Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

Capsular Contracture
Capsular contracture is a pathologic process thought to result from chronic inflammation of the
periprosthetic capsule, resulting in thickening of the capsule and tightening around the implant (Figure
59.8). The Baker Scale is used to grade severity of capsular contracture: grade 1 is a normal, soft breast;
grade 2 is a minimally firm breast; grade 3 capsular contracture results in a visible distortion of the breast,
and grade 4 capsular contracture causes a painful breast with severe distortion. Rates of capsular
contracture following implant-based reconstruction at 3 years are estimated at between 10% and 13% in
core studies from Mentor and Allergan. Hematoma, radiation, silicone rupture, and biofilm formation are
all considered to increase the incidence of capsular contracture. Techniques for prevention of capsular
contracture attempt to target these risk factors (meticulous sterile technique, hemostasis, and pocket
irrigation), but an evidence-based approach to treatment of capsular contracture is lacking. A good
summary of the current evidence for capsular contracture management was published by Wan and
Rohrich; in general, effective surgical techniques require capsulectomy, implant exchange, change of
implant position, and use of ADM. 67
FIGURE 59.8 Severe capsular contracture several years following implant-based reconstruction resulting in pain and implant
malposition.
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Implant Malposition or Asymmetry
Breast symmetry can be difficult to achieve, particularly in patients with significant premorbid breast
asymmetry with respect to both breast size and shape. It is important to point out to the patient any
notable asymmetries preoperatively because these may become more apparent after reconstruction. In
unilateral reconstruction, contralateral procedures such as breast reduction or mastopexy may be needed
to achieve better symmetry. It is important to discuss the likelihood of needing secondary procedures to
achieve the best overall result.
Implant malposition is a common complication that may result from overdissection of the mastectomy
pocket, expansion in an inappropriate vector, poor implant choice, or capsular contracture. Attention to
maintaining or recreating the native breast landmarks at the first stage of reconstruction, in particular the
inframammary fold and lateral breast border, can help prevent this complication. At the second stage of
reconstruction, capsulorrhaphy may be needed to reestablish the optimal implant pocket.
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Postoperative Care
Drains
Drains are considered a standard though inconvenient part of implant-based reconstruction. Practice
patterns vary considerably, but in our practice one or two closed-suction drains are left in the
subcutaneous space until output is less than 30 cc over a 24-hour period. Typical drain duration is 1 to
2 weeks. Persistent high output from a drain can sometimes be improved by partially inflating the tissue
expander to decrease the amount of dead space.
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Antibiotics
The data supporting antibiotic use in implant-based reconstruction are mixed, and practice patterns vary
significantly. Whereas some surgeons treat patients with a preoperative dose of antibiotics only, others
prefer to treat with oral outpatient therapy until surgical drains are removed. A recent review by Phillips
and Halvorson noted that although data seem to support preoperative antibiotic dosing in decreasing the
risk of infectious complications, there was insufficient evidence to recommend continuing antibiotics on
an outpatient basis. 68
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Questions
1. A 44-year-old woman undergoes immediate right breast reconstruction with placement of a tissue
expander in the partial submuscular position. ADM is used to cover the lower pole of the device.
Which of the following is not a potential advantage of ADM use in this patient?
a. Maintains optimal implant position on the chest wall
b. Reduced risk of seroma and implant infection
c. Reduced rate of capsular contracture
d. Improved definition of inframammary fold and lateral breast border
e. Improved aesthetic outcome
2. A 30-year-old fitness instructor comes to clinic to discuss prosthetic breast reconstruction. She
would like to know if she is a candidate for single-stage direct-to-implant reconstruction. Which of the
following patient characteristics is not a contraindication to single-stage prosthetic reconstruction?
a. BMI >30
b. Active smoker
c. Thin mastectomy skin flaps
d. B-cup breasts prior to mastectomy
e. Desire for larger postreconstruction breast size
3. A 38-year-old woman with large breasts comes to clinic to discuss reconstruction after planned
mastectomy for a newly diagnosed right breast cancer. Which of the following is not considered an
advantage of implant-based reconstructions over autologous reconstruction methods?
a. Shorter operative time
b. Easier to achieve symmetry with contralateral breast
c. Greater long-term patient satisfaction
d. Improved control over final reconstructed breast volume
e. Both b and c
4. A 45-year-old woman who underwent bilateral breast reconstruction with tissue expanders
3 weeks prior 
 comes to clinic with a warm, swollen, red right breast. Her drain output is cloudy.
She has a low-grade temperature. Her WBC is 13. She is admitted for IV antibiotic therapy and
attempted implant salvage. Which of the following clinical findings is most predictive of failure of
implant salvage?
a. Diffuse breast erythema
b. Purulent drain output
c. Temperature greater than 38.6
d. WBC greater than 13
e. Wound cultures growing methicillin-sensitive staphylococcus.
1. Answer: b. ADM has become a useful adjunct in implant-based breast reconstruction as a reliable
method to maintain the implant pocket, specifically by reconstituting the inframammary fold and
lateral breast border, thereby maintaining the device in the optimal position on the chest wall. This
has been shown in some studies to translate into improved aesthetic results as graded by both
surgeon and patient. Evidence from multiple studies demonstrated decreased risk of capsular
contracture when ADM is used at the time of reconstruction. Despite this positive effect, several
retrospective reviews have demonstrated an increased risk of other complications including seroma
and infection with ADM. A recent meta-analysis of ADM use demonstrated no clear increase in
incidence of seroma or infection when ADM was used, but there is no evidence that ADM results in a
lower incidence of these complications. 2
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2. Answer: d. When considering single-stage implant-based reconstruction following mastectomy,
patient selection is key. There are added technical considerations when direct placement of
permanent implant is performed that must be considered to obtain the best possible outcome. None
of these appears more important than the overall quality and viability of the mastectomy skin flaps.
Flaps that are overly thin or that exhibit poor bleeding are more prone to skin necrosis, implant
exposure, and reconstructive failure from the added stress of the device, and are therefore a
contraindication to single-stage implant reconstruction. Along similar lines, smoking significantly
increases the risk of wound complications following direct-to-implant reconstruction, and is a
relative contraindication to this technique. Healthy patients without comorbidities such as obesity
and diabetes have been shown to have the best outcomes with this technique. The need for revision
and complication rates appear to correlate with increasing premastectomy breast size; therefore,
patients with small (A or B cup) breasts tend to make the best candidates for a single-stage technique.
3. Answer: e. Implant-based reconstruction techniques have several advantages when compared to
autologous reconstructions. Implant-based reconstructions can typically be performed in a much
shorter period of time, as they do not require dissection of autologous donor tissue or, as in the case
of microsurgical reconstruction, the dissection of recipient vessels. Although the volume of an
autologous reconstruction is limited by the quantity of donor tissues, the final volume of an implant-
based reconstruction can to a certain extent be controlled by the surgeon, both through tissue
expansion and final implant selection. One downside of implant-based reconstruction is the ability to
obtain symmetry of the reconstructed breast with contralateral native breast tissue. Over time, as the
contralateral breast develops ptosis, asymmetry may become even more evident. The difference in
the long-term behavior of an implant reconstruction may partially account for differences in long-
term patient satisfaction between prosthetic and autologous methods. There are data that though
patient satisfaction initially is no different between prosthetic and autologous reconstruction, over
time patients tend to become less satisfied with the appearance of an implant reconstruction whereas
their satisfaction with an autologous reconstruction remains relatively constant. 69
4. Answer: d. There is a broad range of severity of surgical site infections following implant-based
reconstruction. Although erythema isolated to the mastectomy incision may represent a more
superficial process that can be managed with outpatient oral antibiotics, infections involving the
implant pocket itself may present with whole breast erythema, purulent drain output, and systemic
signs such as fever and leukocytosis. Even in the setting of more severe infections, implant salvage is
possible and can be considered for certain properly selected patients. A recent study of nearly 2000
implant reconstructions identified elevated WBC at admission and intraoperative cultures growing
MRSA as independent predictors of salvage failure. 65 Diffuse erythema, character of drain output,
fever, and methicillin-sensitive Staphylococcus aureus growth were not predictive of need for
explantation.
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versus conventional two-stage implant reconstruction. Plast Reconstr Surg. 2015;136(6):1135-1144.A meta-analysis of studies comparing single-
versus two-stage implant reconstruction complication rates and outcomes.
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contracture: a 13-year experience. Plast Reconstr Surg. 2016;138(2):329-337.
Antony, AK, McCarthy, CM, Cordeiro, PG, et al. Acellular human dermis implantation in 153 immediate two-stage tissue expander breast
reconstructions: determining the incidence and significant predictors of complications. Plast Reconstr Surg. 2010;125(6):1606-1614.
Chun, YS, Verma, K, Rosen, H, et al. Implant-based breast reconstruction using acellular dermal matrix and the risk of postoperative
complications. Plast Reconstr Surg. 2010;125(2):429-436.
Lanier, ST, Wang, ED, Chen, JJ, et al. The effect of acellular dermal matrix use on complication rates in tissue expander/implant breast
reconstruction. Ann Plast Surg. 2010;64(5):674-678.
Treiser, MD, Lahair, T, Carty, MJ. Tissue expander overfilling: achieving new dimensions of customization in breast reconstruction. Plast
Reconstr Surg Glob Open. 2016;4(2):e612.
Cunningham, BL, Lokeh, A, Gutowski, KA. Saline-filled breast implant safety and efficacy: a multicenter retrospective review. Plast Reconstr
Surg. 2000;105(6):2143-2149; discussion 2150–2141.
Holmich, LR, Friis, S, Fryzek, JP, et al. Incidence of silicone breast implant rupture. Arch Surg. 2003;138(7):801-806.
Rohrich, RJ, Reece, EM. Breast augmentation today: saline versus silicone—what are the facts? Plast Reconstr Surg. 2008;121(2):669-672.
Macadam, SA, Ho, AL, Cook, EF Jr, et al. Patient satisfaction and health-related quality of life following breast reconstruction: patient-
reported outcomes among saline and silicone implant recipients. Plast Reconstr Surg. 2010;125(3):
 761-771.
Singh, N, Picha, GJ, Hardas, B, et al. Five-year safety data for more than 55,000 subjects following breast implantation: comparison of rare
adverse event rates with silicone implants versus national norms and saline implants. Plast Reconstr Surg. 2017;140(4):666-679.
Barnsley, GP, Sigurdson, LJ, Barnsley, SE. Textured surface breast implants in the prevention of capsular contracture among breast
augmentation patients: a meta-analysis of randomized controlled trials. Plast Reconstr Surg. 2006;117(7):
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Gahm, J, Edsander-Nord, A, Jurell, G, Wickman, M. No differences in aesthetic outcome or patient satisfaction between anatomically shaped
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Barry, M, Kell, MR. Radiotherapy and breast reconstruction: a meta-analysis. Breast Cancer Res Treat. 2011;127(1):15-22.
Lam, TC, Hsieh, F, Boyages, J. The effects of postmastectomy adjuvant radiotherapy on immediate two-stage prosthetic breast
reconstruction: a systematic review. Plast Reconstr Surg. 2013;132(3):511-518.
Jagsi, R, Momoh, AO, Qi, J, et al. Impact of radiotherapy on complications and patient-reported outcomes after breast reconstruction. J Natl
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National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Breast Cancer. Version 2. Published April 26, 2017;
Accessed July 19, 2017.
Nava, MB, Pennati, AE, Lozza, L, et al. Outcome of different timings of radiotherapy in implant-based breast reconstructions. Plast Reconstr
Surg. 2011;128(2):353-359.
Cordeiro, PG, Albornoz, CR, McCormick, B, et al. What is the optimum timing of postmastectomy radiotherapy in two-stage prosthetic
reconstruction: radiation to the tissue expander or permanent implant? Plast Reconstr Surg. 2015;135(6):1509-1517.Single surgeon experience
looking at both surgeon and patient-reported outcomes following radiation of either the tissue expander or the permanent implant in two-stage
reconstruction.
Santosa, KB, Chen, X, Qi, J, et al. Postmastectomy radiation therapy and two-stage implant-based breast reconstruction: is there a better time
to irradiate? Plast Reconstr Surg. 2016;138(4):761-769.
Peled, AW, Foster, RD, Esserman, LJ, et al. Increasing the time to expander-implant exchange after postmastectomy radiation therapy
reduces expander-implant failure. Plast Reconstr Surg. 2012;130(3):503-509.
Lentz, R, Ng, R, Higgins, SA, et al. Radiation therapy and expander-implant breast reconstruction: an analysis of timing and comparison of
complications. Ann Plast Surg. 2013;71(3):269-273.
Chen, SA, Hiley, C, Nickleach, D, et al. Breast reconstruction and post-mastectomy radiation practice. Radiat Oncol. 2013;8:45.
Kronowitz, SJ, Lam, C, Terefe, W, et al. A multidisciplinary protocol for planned skin-preserving delayed breast reconstruction for patients
with locally advanced breast cancer requiring postmastectomy radiation therapy: 3-year follow-up. Plast Reconstr Surg. 2011;127(6):2154-
2166.
Woo, KJ, Paik, JM, Bang, SI, et al. The impact of expander inflation/deflation status during adjuvant radiotherapy on the complications of
immediate two-stage breast reconstruction. Aesthet Plast Surg. 2017;41(3):551-559.
Momoh, AO, Ahmed, R, Kelley, BP, et al. A systematic review of complications of implant-based breast reconstruction with
prereconstruction and postreconstruction radiotherapy. Ann Surg Oncol. 2014;21(1):118-124.
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Cordeiro, PG, Snell, L, Heerdt, A, McCarthy, C. Immediate tissue expander/implast breast reconstruction after salvage mastectomy for
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risk of preoperative and postoperative radiation therapy for surgical outcomes. Plast Reconstr Surg. 2014;134(3):396-404.Retrospective review
comparing outcomes of immediate reconstruction in setting of premastectomy or postmastectomy radiation.
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Warren Peled, A, Itakura, K, Foster, RD, et al. Impact of chemotherapy on postoperative complications after mastectomy and immediate
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acellular dermal matrix. Aesthet Plast Surg. 2015;39(6):892-901.
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2016;137(3):826-841.
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C H A P T E R 6 0
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Breast Reconstruction: Autologous Flap
Techniques
Shailesh Agarwal and Adeyiza O. Momoh
Key Points
Autologous flap breast reconstruction is a mainstay in modern day approach to postmastectomy
breast reconstruction.
An understanding of the multidisciplinary aspects and components of cancer care is important when
formulating a plan for reconstruction
Free flap selection is based on surgical history and presence of sufficient tissue at proposed donor
site.
A variety of flap donor options exist including the abdomen, buttocks, and thighs.
Preoperative imaging may elucidate vessel anatomy, but is not always critical.
Clinical exam remains the standard for postoperative flap monitoring.
Breast reconstruction is a critical component of the comprehensive management of the breast cancer
patient. The primary goal of breast reconstruction is to restore a natural appearing form of the breast,
with additional benefits in the quality of life experienced after cancer treatment. Breast reconstruction
may be performed using implants or tissue derived from the patient (autologous tissue). A number of
studies evaluating national reconstruction trends have reported ratios of implant to autologous breast
reconstruction in the range of 2:1 to 9:1. 1-4 That a minority of breast reconstruction patients undergo
autologous tissue reconstruction is likely due to patient- and nonpatient-related factors. Patient-related
factors include a lack of donor site tissue, comorbidities that preclude use of flaps, desire to avoid
recovery from the donor site and patient preference. Operative requirements, such as increased operative
time, need for specialized instruments, specialized technical training and skills, and greater resources,
comprise nonpatient-related factors that impede the utilization of autologous breast reconstruction. 4-6
However, by using autologous tissue, one may obviate the postoperative risks of morbidity associated
with implants including infection, rupture, capsular contracture, and malposition. In addition,
autologous tissue is generally preferred in patients expecting to receive radiation therapy, or with a
history of radiation therapy including radiation previously delivered as part of breast conservation
therapy (BCT). 7-10 Finally, quality of life in patients undergoing autologous tissue reconstructions is
maintained at a high level over time after completion of reconstruction. 11
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Preoperative Evaluation
Breast Cancer Treatment Plan
The preoperative evaluation of the patient interested in postmastectomy breast reconstruction includes a
thorough history and physical examination. The patient’s goals, including desired breast size, should be
discussed in the context of the utility and limitations of the reconstructive options. The oncologic plan
should also be reviewed including the possibility of chemotherapy, radiation therapy, and contralateral
prophylactic mastectomy (CPM). Tamoxifen increases the likelihood of thrombotic complications. 12 A
history of radiation or plan for future radiation delivery may make autologous breast reconstruction
more desirable given greater morbidity with radiation and implant reconstruction. 7-10 Often, patients
presenting for mastectomy have previously been treated for breast cancer with BCT, which includes
whole breast radiation (Figure 60.1). These variables should be considered in decisions made for
immediate or delayed breast reconstruction and on the type of reconstruction recommended.
FIGURE 60.1 A patient with a left invasive breast cancer who has undergone breast conservation therapy (BCT—lumpectomy,
adjuvant chemotherapy, and radiation) with gross changes to the left breast seen on AP (A), oblique (B) and lateral (C) views.
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Timing of Breast Reconstruction
When possible immediate breast reconstruction tends to be preferred by a majority of patients
undergoing mastectomies. The decision on immediate or delayed reconstruction in general is influenced
by cancer staging, with delayed reconstruction favored in advanced stage cancers that require
postmastectomy radiation therapy (PMRT) or close surveillance. Some patients may also opt to wait on
reconstruction if the combined process of oncologic treatment and reconstruction seems overwhelming.
The need for PMRT, though not an absolute contraindication to immediate reconstruction, tends to be the
predominant reason to consider delayed reconstruction. Delayed reconstruction is typically advocated for
multiple reasons including the avoidance of untoward effects of radiation on the results of an immediate
reconstruction and the potential for delaying oncologic treatment because of complications from
reconstruction.
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History and Exam
Obtaining an accurate medical and surgical history is critical when evaluating patients for autologous
reconstruction. Because autologous operations often require longer operative times, it is imperative to
ensure that the patient is medically appropriate for a longer operation from cardiac and pulmonary
perspectives. In addition, a history of previous surgeries may impact the use of specific donor sites for
autologous breast reconstruction. For instance, previous abdominal operations that compromise
abdominal soft tissue blood supply may preclude use of the abdomen as a donor site for reconstruction.
A known history of hypercoagulable conditions would be a contraindication to performing a free tissue
transfer with an increased risk for vessel thrombosis; pedicled flap options would be possible in this
context. Active smoking would be a relative contraindication for performing any autologous flap
procedure with increased risk for wound dehiscence and delayed wound healing. Patients are typically
counseled to quit smoking for a minimum of 4 weeks before surgery and often preoperatively evaluated
with a urine cotinine test.
Patient preferences for postreconstruction breast size is also important for operative planning. For
example, thin patients with a paucity of abdominal tissue who desire CPM may not be candidates for
bilateral breast reconstruction using abdominal tissue alone. In some patients, use of the entire lower
abdominal soft tissue in the form of bipedicled or stacked flaps may be required to attain unilateral breast
reconstruction of sufficient size. Alternative donor sites such as the buttocks (superior gluteal artery
perforator flap), medial thigh (transverse upper gracilis flap), or posterior thigh (profunda artery
perforator flap) may also be options for patients with insufficient abdominal tissue. All potential donor
sites should be examined for the presence of adequate skin laxity and adipose tissue by inspection for
scars, palpation, and pinch testing.
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Perforator and Pedicle Evaluation
Although useful for preoperative planning, imaging is not absolutely needed in patients without a
surgical history that raises concerns about pedicle compromise. Scans may be necessary to evaluate the
thoracodorsal (TD) vessels in patients desiring latissimus dorsi reconstruction who have undergone
axillary lymph node dissections, where the status of the TD vessels is unclear. Similar concerns exist and
may prompt imaging to confirm an intact pedicle in patients with low and lateral abdominal incisions in
patients considered for abdominal free flaps. Computed tomography angiography (CTA) provides
information regarding perforator distribution and pedicle course (Figure 60.2). Studies have shown that
CTA may reduce operative time for abdominal-based reconstruction, ostensibly by aiding in perforator
identification/selection and deep inferior epigastric artery dissection; however, CTA may also lead to
increased healthcare costs. 13-19 Alternative imaging techniques have also been studied including duplex
ultrasound and MR angiography, although to a lesser extent. Many surgeons who do not implement
preoperative imaging may instead use the pencil Doppler to simply confirm perforator location on the
abdominal wall. Still others may choose not to perform any initial perforator or pedicle evaluation, but
rather begin flap elevation knowing that the abdomen has reliable perforator anatomy.
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FIGURE 60.2 Preoperative CT angiogram of the abdomen (A), identifying perforators (B) and outlining the branching pattern
(C) of the abdominal vascular pedicle. Also, valuable in evaluating thoracodorsal vessel patency (D) with a history of axillary
lymph node dissection.
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Pedicled Flaps
Latissimus Dorsi Flap
The latissimus dorsi (LD) myocutaneous flap is a well-established pedicled flap option for breast
reconstruction. The LD flap is based on the thoracodorsal vessels, which arises from the subscapular
vessels that branch off of the axillary vessels (Figure 60.3). Within the latissimus the thoracodorsal
branches into a medial or transverse and a lateral or descending branch, which allow for muscle-sparing
procedures with use of part of the LD for reconstruction. The LD flap is a broad muscle that covers a large
surface area and can be used with or without a skin paddle for reconstruction. However, the muscle
harvested with a skin paddle typically does not provide sufficient volume for breast reconstruction. To
achieve a desired breast volume the LD flap is often used in combination with a prosthesis (Figure 60.4).
The LD may also be used in setting of salvage procedures to replace compromised mastectomy skin flaps
over implants or in cases of failed free-flap breast reconstructions.
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FIGURE 60.3 Thoracodorsal vascular anatomy.
(Reproduced with permission from Kung, TA, Momoh, AO. Recipient vessel exposure: internal mammary and thoracodorsal. In: Chung, KC , ed. Operative
Techniques in Plastic Surgery. Philadelphia, PA: Wolters Kluwer; 2019. Part 4, Figure 24-1.)
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FIGURE 60.4 A, B. A patient with a history of invasive right breast cancer who has undergone bilateral mastectomies with
right chest wall radiation. C, D. Postoperative result after completion of delayed bilateral breast reconstruction with a latissimus
dorsi myocutaneous flap and implant on the right and an implant alone on the left. E. Obliquely oriented donor site scar on the
right back.
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Pedicled Transverse Rectus Abdominis Myocutaneous (TRAM) Flap
The pedicled TRAM flap takes advantage of lower abdominal soft tissue adiposity that is present in many
patients and is based on the superior epigastric artery, a continuation of the internal mammary artery
(IMA). The pedicled TRAM is elevated with the ipsilateral rectus muscle and tunneled into the
mastectomy defect site through the inframammary fold. 20-22 Flap harvest includes fascia overlying the
rectus muscle and often requires mesh placement for closure of the donor site. The use of the rectus
muscle contributes to weakened abdominal wall strength and an increased risk for abdominal bulge. 23-25
Because the deep inferior epigastric artery system is the more dominant blood supply to the abdominal
skin and fat, maneuvers to improve the blood supply (from the superior vasculature) to the flap are
sometimes employed. One such maneuver is a delay procedure, which is often performed 2 or 3 weeks
before the pedicled TRAM procedure, when the ipsilateral deep inferior epigastric artery is ligated to
facilitate the recruitment of choke vessels with perfusion from the superior epigastric vessels. 26 Efforts to
avoid donor site morbidity while taking advantage of the more dominant deep inferior epigastric system
encouraged the evolution of free tissue transfer options described later.
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Free Flaps
Abdomen-Based Flaps
Abdomen-based breast reconstruction is the mainstay of autologous microvascular breast reconstruction.
The benefits of this well-described reconstructive technique include reliable vascular anatomy, extensive
reported clinical experience, reduced donor site morbidity with muscle-sparing/perforator flap options, a
long pedicle with similar caliber to recipient vessels, and typically, the presence of sufficient soft tissue
for reconstruction.
Flap types include the free transverse rectus abdominis musculocutaneous (TRAM), free muscle-sparing
TRAM (ms-TRAM), deep inferior epigastric perforator (DIEP), and the superficial inferior epigastric
artery (SIEA) perforator flaps. The free TRAM, free ms-TRAM, and DIEP flaps are based on the deep
inferior epigastric vessels, which are branches from the external iliac vessels. Perforating vessels from the
deep inferior epigastric system perfuse varying aspects or zones of the abdominal wall skin and adipose
tissue. The SIEA flap is based on the superficial inferior epigastric vessels, which are branches from the
femoral vessels, run superficial to the abdominal wall fascia, and perfuse the abdominal soft tissue in
parallel to the deep inferior epigastric system (Figure 60.5); violation of the anterior rectus fascia is
avoided with this flap. A small percentage of flaps (less than 10%) are reported to be superficially
dominant. 27
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FIGURE 60.5 Superficial inferior epigastric and deep inferior epigastric vascular anatomy.
The operation is performed with the patient in the supine position. For patients who are undergoing
immediate breast reconstruction, flap elevation may be performed while the breast surgery team
performs the mastectomy. A lenticular design is employed with tissue based around and inferior to the
umbilicus (Figure 60.6). Consideration is given for SIEA flap reconstruction whenever possible. Early in
the abdominal flap elevation, along the inferior aspect of the designed abdominal flap, generally
superficial to the Scarpa fascia and within 5 to 10 cm lateral from the midline, is explored for the SIEA
and SIEV (Figure 60.7). 28 SIEA/V vessels that can be used are reported to be present in 30% of patients. 29
In flaps with vessels that are present and of appropriate size (1.5 mm diameter SIEA at the inferior edge
of the flap) dissection of the SIEA and SIEV are carried to the femoral vessels. 29 Once adequate perfusion
based on the superficial vessels is confirmed, all other perforators from the deep inferior epigastric
system are divided. Perfusion of flaps based on the SIEA/SIEV is not reliable across the midline.
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FIGURE 60.6 Preoperative markings for abdominal based flap breast reconstruction. The flap is designed to capture
perforators typical localized around the umbilicus (superior marking just above the umbilicus and extending laterally toward the
anterior superior iliac spines). Consideration is given for primary closure of the donor site, which determines the position of the
lower marking above the pubis.
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FIGURE 60.7 Superficial inferior epigastric artery and vein, at the inferior border of abdominal flap dissected toward the
femoral vessels.
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FIGURE 60.8 DIEP flap zones of perfusion.
Most of the perforators required for DIEP flap elevation are located within a 10 cm radius from the
umbilicus. 30 These perforators perfuse predictable zones of the lower abdominal soft tissue, with
perfusion zones initially described by Hartrampf for TRAM flaps and subsequently modified by Holm
for DIEP flaps 22,31 (see Figure 60.8). Zones of perfusion have since been shown to be varying depending
on the row of perforators (medial or lateral) selected (Figure 60.8). 30 When reconstructing a single breast,
the midline may be crossed to include the zone immediately adjacent to the midline to provide sufficient
tissue for symmetry with the contralateral side; for bilateral breast reconstruction, the abdominal tissue is
bisected down the midline. The superior abdominal flap is elevated from the superior incision for closure
with the inferior incision, which is not undermined. The umbilicus is transposed and delivered through
the superior abdominal flap. At the inferior aspect of the flap, even in cases where the SIEA is absent or
too small to rely upon, the SIEV if present is dissected out to a length (5–7 cm) for potential use as an
alternate flap outflow option.
Suprafascial identification of lateral and medial row perforators (over the rectus abdominis muscle) is
performed and an ideal perforator or group of perforators are selected. With use of a preoperative CT
scans, identification of perforators may be simplified.
Perforator row selection may be based on a combination of factors including perforator size, location
(central or peripheral) and branching pattern within the adipose tissue of the flap. In addition, perforators
considered for exclusion may be clamped temporarily with assessment of flap perfusion by assessing
color and capillary refill; perfusion with select perforators clamped may also be assessed with
indocyanine green perfusion imaging. Once perforators are selected, the anterior rectus fascia is incised
and careful intramuscular dissection of the selected perforators through the rectus muscle is performed
down to the deep inferior epigastric vessels (Figure 60.9). If perforators from separate rows (e.g., medial
and lateral row) are to be included to improve tissue perfusion, the intervening segment of muscle
between the two rows may be harvested with the flap as a muscle-sparing TRAM flap, obviating
perforator dissection through the muscle. Complete transection of a segment of the rectus muscle that
includes perforators without preserving continuity of any aspects of the rectus muscle constitutes a free
TRAM flap. In all three described flaps, the pedicle is traced proximally toward its takeoff from the
external iliac vessels. The pedicle, typically consisting of two veins and one artery, is ligated distal to the
takeoff from the external iliac vessels. The pedicle is ligated to ensure sufficient vessel length and caliber
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for anastomosis with the internal mammary vessels. In the repair of abdominal fascial defects after flap
harvest, primary closure without mesh is often possible with DIEP flap and free ms-TRAM flap harvests.
Free TRAM harvests tend to include wide sections of anterior rectus fascia and may require mesh
placement, particularly in cases with bilateral flaps.
FIGURE 60.9 DIEP flap with three medial row perforators dissected through the rectus muscle and inclusion of a zone across
the midline.
On completion of the microvascular anastomoses, with perfusion reestablished, flaps are shaped on the
chest wall to achieve the contour of a breast mound. Varying amounts of skin and adipose tissue are
utilized based on existing deficiencies as is encountered in cases of immediate and delayed breast
reconstruction (Figures 60.10 and 60.11).
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FIGURE 60.10 A–C. Preoperative views of a patient with a right invasive breast cancer considering bilateral mastectomy and
immediate reconstruction. D–F. Postoperative results after immediate bilateral DIEP flap breast reconstruction, with nipple
reconstruction and tattooing. G, H. Abdominal donor site before and after reconstruction.
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FIGURE 60.11 A–C. Preoperative views of a patient with a left invasive breast cancer who has undergone a left mastectomy
with postmastectomy radiation therapy. She plans on a right contralateral prophylactic mastectomy with bilateral breast
reconstruction. D–F. Postoperative results after immediate right and delayed left breast reconstructions. G, H. Abdominal donor
site before and after reconstruction.
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Medial Thigh Flaps
Medial thigh flaps incorporating the gracilis muscle provide another option for breast reconstruction in
patients who have had previous abdominoplasty or abdominal flaps, or insufficient abdominal tissue. 32
The medial circumflex femoral artery, a branch of the profunda femoris artery, serves as the pedicle to the
gracilis muscle to support the overlying fat and skin (Figure 60.12). The pedicle is identified in the
interval between the gracilis and adductor longus muscles and is traced proximally (Figure 60.13). The
skin may be oriented transversely (transverse upper gracilis (TUG) flap), vertically (vertical upper gracilis
(VUG) flap) or designed as a combination of both with a bipedicled skin paddle. 32 Although the TUG
does not provide as much skin or fat as the VUG, it may provide a more reliable skin paddle. The
transverse upper thigh scar is better hidden than the vertical scar; however, excessive tension from
closure of the transverse skin paddle donor site may cause labial spreading. Medial thigh flaps are ideal
for patients with small- to moderate-sized breast who desire similar-sized reconstruction. The overall
availability of sufficient tissue for breast reconstruction is one drawback of medial thigh flaps. In a
retrospective study, Park et al. reported a mean weight of 342 g among VUGs and 268 g among TUGs 32 ;
however, use of bilateral stacked flaps (bilateral upper gracilis (BUG) flap) may address this concern for
patients undergoing unilateral breast reconstruction. 32 One advantage of this form of reconstruction is
that flap harvest and breast reconstruction can be performed in one position with the patient supine and
the hip externally rotated (thigh frog legged) for flap harvest. However, the length of the vascular pedicle
is relatively short, measuring approximately 7 cm and the flap artery is often smaller than recipient
arteries used for breast reconstruction (e.g., internal mammary or thoracodorsal vessels). 33
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FIGURE 60.12 Medial circumflex femoral artery and vein anatomy with transversely oriented skin paddle for medial thigh flap.
(Reproduced with permission from Momoh, AO. Transverse upper gracilis flap for breast reconstruction. In: Chung, KC , ed. Operative Techniques in Plastic
Surgery. Philadelphia, PA: Wolters Kluwer; 2019. Part 4, Figure 28-2.)
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FIGURE 60.13 Medial circumflex femoral vessels extending from the medial border of the gracilis. Vessels are dissected
underneath the adductor longus muscle (retracted) to the profunda femoris.
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Posterior Thigh Flaps
The profunda artery perforator (PAP) flap uses posterior thigh skin and adipose tissue as an option for
breast reconstruction 34 (Figure 60.14). The consistent presence and length of the pedicle—reported to
average 10.6 cm—allows for the internal mammary or thoracodorsal vessels to serve as recipient vessels.
35,36 Perforators from the pedicle are located roughly 5 to 6 cm below the gluteal crease, both medial and
lateral to the midline of the posterior thigh. 36,37 The flap is designed as a horizontal ellipse with superior
incision at or immediately below the gluteal crease; the perforator travels through the adductor magnus.
Flap elevation can be performed in the prone position; however, to avoid intraoperative position change
and to facilitate a two-team approach, the flap may also be elevated in a lithotomy or frog-leg position
(Figure 60.15). Although it has been reported that the horizontally designed PAP flap offers mean weight
of 220 g, larger flaps are possible with the PAP designed as a fleur-de-lis (range 340–735 g). 38
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FIGURE 60.14 Profunda artery perforator vascular anatomy with transversely oriented skin paddle for a posterior/medial thigh-
based flap.
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FIGURE 60.15 A. Supine position with medial thigh marking of flap visible. B. Two perforators dissected underneath the
gracilis and thrugh the adductor magnus muscle (both retracted), towards the profunda femoris.
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Gluteal Artery Perforator Flaps
The superior or inferior gluteal artery perforator (SGAP or IGAP) flaps are autologous alternatives to
abdominal-based flaps for patients who do not have reliable abdominal vascular anatomy due to
previous surgery, or who do not have sufficient abdominal tissue to reconstruct breasts of sufficient size.
The superior gluteal artery exits the pelvis superior to the piriformis muscle at approximately the point
marking the junction of the upper and middle third of a line drawn from the posterior superior iliac spine
(PSIS) to the greater trochanter. The inferior gluteal artery exits the pelvis inferior to the piriformis
muscle, at approximately the point marking the junction of the upper and middle third of a line drawn
from the PSIS to the ischial tuberosity. 39 Perforators are identified preoperatively using CT angiogram
and/or Doppler probe. Patients are either positioned lateral or prone and might need position changes for
flap elevation and for transfer of the flap to the breast. A skin paddle is designed over anticipated
perforators and an adipocutaneous flap is elevated intramuscular perforator dissection (Figure 60.16).
One perforator is many times sufficient to support the GAP flap. One advantage provided by use of this
flap is the presence of a good amount of adipose tissue for reconstruction even in patients with lower
BMIs. However, the length of the vascular pedicle for this flap is relatively short, measuring 5.6 cm on
average. 40
FIGURE 60.16 A. Lateral positioning for SGAP flap harvest with flap centered over the upper to middle third of axis from PSIS
to greater trochanter. B. Single perforator dissected between gluteal muscle fibers.
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Recipient Vessels
The IMA and internal mammary vein (IMV) are the more commonly utilized recipient vessels for free
flap breast reconstruction; alternatives are the thoracodorsal artery and vein. The IMA arises from the
subclavian artery, run 1 to 2 cm lateral to the sternum, deep to the intercostal muscles and ribs, and are in
continuity with the superior epigastric vessels. The internal mammary vessels can be accessed by removal
of the third or fourth rib cartilage; the rib level is determined by ease of access and size of the flap pedicle
to avoid a significant vessel size mismatch. At the level of the third rib, the IMA generally lies lateral to
the IMV. The right and left IMAs are of similar diameter (1.9–2.1 mm) at third and fourth intercostal
spaces. The left IMV bifurcates at a higher level than the right IMV (third rib on the left vs. fourth rib on
the right). At the level of the third intercostal space, the left IMV is on average smaller than the right
(2.5 mm vs. 3 mm).
Branches of the IMA and IMV are ligated using clips under Loupe magnification, and further under the
microscope if necessary. Alternatively, a rib-sparing approach may be performed if the interspace width
is adequate to perform anastomoses. This approach limits vessel exposure and introduces greater
technical challenge. Here, the intercostal muscles are elevated to access the internal mammary vessels.
Care is taken during internal mammary vessel exposure to avoid injury to the pleura, deep to the vessels,
which could result in a pneumothorax.
The thoracodorsal vessels arise from the axillary artery and travel along the lateral thoracic wall and into
the latissimus dorsi muscle. The vessels are typically identified at the lateral border of a mastectomy
defect on the deep surface of the latissimus muscle.
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Microvascular Anastomosis
Once flap harvest and recipient vessel exposure is complete, flap vessels are divided rendering the flap
ischemic. End-to-end arterial and venous anastomoses are performed either under loupe magnification or
using an operating microscope. Arteries are typically hand sewn with fine sutures (8-0 to 10-0 nylon
sutures) and veins coupled with a coupling device (Figure 60.17).
FIGURE 60.17 Hand-sewn arterial anastomosis to the IMA. Coupled veins in the background.
After completion of the arterial and venous anastomoses, assessment of perfusion can be determined by
confirming capillary refill time (∼2–3 seconds), warmth, and flap edges with bright red bleeding. Hand-
held Doppler ultrasound may be used to confirm a signal over perforators within the flap and on the
external surface of the flap. The external site can then be marked with a suture to facilitate postoperative
monitoring as well. Venous outflow can be confirmed based on appearance of the flap—a congested flap
typically appears dark and has dark red blood from the edges. The identification of venous congestion
without obvious mechanical obstructions within the pedicle and perforators may lead the surgeon to
consider augmenting venous outflow through use of the superficial inferior epigastric vein (SIEV).
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Postoperative Free Flap Care and Monitoring
Postoperatively, flaps are kept warm with either a blanket with forced warm air over the flap or with
control of the room temperature. Flaps are evaluated often, typically every hour for the first 24 hours.
Postoperative flap monitoring consists of clinical exam including capillary refill (∼2–3 seconds), color,
warmth, and hand-held Doppler signals. Adjuncts to the clinical exam that are often implemented
include near-infrared tissue oximetry, implantable arterial Doppler, or venous flow coupler. Tissue
oximetry reflects a combination of arterial inflow and venous outflow. The implantable arterial Doppler
provides real-time audible information regarding arterial inflow. The venous flow coupler provides real-
time audible information regarding venous outflow. Anticoagulation with an antiplatelet agent (Aspirin)
and venous thromboembolism (VTE) prophylaxis (subcutaneous heparin or enoxaparin) is typical.
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Flap and Donor Site Complications
During the first 24 to 48 hours, vascular compromise may occur due to occlusion of the artery or vein due
to thrombus, compression caused by hematoma, or positioning of the vessels (e.g., kinking). Vascular
compromise can be identified on the basis of postoperative monitoring techniques described earlier; the
rule of thumb is that early vascular compromise necessitates reoperation for salvage. Beyond the early
postoperative vascular compromise other flap-related complications include fat necrosis, partial flap loss,
wound dehiscence, infections, hematomas, and seromas.
Donor site complications also occur and include infection, hematoma, seroma, wound dehiscence, skin
flap necrosis, umbilical necrosis, abdominal wall hernias and bulges, medial thigh lymphatic leaks, and
unfavorable scars.
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Questions
1. You plan to perform a pedicled TRAM flap for breast reconstruction and would like to
physiologically augment blood flow to the flap through the intended pedicle. What can you do to
achieve this?
a. Ligate the superior epigastric artery 3 weeks before the TRAM procedure
b. Ligate the deep inferior epigastric artery 3 weeks before the TRAM procedure
c. Ligate the intercostal arteries 3 weeks before the TRAM procedure
d. Elevate the entire TRAM flap and then replace it on the abdomen
e. Perform an additional microvascular anastomosis
2. A 45-year-old patient with a history of right-sided breast cancer treated with BCT 5 years ago
comes to your clinic to discuss reconstructive options to restore size and symmetry. She has a history
of abdominoplasty at the age of 35 years. On examination, her left breast is approximately a B-cup
bra-size. Her BMI is 30 kg/m2. Which of the following reconstructive options would be most
appropriate for her?
a. Ipsilateral breast reconstruction with DIEP flap
b. Ipsilateral breast reconstruction with latissimus dorsi musculocutaneous flap
c. Contralateral breast reduction
d. Ipsilateral breast reconstruction with PAP flap
e. Silicone implant placement
3. In preparation for microvascular reconstruction of the left breast with a DIEP flap (pedicle: 2.5 mm
artery/3.0 mm vein), exposure of the IMA/IMV is planned with a rib cartilage resection. Which rib is
the most appropriate to resect?
a. Rib 1
b. Rib 2
c. Rib 3
d. Rib 4
e. Rib 5
4. A 37-year-old woman with a genetic predisposition for breast cancer undergoes bilateral nipple-
sparing prophylactic mastectomies with immediate microvascular breast reconstructions. The flaps
are buried and without skin paddles. Which of the following offers you the ability for postoperative
monitoring of the flap?
a. Transcutaneous tissue oximetry
b. Pencil Doppler
c. Exam (warmth, color)
d. Venous coupler
e. Arterial Doppler probe
5. You are in the operating room and performing autologous breast reconstruction with a DIEP flap.
Immediately on completion of the arterial and venous anastomoses, you note that both anastomoses
are patent, but you also see dark red blood from the edges of the flap. What is the next appropriate
action to take?
a. Begin intraoperative leeches
b. Perform additional venous anastomosis with SIEV from the flap to the retrograde IMV
c. Give the flap 5 to 10 minutes to allow for old venous blood to clear
d. Take down and redo the venous anastomosis with the IMV
e. Initiate an intravenous heparin drip
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1. Answer: b. Ligating the deep inferior epigastric artery several weeks before the TRAM flap is
performed is known as a TRAM delay procedure. Studies have shown that this improves flap
survival and augments blood flow through the superior epigastric artery. The pedicled TRAM flap is
based on the superior epigastric artery. Ligating this artery would render the flap unuseable.
Ligating the intercostal arteries would risk causing abdominal necrosis superior and lateral to the
TRAM donor site. It would not be reasonable to elevate the entire TRAM flap and then replace it on
the abdomen. In addition, this would not augment flow through the superior epigastric artery.
Additional microvascular anastomosis can be performed if the superior epigastric artery is injured
during flap elevation. In that setting, the DIEA, if left long enough can be used to augment flow.
However, this would not augment flow through the pedicle (superior epigastric artery).
2. Answer: d. The PAP flap provides a reasonable alternative to abdominal-based free flaps in
patients with a prior history of abdominal surgery, which would place abdominal-based flaps at risk.
In this patient with a history of abdominoplasty, an abdominal-based free flap would not be a viable
reconstructive strategy. The PAP flap can provide sufficient tissue in patients with B or C-cup
breasts. The DIEP flap is no longer an option in patients who have had an abdominoplasty. The
latissimus dorsi musculocutaneous flap is not likely to provide sufficient tissue to reconstruct B-cup
breasts in this patient. A contralateral breast reduction is unlikely to restore size, one of the concerns
for this patient. In many patients, breast reduction is also unlikely to yield symmetry unless
additional operations are performed on the ipsilateral side. A silicone implant would be inadvisable
in a patient with a history of radiation on the ipsilateral side, which is a part of the BCT protocol.
3. Answer: c. The IMA and particularly the IMV have sufficient size on the left side to match the flap
pedicle diameters at rib 3. In addition, if the vessel is injured during exposure, there is an
opportunity to obtain sufficient exposure to anastomose proximal on the vessels. On the right side,
the veins are slightly larger than they are at the same rib level on the left and as such should be of
reasonable size for the described flap at either rib 3 or 4. Rib 1 sits just below the clavicle and
resection of this rib would not be appropriate for anastomosis. Rib 2 is still located too far superior
for anastomosis between the IMA/IMV and DIEA/DIEV. In addition, if any difficulty is encountered
during exposure of the IMA/IMV, use of the second rib does not allow sufficient operative exposure
superiorly to perform anastomosis. IMV on the left side can be substantially smaller at ribs 4 and 5.
4. Answer: e. The arterial Doppler probe, or Cook arterial Doppler, is a probe that wraps around the
artery distal to the anastomosis and provides audible feedback. If the Doppler no longer provides a
signal, the reasons can include thrombosis of the artery or in some circumstances, dislodgement of
the probe. Transcutaneous tissue oximetry, pencil Doppler, and physical examination all require
exposed skin paddle on the flap to be useful. The venous coupler facilitates the anastomosis and has
been shown to reduce operative time. However, it alone does not provide monitoring. However,
modifications of the venous coupler include the implantable venous flow coupler with Doppler,
which allows for venous monitoring.
5. Answer: c. Giving the flap 5 to 10 minutes to allow for blood inflow through the DIEA-IMA
anastomosis will help determine whether the observed dark blood is a symptom of true venous
congestion or of stagnant blood in the flap that remained from the flap harvest. If venous congestion
persists despite an intact DIEV-IMV anastomosis, additional anastomosis with the SIEV to the
retrograde IMV can be performed. Leeches would be typically used postoperatively. However, in the
setting of free-flap breast reconstruction, postoperative venous congestion should be treated with
operative exploration. Additional SIEV anastomosis to the retrograde IMV would be appropriate if
the flap exhibits congestion for a prolonged period of time in the operating room despite a patent
DIEV-IMV anastomosis. This would not be the next action to take, however. The DIEV-IMV
anastomosis is patent based on the question stem. Therefore, it would not be appropriate to redo the
anastomosis at this time. There is no evidence of thrombosis and as such anticoagulation in response
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to the clinical finding would not be indicated.
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References
Albornoz, CR, Bach, PB, Mehrara, BJ, et al. A paradigm shift in U.S. breast reconstruction: increasing implant rates. Plast Reconstr Surg.
2013;131:15-23.Cross-sectional study of immediate breast reconstruction trends in a national patient sample. One of the better known contemporary
studies that demonstrates rising reconstruction rates following the Women Health and Cancer Rights Act of 1998. Also, a key study that shows a rise
in implant use in the United States.
Panchal, H, Matros, E. Current trends in postmastectomy breast reconstruction. Plast Reconstr Surg. 2017;140:7S-13S.
Barnow, A, Canfield, T, Liao, R, et al. Breast reconstruction among commercially insured women with breast cancer in the United States. Ann
Plast Surg. 2018;81:220-227.
Sheckter, CC, Panchal, HJ, Razdan, SN, et al. The influence of physician payments on the method of breast reconstruction: a national claims
analysis. Plast Reconstr Surg. 2018;142(4):434e-442e.
Billig, JI, Lu, Y, Momoh, AO, Chung, KC. A nationwide analysis of cost variation for autologous free flap breast reconstruction. JAMA Surg.
2017;152:1039-1047.
Sheckter, CC, Yi, D, Panchal, HJ, et al. Trends in physician payments for breast reconstruction. Plast Reconstr Surg. 2018;141:493e-499e.
Jagsi, R, Momoh, AO, Qi, J, et al. Impact of radiotherapy on complications and patient-reported outcomes after breast reconstruction. J Natl
Cancer Inst. 2018;110(2):157-165.A multicenter observational study from the Mastectomy Reconstruction Outcomes Consortium (MROC) focusing
on postoperative morbidity and patient reported outcomes (PROs) in radiated and nonradiated patients undergoing breast reconstruction. Findings of
superior PROs and lower risk of complications with autologous reconstruction in patients receiving postmastecomy radiation therapy.
Billig, J, Jagsi, R, Qi, J, et al. Should immediate autologous breast reconstruction be considered in women who require postmastectomy
radiation therapy? A Prospective analysis of outcomes. Plast Reconstr Surg. 2017;139:1279-1288.
Aliu, O, Zhong, L, Chetta, MD, et al. Comparing health care resource use between implant and autologous reconstruction of the irradiated
breast: a national claims-based assessment. Plast Reconstr Surg. 2017;139:1224e-1231e.
Chetta, MD, Aliu, O, Zhong, L, et al. Reconstruction of the irradiated breast: a national claims-based assessment of postoperative morbidity.
Plast Reconstr Surg. 2017;139:783-792.
Santosa, KB, Qi, J, Kim, HM, et al. Long-term patient-reported outcomes in postmastectomy breast reconstruction. JAMA Surg.
2018;153(10):891-899.A multicenter observational study from the Mastectomy Reconstruction Outcomes Consortium (MROC) evaluating long-term
patient reported outcomes in patients undergoing implant or autologous breast reconstruction. Patients undergoing autologous breast reconstruction
(relative to implant reconstructions) were found to be more satisfied with their breasts, in addition to other specific quality of life measures, 2 years after
reconstruction.
Kelley, BP, Valero, V, Yi, M, Kronowitz, SJ. Tamoxifen increases the risk of microvascular flap complications in patients undergoing
microvascular breast reconstruction. Plast Reconstr Surg. 2012;129:305-314.
Agarwal, S, Talia, J, Liu, PS, et al. Determining the cost of incidental findings for patients undergoing preoperative planning for abdominally
based perforator free flap breast reconstruction with computed tomographic angiography. Plast Reconstr Surg. 2016;138:804e-810e.
Rozen, WM, Ashton, MW, Grinsell, D, et al. Establishing the case for CT angiography in the preoperative imaging of abdominal wall
perforators. Microsurgery. 2008;28:306-313.
Rozen, WM, Phillips, TJ, Ashton, MW, et al. Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic
angiography and Doppler ultrasound. Plast Reconstr Surg. 2008;121:1-8.
Malhotra, A, Chhaya, N, Nsiah-Sarbeng, P, Mosahebi, A. CT-guided deep inferior epigastric perforator (DIEP) flap localization—better for
the patient, the surgeon, and the hospital. Clin Radiol. 2013;68:131-138.
Teunis, T, Heerma van Voss, MR, Kon, M, van Maurik, JF. CT-angiography prior to DIEP flap breast reconstruction: a systematic review and
meta-analysis. Microsurgery. 2013;33:496-502.
Klasson, S, Svensson, H, Malm, K, et al. Preoperative CT angiography versus Doppler ultrasound mapping of abdominal perforator in DIEP
breast reconstructions: a randomized prospective study. J Plast Reconstr Aesthet Surg. 2015;68:782-786.
Offodile, AC II, Chatterjee, A, Vallejo, S, Fisher, CS, Tchou, JC, Guo, L. A cost-utility analysis of the use of preoperative computed
tomographic angiography in abdomen-based perforator flap breast reconstruction. Plast Reconstr Surg. 2015;135:662e-669e.
Alderman, AK, Kuzon, WM Jr, Wilkins, EG. A two-year prospective analysis of trunk function in TRAM breast reconstructions. Plast
Reconstr Surg. 2006;117:2131-2138.
Wilkins, EG, August, DA, Kuzon, WM Jr, et al. Immediate transverse rectus abdominis musculocutaneous flap reconstruction after
mastectomy. J Am Coll Surg. 1995;180:177-183.
Hartrampf, CR, Scheflan, M, Black, PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 1982;69:216-225.A
classic article and one of the earlier descriptions of the the pedicled TRAM flap and its vascular anatomy for breast reconstruction.
Vyas, RM, Dickinson, BP, Fastekjian, JH, et al. Risk factors for abdominal donor-site morbidity in free flap breast reconstruction. Plast
Reconstr Surg. 2008;121:1519-1526.
Nahabedian, MY, Dooley, W, Singh, N, Manson, PN. Contour abnormalities of the abdomen after breast reconstruction with abdominal
flaps: the role of muscle preservation. Plast Reconstr Surg. 2002;109:91-101.
Nahabedian, MY, Manson, PN. Contour abnormalities of the abdomen after transverse rectus abdominis muscle flap breast reconstruction: a
multifactorial analysis. Plast Reconstr Surg. 2002;109:81-87.
Atisha, D, Alderman, AK, Janiga, T, et al. The efficacy of the surgical delay procedure in pedicle TRAM breast reconstruction. Ann Plast Surg.
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2009;63:383-388.
Sbitany, H, Mirzabeigi, MN, Kovach, SJ, et al. Strategies for recognizing and managing intraoperative venous congestion in abdominally
based autologous breast reconstruction. Plast Reconstr Surg. 2012;129:809-815.
Reardon, CM, O’Ceallaigh, S, O’Sullivan, ST. An anatomical study of the superficial inferior epigastric vessels in humans. Br J Plast Surg.
2004;57:515-519.
Spiegel, AJ, Khan, FN. An Intraoperative algorithm for use of the SIEA flap for breast reconstruction. Plast Reconstr Surg. 2007;120:1450-1459.
Schaverien, M, Saint-Cyr, M, Arbique, G, Brown, SA. Arterial and venous anatomies of the deep inferior epigastric perforator and superficial
inferior epigastric artery flaps. Plast Reconstr Surg. 2008;121:1909-1919.Contemporary cadaver studies of DIEP and SIEA flap zones of perfusion
that demonstrate similar perfusion pattens for lateral row perforators and SIEA vascular pedicles, consistent with Holm’s Zones of perfusion. Medial
row perforators were found to perfuse in a pattern similar to Zones described by Hartrampf.
Holm, C, Mayr, M, Hofter, E, Ninkovic, M. Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg. 2006;117:37-43.An
evaluation of DIEP flap zones of perfusion using laser-induced fluorescence that redefined the zones of perfusion as described earlier by Hartrampf.
Park, JE, Alkureishi, LW, Song, DH. TUGs into VUGs and friendly BUGs: transforming the gracilis territory into the best secondary breast
reconstructive option. Plast Reconstr Surg. 2015;136:447-454.
Arnez, ZM, Pogorelec, D, Planinsek, F, Ahcan, U. Breast reconstruction by the free transverse gracilis (TUG) flap. Br J Plast Surg. 2004;57:20-
26.
Allen, RJ, Haddock, NT, Ahn, CY, Sadeghi, A. Breast reconstruction with the profunda artery perforator flap. Plast Reconstr Surg.
2012;129:16e-23e.
Saad, A, Sadeghi, A, Allen, RJ. The anatomic basis of the profunda femoris artery perforator flap: a new option for autologous breast
reconstruction—a cadaveric and computer tomography angiogram study. J Reconstr Microsurg. 2012;28:381-386.
DeLong, MR, Hughes, DB, Bond, JE, et al. A detailed evaluation of the anatomical variations of the profunda artery perforator flap using
computed tomographic angiograms. Plast Reconstr Surg. 2014;134:186e-192e.
Haddock, NT, Greaney, P, Otterburn, D, et al. Predicting perforator location on preoperative imaging for the profunda artery perforator flap.
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C H A P T E R 6 1
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Reconstruction of the Nipple-Areolar Complex
Anne C. O’Neill and Toni Zhong
Key Points
Reconstruction of the nipple-areolar complex (NAC) is the final step in the breast restoration process
and should only be performed when optimal breast symmetry has been achieved.
The nipple and areola are reconstructed separately.
A number of local flaps have been described for reconstruction of the nipple. Maintaining nipple
projection is one of the greatest challenges in NAC reconstruction.
Areolar reconstruction can be achieved with pigmented skin grafts or tattooing.
Nonsurgical options are also available and can achieve satisfactory reconstitution of the NAC.
Reconstruction of the nipple-areolar complex (NAC) is most commonly performed as a component of
breast reconstruction following mastectomy for the treatment of cancer. Other indications for NAC
reconstruction may include trauma, burns, nipple loss following reduction mammoplasty, or congenital
absence of the NAC (athelia) or breast (amastia). Reconstruction of the NAC was first described by
Adams in 1944 and was followed by a steady evolution of techniques up to the early 2000s. 1,2 In recent
years, however, there has been increasing acceptance of nipple sparing mastectomies, and the demand for
NAC reconstruction has consequently declined. 3 Reconstruction of the NAC is usually the final stage in
breast reconstruction and so for many women marks the completion of their breast cancer treatment.
Although reconstruction of the NAC is a relatively simple procedure, it can make a significant
contribution to patient satisfaction and psychosexual well-being. 4,5
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Preoperative Planning
The nipple is an elevated structure that projects approximately 5 to 10 mm and arises in pigmented skin
known as the areola, which is on average 4.2 to 4.5 cm in diameter. The NAC is a critical landmark of the
breast. Other aesthetic components of the breast such as the inframammary fold (IMF), breast meridian,
and parenchymal position are frequently assessed in terms of their relationship to the NAC. The NAC is
generally situated at the prominence of the breast mound, but there is considerable variation in position,
size, color, and texture in individual patients. The ideal NAC position is variably described as 22 to 24 cm
from the sternal notch or the level of the midhumerus. In unilateral cases, the size and position of the
reconstructed NAC is designed to match the contralateral side. In bilateral cases, the optimal position
must be carefully selected, and the breast prominence, the breast meridian, the IMF, and the midline of
the chest must be considered. Although some surgeons advocate simultaneous reconstruction of the
breast and NAC, most would agree that NAC reconstruction should be performed 3 to 6 months later. 6-8
This enables the reconstructed breast to settle into its final position and allows the surgeon to consider
any contralateral balancing procedures that may be required.
For the purposes of reconstruction, the nipple and the surrounding areola are generally considered
separately.
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Nipple Reconstruction
Grafts
The nipple share technique was introduced by Millard in 1972 and remains a popular technique in
selected patients. 9 A segment of the contralateral natural nipple is harvested and transferred to the
reconstructed breast as a composite graft. This technique is most effective in patients with a large
contralateral nipple where projection exceeds 5 to 6 mm. It has been reported that composite nipple
grafting can provide sensation and erectile function in the reconstructed nipple in some cases. 10
However, many patients are reluctant to have surgery on the normal nipple. The risk of reduced
sensation and impaired erectile function at the donor site has limited the popularity of this technique. In
an effort to avoid contralateral surgery, banking of the affected nipple at the time of mastectomy has been
proposed. However, cryopreservation of the nipple results in tissue damage and loss of pigmentation that
adversely affects aesthetic outcomes. 11
The desire to avoid surgery on the contralateral nipple has resulted in a number of alternative donor sites
for nipple grafts including labia, earlobe, toe pulp, and skin from the postauricular area, medial thigh,
and axilla. 12,13 Although most of these areas provide hyperpigmented skin, they usually fade over time
and are a poor match for the contralateral nipple. The popularity of grafting has waned with the advent
of a multitude of local flap techniques that eliminate the need for a secondary donor site and the risk of
associated morbidity. Grafting remains a favorable option in patients who have thin skin and
subcutaneous tissues following alloplastic breast reconstruction.
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Local Flaps
The first description of nipple reconstruction using local skin flaps was by Berson in 1946. 14 A recent
review by Sisti et al identified 30 subsequently described flap designs that have contributed to the
evolution of nipple reconstruction in the intervening 70 years. 15 Nimboriboonporn and Chuthapisith
proposed a simple classification system for these techniques that divided them into (1) centrally based
flaps, (2) subdermal pedicle local flaps with single pedicle, and (3) subdermal pedicle local flaps with
double pedicle. 16
Description of all the described local flap options for nipple reconstruction is beyond the scope of this
chapter. The commonest techniques currently in use (skate flap, star flap, and C-V flap) consist of two
larger lateral flaps that are approximated to create the circumference of the nipple and a smaller central
flap that forms the tip of the nipple (Figure 61.1). Although several more complicated techniques have
been described, most surgeons favor modifications of these classic flap designs because of their relative
simplicity and the fact that complex designs with multiple incisions may be more prone to complications
including contracture and loss of projection.
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