bottoming out,” or pseudopto-
sis, particularly concerning in larger breasts, prompted
technical modifi cations. These modifi cations have been
reported to minimize this aesthetic complication and
mitigate these shortcomings. One approach is to pli-
cate the inferior pedicle which decreases inferior pedi-
cle length. This is done by folding the dermis on top of
itself at the base of the pedicle. The dermal pedicle is
then sutured to the pectoral fascia 2 to 4 cm above the
inframammary fold in order to lift the breast. The end
goal of these maneuvers is to lift the inframammary fold
and narrow the breast, particularly in the inferior aspect.
There have also been descriptions of an acellular dermal
matrix placed as an inferior hammock to improve out-
comes in inferior pedicle mammaplasty. However, acel-
lular dermal matrix is both a foreign body and a costly
expenditure that likely does not have a justifi able role in
reduction mammaplasty.
Superior Pedicle With Wise Pattern . Superior pedicle
techniques are preferred by those who argue that most
patients are defi cient in the superior pole and that infe-
rior tissue contributing to ptosis should resected. A key-
hole wire can be used the mark the new nipple-areola
and lateral limbs. The lateral limbs are typically around
5 cm. Horizontal markings then connect the medial limb
to the medial inframammary fold, and another horizon-
tal line is drawn to connect the lateral limb to the lateral
inframammary fold. The new periareola marking pro-
vided by the cookie-cutter template is incised superfi -
cially through the epidermis. De-epithelialization begins
at the “upper keyhole” and proceeds inferiorly between
the lateral limbs, then down to the periareola region,
de-epithelializing around to leave about 1 cm around the
old nipple-areola complex. Using the horizontal mark-
ings, the inferior tissue is excised en bloc down to the
pectoral fascia. The dermis of the lateral keyhole limbs is
then divided, and the nipple is then transposed directly
superiorly on along the hemiaxis of the breast. The nip-
ple is secured with intradermal sutures, and the remain-
der of the skin edges are approximated.
Medial/Superomedial Pedicle. The medial/superome-
dial approach has been advocated because is promotes
superomedial fullness. Fullness in this region is generally
thought to be an aesthetic goal in breast surgery. A key-
hole pattern is marked in manner similar to the superior
pedicle described above. The pedicle is then designed
by dividing the keyhole longitudinally in line just lat-
eral to the new nipple-areola border. The pedicle is then
raised with approximately 2 to 3 cm of thickness at the
nipple-areola complex and beveled toward the base. The
lateral remainder of the keyhole and inferolateral tis-
sue is excised en bloc with skin, fat, and parenchyma.
The 9 o’clock of the pedicled nipple-areola is rotated to
12 o’clock of the keyhole excision.
Vertical Scar Reduction. Vertical scar reduction tech-
niques are typically associated with a superior and/
or medial dermoglandular pedicle. Lista et al. describe
an interesting intraoperative anatomical landmark
to dictate pedicle choice. A mosque-shaped dome is
marked around the nipple-areola complex with point
A (12 o’clock) being marked the transposed inframam-
mary fold. 3 This represents the superior aspect of the
new areola (again, the nipple should be marked lower in
vertical than in Wise resection patterns). Points C and D
are marked inferiorly at the base of the mosque-shaped
dome. The skin markings then taper downwards in a nar-
row semicircle to point B which is marked in the breast
meridian, 2 to 4 cm above the inframammary crease. The
new nipple-areola complex is marked with a cookie cut-
ter. If any part of the nipple-areola marking lies above
the level of points C and D, then a superior pedicle is
used, otherwise a medial pedicle is chosen. The resec-
tion is then performed in a manner similar to the above
descriptions.

522 • CHAPTER 44
The medial and lateral pillars of the breast parenchyma
are approximated to shape the breast for greater pro-
jection. The skin is then gathered in the vertical wound
so as to eliminate a horizontal inframammary scar. The
wound is temporarily approximated with skin staples,
and the vertical short is shortened with interrupted four-
point gathering box stitches. This is done by taking two
sequential bites on either side of the wound parallel to
the deep dermis.
There are three classically described approaches
which have been described in the literature regarding
vertical reduction: Lassus technique, Lejour technique,
and Hall-Findlay technique. The most recent permuta-
tion of this technique was described by Hall-Findlay,
which was born from the Lejour description. The Hall-
Findlay modifi cation varies from the Lejour technique
by utilizing a mosque-dome skin resection pattern and
full-thickness medial dermoglandular pedicle. Similar to
Lassus, the Hall-Findlay technique also makes a point to
avoid liposuction prior to en bloc resection, skin under-
mining, and pectoral fascia suspension sutures.
Some would argue that vertical scar reduction is more
limited with regard to the amount of skin and tissue that
can be removed compared with the more traditional
inferior pedicle Wise reduction. Proponents of the verti-
cal techniques disagree plus they believe that the vertical
technique results in improved long-term projection. This
improved projection is theoretically the result of the
coning of the breast as the medial and lateral pillars are
sutured together. By resecting excess tissue and approxi-
mating these pillars, the breast is given a conical shape
with improved projection. While there is certainly merit
to this argument, a well-approximated, tensionless infra-
mammary scar is more desirable than a forced, bunched,
and ultimately, hypertrophic vertical scar. Thus, it is rea-
sonable to avoid an inframammary scar; however, this is
dependent on surgeon familiarity with the vertical tech-
nique and proper patient selection.
Central/Septum-based Approach. Recently Hamdi
et al. has published a series detailing septum-based mam-
maplasty, which utilizes Wuringer horizontal septum.
This can be done to augment a medial or lateral pedi-
cle. Again this septum relies on the anterior intercostal
arteries. 4 In a similar manner, a double pedicle technique
in which the central septum-based pedicle augments a
superior pedicle can be utilized.
No Vertical Scar. A new nipple-areola complex is marked
as in the techniques described above. A new inframam-
mary fold is then drawn approximately 7 cm below
(yet about a centimeter above the current nipple-areola
complex). A vertical scar can be avoided by essentially
creating a superior skin fl ap superior to the nipple-are-
ola complex. This is analogous to a thick, robust mas-
tectomy skin fl ap. A new nipple-areola is excised with
a full-thickness circular excision through the skin fl ap.
The entire region below the skin fl ap (ie, the old nipple-
areola complex periareola region is de-epithelialized).
The nipple-areola complex is then transposed superiorly
to the full-thickness, circular excision previously placed
on the skin fl ap. 5
Free Nipple Grafting. Free nipple grafting has been used
in cases of gigantomastia and severe ptosis. Arbitrary cut-
off values (ie, >12 or 15 cm of nipple transposition) have
traditionally been used to dictate when free nipple graft-
ing may be indicated. The thinking has been that dis-
tant nipple transposition risks an insuffi cient subdermal
plexus, kinking, and/or compression of the dermoglan-
dular pedicle. Therefore, a free nipple graft, essentially
serving as a full-thickness dermal graft, would result in
lower rates of necrosis. While free nipple grafting may
have some residual role in the reduction armamentarium,
multiple large outcomes studies have been published on
pedicled dermoglandular vascular supply for severe cases
of gigantomastia and severe ptosis. Therefore, as one
becomes more comfortable in performing a preferred
technique, most can be applied to these more extreme
cases. In doing so, one can minimize the risk of nipple-
areola necrosis, discoloration, hyposensitivity, and poor
projection which can accompany free nipple grafting.
Suction-assisted Lipectomy. An alternative to en bloc
excision of tissue is to offer patients suction-assisted
lipectomy, which is essentially a scar-less solution for
breast reduction. While suction-assisted lipectomy does
not have a prominent role in reduction mammoplasty, it
may be appropriate for a small niche of carefully selected
patients. Patients who would be reasonable candidates
for suction-assisted lipectomy are generally young, lim-
ited to grade I ptosis, have an acceptable skin brassiere/
skin envelope, and do not desire a change to their nipple-
areola complex. It is also often used as an adjunct to the
surgical resection methods.
Incidental Cancer Detection. Tissue specimens from
en bloc excision should be sent to pathology. The rate
of incidental breast cancer fi nding has been traditionally
reported to be around 0.5%; however, a large prospective
study revealed the rates of carcinoma to be 4% (includ-
ing rates of 12.4% for carcinoma and atypical hyperpla-
sia combined). 6 For this reason, it is recommended that
resected breast specimens should be routinely sent for a
formal evaluation. Aside from the less common fi nding
of invasive occult malignancy, formal sectioning of speci-
mens can reveal proliferative or atypical hyperplasia fi nd-
ings which can identify patients at an increased risk for
future carcinoma. Interestingly, there has also been data
to suggest that the risk of breast cancer is decreased fol-
lowing reduction. This is logically the result of a decrease
in the volume of breast tissue. 7
Drains and Antibiotics. To date, there has been no
evidence to suggest that the usage of either drains or

REDUCTION MAMMAPLASTY • 523
postoperative antibiotics are effi cacious following reduc-
tion mammoplasty. Studies examining this issue have
found that neither drains nor postoperative antibiotics
conferred a reduction in complications to patients. While
many surgeons use both of these measures, at the current
time, these are not evidence-based strategies. 8
Postoperative Care. Most often, postoperative care
can safely be performed on an outpatient basis, thus
patients should plan accordingly. Patients are sent home
in a soft support bra along with a pain control pump
which delivers local anesthetic to the wound. Pain con-
trol pumps have been associated with decreased narcotic
use and shortened time in the postanesthesia care unit.
Upon discharge patients should be instructed to wear a
soft bra and avoid strenuous exercise for 3 months. They
should be followed on a outpatient basis with a return
to the offi ce at approximately 1 week, 6 months, 1 year,
and then as needed.
COMPLICATIONS
Local wound complications can be expected in a small
percentage of patients postoperatively, and it is important
to manage these complications appropriately. Wound
dehiscence, particularly at the T junction of Wise pattern
incisions, is a more frequent local wound complication.
This can often be managed conservatively with obser-
vation or wound packing, if necessary. Patients can also
present with seroma or hematoma formation. It is advis-
able to drain these collections in either the offi ce or with
a return to the operating room. Prolonged serosanguinous
collections place the patient at risk for infection.
Nipple-areola necrosis is the most troublesome and
irreversible of the complications. Partial necrosis can
be managed more conservatively, whereas total nipple-
areola necrosis ultimately results in loss of the nipple.
Following debridement and wound healing of the
necrosed nipple-areola, nipple reconstruction techniques
(as described for breast reconstruction) and areola tat-
tooing can be performed. In some instances, a healthy
but hypochromic nipple may result postoperatively. If
this is of concern for the patient, this can be addressed
with tattooing after healing is complete.
Another complication which can result following
reduction is loss of nipple sensitivity. Some monofi la-
ment testing has suggested that superior pedicle reduc-
tions result in lower nipple sensation as compared with
other pedicle designs. 9 In another study, medial and infe-
rior pedicle reductions demonstrated no difference in
sensibility, and both pedicle types resulted in an approxi-
mately 90% rate of total nipple-areola sensation postop-
eratively. 10 , 11 As a whole, clinical outcomes studies have
not provided clear evidence to suggest that one pedicle
is superior over another in having a higher likelihood of
sensation preservation. Theoretically, the 4th intercos-
tal nerve (the main sensory component to the nipple)
runs with the anterior intercostals artery, therefore the
chance of this complication is affected by reduction size
and preservation this neurovascular bundle.
Related to the issue of sensibility, a concerning com-
plication for fertile women is the loss of lactational
function. Level III evidence has suggested that superior,
medial, and inferior pedicles were all comparable to a
control group of women regarding the ability to lactate.
All groups in the previously mentioned study all had a
lactation success rate of approximately 60% to 65%. 12
The continued ability to lactate is likely a function of the
about of remaining lobules rather than pedicle choice,
and generally speaking, reduction does not preclude the
large majority of women who wish to do so.
OUTCOMES ASSESSMENT
Regardless of the technique used, few other procedures,
cosmetic or reconstructive, produce such high rates of
patient satisfaction. Large series of postoperative patient
surveys have demonstrated a satisfaction rate this has
been reliably above 90%. 13 , 14 In conjunction with satis-
factory results, patients have noted improved self-esteem
measures. Given that there is also a functional improve-
ment component, the overall patient satisfaction and aes-
thetic satisfaction outcomes are not entirely equivalent.
Nonetheless, in an examination into strictly aesthetics,
patients were pleased with the aesthetic outcomes. The
most common cause of aesthetic dissatisfaction amongst
the patients and independent plastic surgeon review-
ers was scarring, and to a lesser extent, high nipple
position. 15
Symptom Improvement
A recent prospective study examined 1 year of con-
secutive reduction mammaplasty patients. All patients
completed an assessment that used fi ve independently
validated measures of quality of life. Uniformly, patients
scored higher with each of these instruments which dem-
onstrated marked improvements in musculoskeletal pain
and psychosocial measures. This same study predicted
a gain of 5.32 quality-adjusted life-years as a result of
reduction mammaplasty. 16 Even with smaller reductions,
these improvements in musculoskeletal pain are accom-
panied by daily and athletic functional improvements.
In addition to the well-documented amelioration of
musculoskeletal pain, Ducic et al. examined the chronic
headache/migraine pain in this patient population as
well. In a retrospective study of 84 patients, 53% noted
a signifi cant reduction in the severity and frequency of
migraines/headaches. 17

524 • CHAPTER 44
REFERENCES
1. Hammond DC. Short scar periareolar inferior pedicle
reduction (SPAIR) mammoplasty. Plast Reconstr Surg .
1999;103:890–901.
2. Hidalgo DA. Y-scar vertical mammaplasty. Plast Reconstr
Surg . 2007;120:1749–1754.
3. Lista F, Ahmad J. Vertical scar reduction mammaplasty: A
15-year experience including a review of 250 consecutive
cases. Plast Reconstr Surg . 2006;117:2152–2165.
4. Hamdi M, Van Landuyt K, Tonnard P, et al. Septum-based
mammaplasty: A surgical technique based on Wuringer’s
septum for breast reduction. Plast Reconstr Surg . 2009;123:
443–454.
5. Keskin M, Tosun Z, Savaci N. Seventeen years of experience
with reduction mammaplasty avoiding the vertical scar. Aes-
thetic Plast Surg . 2008;32:653–659.
6. Ambaye AB, MacLennan SE, Goodwin AJ, et al. Carcinoma
and atypical hyperplasia in reduction mammaplasty: in-
creased sampling leads to increased detection. A prospective
study. Plast Reconstr Surg . 2009;124:1386–1392.
7. Boice JD, Persson I, Brinton LA, et al. Breast cancer fol-
lowing breast reduction in Sweden. Plast Reconstr Surg .
2000;106:755–762.
8. Noone RB. An evidence-based approach to reduction mam-
maplasty. Plast Reconstr Surg . 2010;126:2171–2176.
9. Schlenz I, Rigel S, Schemper M, Kuzbari R. Alteration of
nipple and areola sensitivity by reduction mammaplasty: A
prospective comparison of fi ve techniques. Plast Reconstr
Surg . 2005;115:743–751.
10. Nahabedian MY, Mofi d MM. Viability and sensation of the
nipple-areolar complex after reduction mammaplasty. Ann
Plast Surg . 2002;49:24–31.
11. Mofi d MM, Dellon AL, Elias JJ, Nahabedian MY. Quantita-
tion of breast sensibility following reduction mammaplasty:
A comparison of inferior and medial pedicle techniques.
Plast Reconstr Surg . 2002;109:2283–2288.
12. Cruz NI, Korchin L. Lactational performance after breast
reduction with different pedicles. Plast Reconstr Surg .
2007;120:35–40.
13. Cardenas-Camarena L. Reduction mammoplasty with supe-
rolateral dermoglandular pedicle: details of 15 year of expe-
rience. Ann Plast Surg . 2009;63:255–261.
14. Davis GM, Ringler SL, Short K, et al. Reduction mamma-
plasty: long-term effi cacy, morbidity, and patient satisfaction.
Plast Reconstr Surg . 1995;96:1106–1110.
15. Goodwin Y, Wood SH, O’Neill TJ. A comparison of the
patient and surgeon opinion on the long-term aesthet-
ic outcome of reduction mammaplasty. Br J Plast Surg .
1998;51:444–449.
16. Thoma A, Sprague S, Veltri K, et al. A prospective study of
patients undergoing breast reduction surgery: health-related
quality of life and clinical outcomes. Plast Reconstr Surg .
2007;120:13–26.
17. Ducic I, Iorio ML, Al-Attar A. Chronic headaches/migraines:
extending indications for breast reduction. Plast Reconstr
Surg . 2010;125:44–49.

45
Advances in Mastopexy
Scott L. Spear, MD / Mark Warren Clemens, MD / Adam D. Schaffner, MD, FACS
INTRODUCTION
The passage of time may result in the loss of skin elastic-
ity and shape of the female breast. Gravity, weight loss,
pregnancy, and breastfeeding all may lead to increasingly
pendulous ptotic breasts with further loss of fi rmness, pro-
jection, and downward pointing nipples. Many women
may express satisfaction with their bra cup size, but still
wish to lift the breast in order to restore a more youthful
appearance. The challenge remains restoring a more youth-
ful breast and preserving nipple sensation while minimiz-
ing complications, side effects, and scars. The four main
variations on mastopexy, in order of ascending complexity
are primary mastopexy, augmentation/mastopexy, mas-
topexy after augmentation, and secondary augmentation
mastopexy. This chapter will focus on appropriate patient
selection and evaluation followed by some of the most cur-
rent, safe, and effective surgical techniques for mastopexy.
PATIENT SELECTION AND EVALUATION
Preoperative evaluation begins with a systematic evalua-
tion of the patient’s ptosis. A thorough history and physical
examination includes particular attention to oncologic his-
tory and previous breast surgeries. All women as appropri-
ate should undergo baseline mammograms prior to surgery
as recommended by published guidelines.
There are a number of variables that may increase
the risks of performing a mastopexy, including, but not
limited to, smoking, collagen vascular diseases, diabetes,
or previous breast surgery such as breast augmentation
or breast reduction. Smokers are counseled regarding
the increased risk of fl ap necrosis and are encouraged to
stop smoking for a minimum of 2 weeks before surgery.
Since the blood supply to the nipple-areola complex is
impaired to some extent in such patients, the procedure
is performed very carefully with minimal undermining.
Previously augmented patients have some degree of infe-
rior pole tissue thinning from the implant and, for the
same reason, a cautious and conservative approach is
necessary in these patients.
The preoperative evaluation includes an assessment of
the size and surface area of the breast, the elasticity of
the skin, and quality of the breast parenchyma, as well
as the relationship between the nipple, the breast gland,
and the inframammary fold. The assessment begins with
two key elements: nipple position and its distance from
the inframammary fold, as classifi ed by Regnault, and the
amount of breast tissue that overhangs the inframammary
fold. Using the Regnault classifi cation, breast ptosis is
rated as grade 1 ptosis, nipple lying at the inframammary
fold; grade 2, nipple below the inframammary fold but
still on the anterior portion of the breast; and grade 3 pto-
sis, where the nipple is at the most inferior portion of the
breast ( Figure 45-1 ). 1 Glandular ptosis or pseudoptosis is
when a signifi cant amount of the breast tissue falls below
the inframammary fold, but the nipple is still located at
or above the inframammary fold. Breast ptosis can be
a complex problem to describe and solve as it involves
more elements than just the relationship between the
nipple position and the inframammary fold designated
by the Regnault classifi cation. There is a broad spectrum
of patients who are possible candidates for mastopexy
that have the same Regnault classifi cation, but have very
different anatomy and present with very different chal-
lenges. For example, a young patient with a small tuber-
ous breast deformity and a Regnault grade 2 ptosis with
a short nipple to inframammary fold distance and a tight
skin envelope represents an entirely different problem
c h a p t e r
Dr. Spear is a paid consultant to LifeCell and Allergan corporations. Drs Clemens and Schaffner have no disclosures.

526 • CHAPTER 45
compared with a postpartum woman with C-cup grade 2
ptosis, a long nipple to inframammary fold distance, and
loose skin envelope with defl ated breasts.
There are four basic situations where patients will
request a mastopexy. The fi rst is the patient interested in
a bilateral mastopexy for an ample breast plus/minus a
small reduction. Principal goals within this patient are to
lift and reshape. Second is the unilateral mastopexy per-
formed opposite a reconstruction or nonptotic breast. The
goals there focus mainly on achieving improved symmetry.
Third is the augmentation/mastopexy, which is intended
to enlarge the breast while reducing the skin envelope
and moving the nipple. And last is the revision mastopexy,
which aims to correct the goals that were not adequately
addressed in the primary procedure. All of these factors
infl uence the mastopexy plan and pattern.
BILATERAL MASTOPEXY
FOR THE AMPLE BREAST
Patient Preparation
The authors’ preferred short scar technique includes
a superior pedicle and a vertical skin excision pattern
from the nipple extending vertically down to just above
the inframammary fold. 2 , 3 If required, a small transverse
skin excision can be added in the inframammary fold
to eliminate any excess skin and dog-ear(s). Creation
of glandular fl aps and joining medial and lateral pillars
narrows and cones the breast, increases projection, and
partially contributes to superior pole fullness. Vertical
mastopexy incorporates all of these principles, and
therefore represents a type of technique, not just a scar
pattern.
FIGURE 45-1. Regnault classifi cation: (A, B) breast ptosis is rated as grade 1 ptosis,
nipple lying at the inframammary fold; (C, D) grade 2 nipple below the inframammary fold
but still on the anterior portion of the breast; and (E, F) grade 3 ptosis, nipple is at the
most inferior portion of the breast.
A
C
E
B
D
F

ADVANCES IN MASTOPEXY • 527
Planning begins with the patient standing upright. First,
draw the midline, breast meridians, and inframammary
folds. A line is drawn tangential to the inframammary folds
across the front of the chest to the midline for use as a
reference. The midline is marked from the sternal notch to
the xiphoid process toward the umbilicus. Careful atten-
tion is paid to marking the breast meridians, as there are
often lateral asymmetries of the nipple-areola complex
that might be improved by adjusting the planned excision
( Figure 45-2 ).
The degree of ptosis is then evaluated noting the rela-
tionship of the nipple to the inframammary fold, the dis-
tance between the nipple and inframammary fold, and the
volume of breast that overhangs the fold. The distance
from the nipple to the inframammary fold is measured
with the skin placed on tension to simulate the stretch that
will be caused after skin excision. Sternal notch to nipple
distance differs among patients with different heights,
and as such, the absolute numerical measurement is not
as helpful as the previously mentioned measurements.
However, the nipple to inframammary fold distance is
used as a guide to assess symmetry of the nipple-areola
complex in each patient. Based on these measurements,
an appropriate excision pattern is planned. First, supero-
medial traction is applied to the breast and vertical marks
are drawn on the lateral surface of the breast skin over the
projected breast meridian. Next, superolateral traction is
applied to the breast and similar vertical marks are drawn
on the medial surface of the skin over the projected breast
meridian. The key to marking the pillars is estimating how
much the medial and lateral portions of the breast can
be mobilized to the breast meridian ( Figure 45-3 ). These
markings extend from the circumareola marks and join in
a V or U shape just above the inframammary fold. These
lines are then pinched together to check if skin closure is
possible. The length of the vertical limb is directly related
to the amount of ptosis, but never extends beyond the
inframammary fold. If there is signifi cant asymmetry
between the two breasts, it follows that the planned skin
excisions may be different. It is made clear to the patient
before surgery that while the intent of the procedure is to
achieve a more symmetrical result, perfect symmetry is
never achieved.
As part of the initial skin marking in the examination
room, the nipple-areola complex is manually stretched
superiorly and tailor-tacked with the examiners fi nger tips
so that the upper border of the planned new areola position
can be marked on the chest with the nipple at or slightly
below the center of the projected dimensions of the breast
mound ( Figure 45-2 ). Gentle downward traction is placed
simultaneously on the superior pole breast skin to simulate
the tension that will be created by the mastopexy. It is
important to note that the vertical component of the exci-
sion will reduce the diameter of the circumareola aper-
ture by a distance measuring approximately one third of
the width of the vertical excision (circumference 5 p 3
diameter). It is this reduction in width which helps cone
and project the breast.
Operative Technique
Circumvertical T`echnique. The procedure itself begins
with the patient in the supine position with arms tucked or
abducted less than 90 degrees. Be sure not to over abduct
the arms in order to minimize the risk of any nerve injury.
Pad both hands, elbows, and any other pressure points. A
38 or 42 mm cookie cutter is centered over each nipple
without undue tension on the skin. After de-epithelializing
the skin between the reduced areola and the outside border
of the new areola window, the outer circumference of the
dermis is incised, ensuring the incision is about 5 to 7 mm
away from the skin edge in order to leave an adequate
dermal cuff in which to place a purse-string suture if
desired. Skin edges may be conservatively undermined
Breast
meridian
Inframammary fold
A
A
A
A
FIGURE 45-2. (A) Marking the patient. The
inframammary fold and breast meridian are marked fi rst. Point
X represents the new nipple position. It is often marked 2 to
3 cm above the inframammary fold. Point A represents the top
of the areola located 2 cm above the nipple site or 4 to 5 cm
above the inframammary fold. (B) Tailor-tacking. The desired
upper border of the areola can be defi ned by lifting the edge
of the areola between the thumb and index fi nger and pinning
it on the upper breast. (Modifi ed from Spear SL, Venturi ML.
Augmentation with periareola mastopexy. In: Spear SL, ed. Surgery
of the Breast: Principles and Art. 2nd ed. Philadelphia: Lippincott
Williams & Wilkins; 2006.)
A
B

528 • CHAPTER 45
(approx. 0.5 cm thickness) from the glandular tissue to
minimize skin retraction and aid in closure.
Along the vertical component, after the skin inci-
sion is made, the skin is de-epithelialized or removed
as marked. A decision at this moment must be made
whether to imbricate the breast or mobilize fl aps based
medially and/or laterally. Our preference is to split the
lower pole of the breast along or near the medial edge
of the window created by the inferior skin excision, thus
allowing the mobilization of all the exposed breast tissue
on a laterally based fl ap. The lower pole breast tissue is
elevated inferiorly at the level of the pectoralis fascia.
This leaves the nipple-areola complex on a superiorly
based pedicle. The central portion of the inferior pole
may either be resected or included as part of the lateral
and/or medial fl aps. De Mey et al. noted a critical length
of the pillars to be an average of 7 cm from inferior bor-
der of the areola to inframammary fold. 4
In their technique, Graf and Biggs advocate the use of
a pectoralis muscle sling to act as support and minimize
breast ptosis recurrence. 5 Their technique involves the
creation of three fl aps: a centrally/inferiorly chest wall-
based fl ap and medial and lateral pillars. The central fl ap
is attached superiorly and held in place by a bipedicled
loop of pectoral muscle over which the medial and lateral
pillars are closed. Ritz et al. 6 similarly describe using a
bipedicled pectoral fascia fl ap to hold an inferiorly pedi-
cled fl ap. Unfortunately, these techniques do violate the
pectoralis muscle and fascia which may raise oncologic
concerns when performing lumpectomy, mastectomy, or
even radiographic studies. Additionally, we have found
that the central fl ap is not actually truly inferiorly based
and adequately mobilizing the fl ap off of the chest wall
may additionally compromise its blood supply.
We do, however, fi nd the creation of glandular fl aps
to be a very powerful tool, but we prefer a different
approach. We too mobilize and attach glandular tissue
to the chest wall in a retroglandular space, which serves
to augment projection. We do this by recruiting tissue
based on a lateral fl ap ( Figure 45-4 ). Absorbable sutures
FIGURE 45-3. After the superior edge of the areola is marked, the new areola is
drawn while the breast mound is gently pinched. A gentle “push-pull” method should
be used to tentatively mark the medial and lateral extent of skin excision. (Reprinted with
permission from Spear SL, Giese SY. Simultaneous breast augmentation and mastopexy. Aesthetic
Surg J. 2000;20:155.)

ADVANCES IN MASTOPEXY • 529
placed high on the chest attach this fl ap to the pectoralis
fascia to overcorrect the lift and compensate for postop-
erative settling. The lateral fl ap is mobilized and rotated/
advanced superomedially to fi ll out the central region of
the breast behind and above the nipple-areola. The medial
glandular pillar is then approximated to the base of the
lateral fl ap. Plication of the pillars from the inframam-
mary fold to just below the areola is then performed in a
vertical fashion to cone the breast. The re-approximated
pillars may be reinforced with several rows of absorbable
sutures, which adds additional projection to the mound
and creates a column of breast tissue. 7
Excess skin may be evenly distributed along the entire
vertical incision. If there is too much excess tissue to be
absorbed by the vertical incision, the skin generated at
the lower pole may be drawn together in a purse string.
Alternatively, any residual dog-ear may be excised leav-
ing a small transverse scar in the inframammary fold. No
matter what, the fi nal vertical scar should be entirely
contained above the inframammary fold. To counteract
unavoidable settling, the superior pole should be overly
full in relation to the inferior pole at the end of the
procedure.
Final nipple position should be in the vicinity of the
apex of the breast. If the circumference of the new areola
risks being signifi cantly larger than desired, a “blocking”
suture can be used by purse-stringing the dermal cuff
with a permanent 3-0 or 4-0 suture. 8 We have adopted
the interlocking Gore-Tex suture technique described by
Hammond for that purpose ( Figure 45-5 ). Finally, the skin
is closed with interrupted and running buried absorbable
monofi lament suture ( Figure 45-6 ).
Wise Pattern Technique. The inverted T skin pattern
remains the most commonly performed type of mastopexy
in the United States. 9 We believe that in the vast majority
of cases, a circumvertical technique is suffi cient, leaving
a formal Wise pattern only to be used to treat the most
severe grades of ptosis such as in the massive weight loss
patient.
Upper limit of
undermining
Inframammary
fold line
Breast tissue removed
Remaining breast tissue
De-epithelialized tissue
Lateral pillar
Medial pillar
Pectoralis fascia
FIGURE 45-4. Creation of lateral and medial glandular fl aps mobilized and
attached to the chest wall in a retroglandular space serves to augment projection. Note
that the longer lateral fl ap is mobilized and rotated/advanced superomedially to fi ll out
the central region of the breast behind and above the nipple-areola. The medial glandular
pillar is then approximated to the base of the lateral fl ap. Plication of the pillars from the
inframammary fold to just below the areola is then performed in a vertical fashion to cone
the breast.

530 • CHAPTER 45
FIGURE 45-5. (A) Purse-string suture. A 3-0 or 4-0 Gore-Tex suture on a straight
needle is run circumferentially around the areola in the deep dermis and sewn down
with the nipple marker in place to set the aperture. (B) Clinical view. (Part A: Reprinted
with permission from Spear, S. L., and Giese SL, Giese SY. Simultaneous breast augmentation
and mastopexy. Aesthetic Surg J. 2000;20:155.)
Superior based
flap
Laterally based
flap
A
B
Preoperative evaluation and markings proceed similar
to a short scar mastopexy with the following exceptions:
(1) the horizontal component of the skin pattern is placed
at the level of the inframammary fold and the fi nal skin
closure should remain within this position ( Figure 45-7 );
(2) after skin incisions have been performed, dissection
may proceed with either a superior, superomedial, inferior,
or central pedicle to supply the nipple-areola complex;
and (3) medial and lateral pillars consisting of skin and
breast parenchyma are then elevated just above the level
of the pectoralis fascia for advancement or transposition,
as described in the circumvertical technique. Excess tissue
may be trimmed from the cut edge of the lateral fl ap and/
or from the inferior aspect of both fl aps.

ADVANCES IN MASTOPEXY • 531
FIGURE 45-6. (Left) Preoperative view of a 19-year-old woman with third-degree
ptosis and tuberous breast deformity. (Right) Postoperative view, 6 months after
undergoing bilateral vertical mastopexies.
Once the vertical and horizontal limbs are sutured
closed, the nipple areolar complex is inset at the apex of
the keyhole pattern with the inferior border of the areola
set 5 to 7 cm superior to the inframammary fold.
Concentric Technique. When planning the mastopexy
pattern, a concentric pattern may at fi rst seem desirable
with respect to limiting the amount of scars placed on
the breast; however, this is at the cost of placing more
tension on the closure and may lead to a fl attened breast,
poor scarring, and/or a distorted nipple-areola complex,
and is not advised for a mastopexy alone. 10 A circumver-
tical excision pattern increases projection by narrowing
and coning the breast and provides the most control in
terms of shaping the breast. Even in situations where
an acceptable result using a concentric pattern could be
achieved, we will often add a conservative vertical exci-
sion to improve the overall shape of the breast.
We rarely perform an isolated concentric mastopexy.
The most common indications for concentric mastopexy
are for attempting to match a reconstructed breast, gyne-
comastia, and unilateral or bilateral mastopexies done
for asymmetry in conjunction with breast augmentation
( Figure 45-8 ). Concentric mastopexy may also be suc-
cessful when combined with implant explantation. 9
It should not be attempted for substantial grade 2 or
3 ptosis.
AUGMENTATION/MASTOPEXY
The single-stage augmentation/mastopexy has the unen-
viable distinction as one of the most litigated procedures
in plastic surgery. 11 An increased risk of skin and nipple
necrosis, distortion of the nipple-areola complex, poor scar-
ring, and even implant extrusion results from an increas-
ingly compromised blood supply and greater stress on the
closure.
The inherent risks of this procedure have not affected its
popularity among patients. Between 1997 and 2007, there
has been a 395% increase in the frequency of breast aug-
mentation and an equal increase in breast lift procedures. 12
The number of combined augmentation/mastopexy pro-
cedures has similarly increased in frequency because of the
convenience of a single-stage operation. We have previ-
ously written extensively on the subject of augmentation/
mastopexy. 13 , 14