Phẫu Thuật Tạo Hình (Tập 5): Tuyến Vú – Neligan (2018)

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CHAPTER 17 • Secondary procedures following prosthetic breast surgery
aesthetic and reconstructive breast surgery.2,5 The major-
ity of revisionary procedures are performed due to cap-
sular contracture.2,6 Many etiologies have been proposed
for this process, and it is clear that prevention in primary
cases is of utmost importance and is principally related
to specific technical maneuvers that include precise,
atraumatic, bloodless dissection; appropriate triple anti-
biotic breast pocket irrigation; and minimizing any
points of contamination during the procedure.4,7 Treat-
ment of an established capsule can be more challenging
and a variety of techniques have been described. It is
important to understand the pathophysiological process
and the disease at the cellular level in order to success-
fully manage capsular contracture. In this case, it is per-
spicuous at the cellular level that capsular contracture is
most likely caused by any process that will produce
increased inflammation, leading to formation of deleteri-
ous cytokines within the periprosthetic pocket. Conse-
quently, in addition to all of the techniques for treating
and preventing capsular contracture described by many
of our colleagues,4,5,8,30–36 the authors believe that the
addition of ADM is another modality in fighting the
evolution of the capsule. ADM can counteract the inflam-
matory process, adding additional availability of tissue
ingrowth and controlling the interface of the pocket.
Acellular dermal matrix
The use of ADMs has been popularized in both breast
and abdominal wall reconstructions and has been
reported in a range of clinical settings.14–24 In reconstruc-
tive cases, it has been used to replace tissue, extend
existing tissue, or act as a supplement. In aesthetic cases
it has been used to correct implant rippling and malpo-
sition as well as for symmastia.26,27,37
Immediate breast reconstruction using tissue expand-
ers or implants has become one of the most commonly
performed surgical techniques. As such, visible rippling
and contour deformities have become a more frequently
encountered problem because of thin tissues.28 The
recent use of allogenic tissue supplements avoids the
problems of autologous tissue coverage and provides
camouflage, thus decreasing rippling and increasing
soft-tissue support.28
The rising demand for acellular dermal matrices has
spurred tremendous growth in the number of available
ADMs. Published research with regard to the use and
efficacy of acellular dermal matrices in immediate breast
reconstruction is growing but has not kept pace with the
market explosion. The many features and indications of
all ADMs can confound the decision-making process for
surgeons who want to incorporate ADMs in their treat-
ment armamentarium.
Basic science and disease process
Acellular dermal materials, biologically derived from
allograft and xenograft, when placed in the human
body, are thought to serve as a regenerative scaffold,
promoting the organization of the healing process.
These materials have become popular in aesthetic and
reconstructive breast surgery where they are can serve
as a tissue extension or tissue replacement (“soft-tissue
patch”) following cancer extirpation of the breast
(so-called “sling technique”).23,24,28
The authors’ work with ADMs began in revisionary
aesthetic breast surgery, attempting to prevent capsular
contracture, rather than as a tissue replacement in breast
reconstruction. Having previously employed “host-
compatible” implant surfaces,29 the authors utilized a
similar concept in the clinical approach to breast revi-
sion: a dermal regenerative interface engaging the
surface geometric contour of a breast implant.
Understanding the changes that occur in the breast
tissue is part of management of the problem at hand.
Following breast surgery many factors play a role in the
changes that are observed in the breast form and at
times are considered as late complications of breast
augmentation. Patients lose or gain weight, which
contributes directly to the breast shape. In addition,
some patients may undergo surgical or non-surgical
menopause, which has deleterious effects on the well-
being of the skin and causes thinning of the breast skin,
with decreased elasticity and increased ptosis. There are
other physiological factors that play an important role
in the pathophysiology of the changing breast forms.
Patients present with any of the following complaints:
capsular contracture, implant malposition, ptosis, and
implant visibility or palpability. Interestingly, patients
with capsular contracture do not realize the primary
reason for the deformity of their breast and present to
the office for other complaints as stated above.
Capsular contracture has plagued plastic surgery
for many years as the most common complication of
Tips
• Four key drivers to revisionary breast surgery: (1) capsular
contracture, (2) implant malposition, (3) ptosis, and (4)
implant visibility or palpability. Frequently these indications
are not singularly distinct but are combined, with two or
more being present in a given patient.
• Capsular contractureis the most common driver for
revisionary breast surgery.
• Site change and ADM are key for successful outcomes in
revisionary breast surgery.

269
Basic science and disease process
Acellular dermal matrices can be categorized under
either xenograft or allograft in origin. All are produced
with a similar objective of removing cellular and anti-
genic components that can cause rejection and infection.
The lack of immunogenic epitopes enables the evasion
of rejection, absorption, and extrusion.15,16,24 Production
processes allow basement membrane and cellular matrix
to remain intact. This scaffold is left in place to allow
ingrowth of the host’s fibroblasts and capillaries, which
are eventually incorporated as its own. Much of this
scaffold matrix consists of intact collagen fibers and
bundles to support tissue ingrowth, proteins, intact
elastin, hyaluronic acid, fibronectin, fibrillar collagen,
collagen VI, vascular channels, and proteoglycans – all
of which allow the body to mount its own tissue regen-
eration process.15,16,23,24
All ADMs are FDA cleared for homologous use only.
Although features and processing may vary between
ADMs, the success of the product will ultimately depend
on its ability to meet the desired characteristics of a
model ADM for revisionary breast surgery. A list of
ADMs that are available on the market for a variety of
applications are included in Table 17.1.
Published literature
AlloDerm is clearly in the forefront with regard to
published literature concerning ADMs for immediate
breast reconstruction. A PubMed search using specific
brand names and breast reconstruction reveals that
the majority of publications involve AlloDerm. Ten of
these papers relate directly to adjunctive ADM treat-
ment of immediate breast reconstruction using Allo-
Derm,15,16,23,24,28,38–40 DermaMatrix,41 and Neoform.42 All
of these papers are recent publications, the oldest dating
back to 2005,15 and are non-controlled, retrospective
case series. PubMed searches were also performed for
all other human and xenograft ADMs – FlexHD,
AlloMax, SurgiMend, Enduragen, Synovis, Permacol,
and Strattice – with breast reconstruction and revealed
no listings. It is likely that studies are underway and not
yet completed.
As new products are introduced to the marketplace,
it is always crucial to understand the science behind
each technology. The device industry should be evalu-
ated as critically as the pharmaceuticals, with regard to
the science and mechanism of action.
When evaluating ADMs critically, it is important that
we understand the differences in how the body responds
to the various materials. Not all soft-tissue materials
elicit the same biologic response. There are three unique
processes that can take place with any tissue material
that is placed into the body, whether it is a biologic or
synthetic material. All products placed into the body
elicit an inflammatory response with involvement of
multiple cytoprotective and cytotoxic cytokines. The
continuum of this reaction is controlled by the intrinsic
mechanism unique to each scaffold.
Regeneration
With this process, the product is accepted by the body
and the intact tissue matrix integrates and becomes part
of the host through rapid revascularization and cellular
repopulation. This is the process that is most beneficial
and important to obtain good outcomes in breast surgery
and perhaps the reason why we see less periprosthetic
capsular contracture.
Resorption
This is the process where the human body attacks the
replaced tissue and breaks it down by completely elimi-
nating it, while depositing scar tissue in its place. This
is commonly seen with absorbable mesh products.
Encapsulation
During this process, the product is encapsulated through
an inflammatory response. The body is unable to break
down the product due to its synthetic nature. Therefore,
the product is encapsulated and walled-off from the
host. This process is not unique to synthetic products
but also applies to any foreign body (e.g., pacemakers
and implants) that is placed into the host.
The goal of regenerating tissue is to recapitulate in
adult wounded tissue the intrinsic regenerative proc-
esses that are involved in normal adult tissue mainte-
nance.43 Scar tissue does not have the native structure,
function, and physiology of the original normal tissue.
When a wound exceeds a critical deficit, it requires a
scaffold to organize tissue replacement. Depending on
the type of scaffold that is in place, different processes,
as described earlier, will respond. At this point the
intrinsic factors of the ADM will be important in aiding
each specific regenerative or reparative process. While
regenerative healing is characterized by the restoration
of the structure, function, and physiology of damaged
or absent tissue, reparative healing is characterized by
wound closure through scar formation.43 All biologic
scaffolds are not the same because of differences in the
methods used to process them – materials that encap-
sulate and scar do not offer the benefits of regenerative
healing but lead to suboptimal results.
Diagnosis and patient presentation
ADM is utilized as an adjunct to the sound surgical
principles necessary to diagnose and treat the

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CHAPTER 17 • Secondary procedures following prosthetic breast surgery
Table 17.1  Comparison of different commercially available acellular dermal matrices
Product
name
Manufacturer
Origin
Method of
preservation
Year
introduced
Time to
hydrate
Shelf life
Refrigeration
required
AlloDerm
LifeCell
Human dermis
Lyophilized;
patented
freeze-drying
process
prevents
damaging ice
crystals from
forming
1994
10–40 min,
depending on
thickness,
with warmed
saline solution
in two-step
bath with light
agitation
2 years
No
DermaMatrix
Processed by
Musculoskeletal
Transplant
Foundation (MTF)
for Synthes CMF
Human dermis
Aseptic
processing
method;
lyophilized
2005
3 min
3 years
No
FlexHD
Processed by
Musculoskeletal
Transplant
Foundation (MTF)
for Ethicon
Human dermis
Aseptic
processing
method;
packaged in an
ethanol solution
2007
None
18 months
No
SurgiMend
TEI Biosciences
Fetal bovine
dermal
collagen
Terminally
sterilized with
ethylene oxide
2007
60 s with room
temperature
saline
3 years
No
Strattice
LifeCell
Porcine
dermal
collagen
Terminally
sterilized via low
dose e-beam;
retains critical
biochemical
components;
significantly
reduces the key
component
believed to play
a major role in
the xenogeneic
rejection
response
2008
Minimum of
2 min in
sterile saline
2 years
No
Veritas
Synovis Surgical
Innovations
Bovine
pericardium
collagen
Terminally
sterilized;
sodium
hydroxide
treatment for
purification and
microbiological
security
2008
None
2 years
No
Surgisis
Cook Biotech
Porcine small
intestinal
submucosal
Sterilized with
ethylene oxide
2004
3–10 min
1 year
No
AlloMax
Manufactured by
Regeneration
Technologies/
Tutogen Medical,
Inc. for Bard
Davol
Human dermis
Terminally
sterilized
2007
Hydrates rapidly
5 years
No
MatriStem
ACell/Medline
Porcine
bladder
Unavailable
2009
None
2 years
No

271
Basic science and disease process
superomedially or inferiorly), and (4) treatment of
capsular contracture (which may be technically similar
to lower pole cover or superior-medial thickening)
(Fig. 17.1).
Coverage of lower pole
This important concept and technique, which is our
most frequently utilized ADM placement, is employed
when performing soft-tissue and skin envelope altera-
tions in revisionary surgery (revision mastopexy with
augmentation). As many patients with previously
placed implants develop laxity, sag, or tissue thinning
over time, mastopexy or revision mastopexy over the
replacement implant is required to achieve the aesthetic
breast form. If the existing implant is subglandular, a
subpectoral (subpectoral-fascial) pocket is created (after
capsule treatment), the new implant inserted in the
newly created subpectoral pocket, and the lower portion
of the implant covered with ADM. This allows a
circumvertical or “inverted T” mastopexy to be safely
performed without underlying muscle, as the ADM
separates the skin closure from the implant. If the
existing implant is already subpectoral, a neopectoral
underlying cause(s) necessitating the revisionary aes-
thetic breast surgery. Clinical data shows the four main
indications (drivers) for revisionary surgery: capsular
contracture, implant malposition, ptosis, and implant
visibility or palpability.25–27 Each patient must be indi-
vidually evaluated with regard to concerns, goals,
knowledge of previous surgical and implant specifics,
and careful evaluation of her breasts – dimensions,
quality/quantity of overlying soft tissue, and scarring
(critical in planning surgery and maintaining necessary
vascularity to manipulated tissues).
Despite the apparent complexity of a given clinical
presentation, there are five underlying basic components
that may be the cause, or contribute to the cause, of the
problem: the skin, soft tissue, capsule, implant, and
chest wall. These underlying components must be care-
fully and systematically analyzed from outside in, or
inside out, until all layers involved are evaluated.
Patient selection
The main drivers for revisionary surgery, as mentioned
earlier, should always be kept in mind as the five com-
ponents (see above) are evaluated. We have learned
from revisionary and reconstructive breast experiences
that one or more of these components and layers may
need to be addressed in addition to the use of ADM.
Such surgical manipulations may include skin envelope
reduction, fat injection, lamellar separation, capsulec-
tomy, capsulotomy, and site change of the replacement
implant. In order to help plan for the surgery some
general principles can be followed.
For patients whose original implants were subglan-
dular, a pocket change to a subpectoral plane and
lower pole coverage with ADM is generally performed.
For those patients whose original implants were sub-
pectoral, a neopectoral pocket with the addition of
ADM is generally performed. For patients with ade-
quate breast tissue, a subfascial pocket may be utilized
with ADM coverage or support as indicated. As
always, appropriate candidate selection is important
for achieving a successful outcome, and high-risk
patients (e.g., smokers and those with a BMI higher
than 35) should be discouraged from elective surgery.
The core principles for aesthetic breast revisions are
summarized in Table 17.2.
Treatment and surgical technique
The use of ADM can be categorized into four distinct
indications based upon the underlying clinical presenta-
tion: (1) coverage of implant lower pole (usually for
revision mastopexy), (2) implant stabilizer (usually for
malposition correction), (3) tissue thickener (usually
Table 17.2  The process of aesthetic breast revision
core principles
Patient–physician education
Patient evaluation
Preoperative planning
1. Listen to patient (concerns,
dislikes, symptoms)
2. Obtain accurate history
3. Interactive assessment
4. Define problem
5. Craft solution(s)
6. Educate/expectations
1. Dimensional and tissue
evaluation (asymmetry)
2. Implant evaluation
3. Periprosthetic pocket
evaluation
4. Define operative strategy
5. Implant selection
6. Pocket selection
7. Soft tissue management
8. Adjunctive techniques
Surgical technique
Postoperative
management
1. Access: incision location/length
2. Implant removal/evaluation
3. Pocket alteration
(location/size/capsule/technique)
4. Implant selection
(intraoperative info) (sizers?,
upright evaluation)
5. Implant handling/irrigation/
positioning
6. Soft tissue alterations (tailor tac)
7. Additional maneuvers (ADM,
drains)
1. Comprehensive patient
experience
2. Commitment to surgical
excellence
3. Short-term postop care
(movement, drains,
dressings, sutures)
4. Long-term postop care
5. Management of
revisions
ADM, acellular dermal matrix.
(Adapted from Adams WP, Jr. Process of breast augmentation. Plast Reconstr
Surg. 2008;122(6):1892–1900.)

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CHAPTER 17 • Secondary procedures following prosthetic breast surgery
site change is carried out, and the ADM utilized simi-
larly. If there has been a previous implant in both the
subglandular and subpectoral pockets, “lamellar” sepa-
ration (dissecting the pectoralis muscle from its super-
ficial and deep scarred attachments) may be necessary
(Fig. 17.2). ADM is considered to be the outer layer of
the underling implant (to which it is intimately engaged
by proximity of placement) and may also require suture
stabilization. Thus the ADM may be tacked to the infe-
rior border of the pectoralis major above and to Scarpa’s
fascia or deep fascia below (at the level of the inframam-
mary fold [IMF]). Parachute pullout sutures may alter-
natively be used to redrape the ADM. When there is
lamellar scarring requiring lamellar separation, the
remaining pectoralis muscle may be “window shaded”
up in the pocket, requiring lower muscle inferior pull
following its release. This lower pole coverage situation
is best achieved by suturing of the ADM along the entire
length of the lower pectoral border, draping it over the
implant inferiorly, and securing it (under more taught-
ness) at or near the IMF. This application is similar to
Fig. 17.1  The use of acellular dermal matrix (ADM) can be categorized into four distinct indications based upon the
underlying clinical presentation: (A) center placement; (B) lower lateral placement; (C) medial placement; and (D) upper
medial placement.
A
Center placement
B
ADM
Soft tissue
Implant
Lower lateral placement
C
Medial placement
D
Upper medial placement
Fig. 17.2  “Lamellar” separation (dissecting the pectoralis muscle from its
superficial and deep scarred attachments).

273
Basic science and disease process
With regard to the biomechanical properties of the
desired ADM, rapid revascularization is required to
provide conformability of the ADM and to redrape over
the surface of the implant (with intimate engagement of
surface contours). If the patient had capsular contrac-
ture, a more elastic material may be desired. If the
patient had more laxity or stretch deformity, less elastic
material might be preferable.
Implant stabilizer
ADM allows for the surgeon to gain enhanced control
in maintaining the implant position in a newly created
“neo” pocket or for re-enforcement after capsulorrha-
phy in various forms of implant malposition correc-
tion. Inferior malposition (double bubble), medial
malposition (symmastia), or lateral malposition are
generally treated by capsulorrhaphy or site change
(the author’s preference and recommendation). In a
certain percentage of patients, the tissue is strong
enough to support this correction with a new pocket
and appropriate suturing alone. A number of these
patients, however, will have thin tissue, previous scar-
ring, or problematic bony contour slopes, such that
re-enforcement of the site change (i.e., neopectoral
pocket of appropriate dimensions in the correct loca-
tion with old pocket obliteration) with ADM is highly
advised to re-enforce or buttress the corrected implant
position (Figs. 17.6–17.8). These materials are sutured
in the appropriate position with proper purchase to
achieve support. The biomechanical properties of the
ADM for this indication are strength and taughtness to
maintain implant stabilization.
Tissue thickener
This concept is an extension of second stage breast
reconstruction where expander to implant conversion is
facilitated by a superomedial placement of an extra-
thick ADM, to enhance soft tissue cover of the implant
and give a better visual and palpable confluence of chest
to breast form.44 In aesthetic revisions this is also most
frequently applied to the upper pole (or superomedial
area) to thicken tissue, minimize visibility of traction
rippling, camouflage implant edges, and enhance cleav-
age. An extra thick allograft material is generally utilized
and appropriately trimmed. It is draped over the implant
(with intimate engagement on its deep surface) and in
contact with the existing capsule or new/neopocket on
its superficial surface. Parachute 2-0 Prolene sutures
with Keith needles are utilized in the ADM corners and
interspersed on the medial side to facilitate placement
and redraping. The suture ends are tied externally,
under no tension, and covered with a Tegaderm for 7–10
the “reconstructive model”, as a “pectoral muscle exten-
sion” (Fig. 17.3). In all instances, adequate environment,
cover, and stability over the non-muscle covered portion
of the implant (lower pole) by the ADM allows the skin
envelope to be safely lifted and tightened (mastopexy),
assuming adequate respect for the vascularity to the
redraped tissue, as well as compliance with all sound
surgical principles (Figs. 17.4–17.6).
Fig. 17.3  When there is lamellar scarring requiring lamellar separation, the
remaining pectoralis muscle may be “window shaded” up in the pocket, requiring
lower muscle inferior pull following its release. This lower pole coverage situation
is best achieved by suturing of the acellular dermal matrix (ADM) along the entire
length of the lower pectoral border, draping it over the implant inferiorly, and
securing it (under more taughtness) at or near the IMF. This application is similar
to the “reconstructive model”, as a “pectoral muscle extension”.
A
B
ADM

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CHAPTER 17 • Secondary procedures following prosthetic breast surgery
Fig. 17.4  (A–C) Preoperative views of a 37-year-old woman after breast augmentation. (D–F) Thirty-two months after revision augmentation mastopexy (inverted T), which
included the development of a neopectoral pocket, lower pole coverage with acellular dermal matrix and replacement of implants with form stable, highly cohesive gel
anatomic implants.
A
B
C
D
E
F

275
Basic science and disease process
The ADM should be conformed to, and in intimate
contact with, the outer surface of the implant (like a
hand in a glove). The appropriate pocket is created
whether it is neopectoral, subpectoral, or subfascial.8,11
Three to five half-mattress stabilizing “parachute”
sutures are placed between the skin and the ADM to
stabilize the tissue and place it in the desired location.
Sizes selected are normally in the 6–8 × 10–16 cm range
(depending on size of implant), rectangle or “contour”
shapes, and trimmed as needed. Seroma formation
should be prevented in all breast revisions in order to
increase revascularization and cellular repopulation of
the ADM, so drains are always recommended.
days. This same application is occasionally used later-
ally or inferolaterally for implant visibility or palpability,
and inferiorly to “thicken” a very thin cutaneous cover
(Figs. 17.7 & 17.8). The key to success is proper pocket
alteration with incorporation of the extra thick ADM
providing bulk, and including revascularization and
cellular repopulation.
Treatment of capsular contracture
Even though the presenting problem may be capsular
contracture, additional deformities may be identified
following detailed analysis from the skin envelope to the
chest wall, as noted above. This can include thinned
tissue over an encapsulated implant, malposition of the
encapsulated implant, or stretched deformity, snoopy, or
ptosis over an encapsulated implant. If the encapsulation
is in the subglandular position, a total capsulectomy with
site change to the subpectoral position is usually per-
formed. If the encapsulation is in the subpectoral posi-
tion, a neopectoral pocket with partial anterior capsule
excision and residual capsule obliteration, or total
(perhaps partial) capsulectomy is performed. In these
cases the ADM is again selected for rapid revasculariza-
tion, conformability to the implant, and performance.
The technique is most frequently similar to the “lower
pole cover” concept, but may be closer to a “medial
thickener”, or “malposition reinforcer” dependent upon
the presenting problem (Figs. 17.9 & 17.10). There is an
increasing body of documentation that the coupling of
the ADM to the implant will further reduce the incidence
of capsular contracture.13,25 If capsular contracture is the
only clinical diagnosis, then we recommend a placement
of the ADM at the lower or middle poles.
The surgical techniques used are based on the preop-
erative findings and the indications as described above.
Fig. 17.5  Patient as seen in Fig. 17.4 demonstrating the softness of the implants
32 months following the treatment of her capsular contracture and ptosis.
Tips
For the operative technique:
• A careful history is imperative in understanding how a
problem came to exist. This includes all previous
operations, what was done, and what implants were used.
Previous operative notes and documentation with specific
details for existing implants are highly desirable. A careful
analysis of the patient’s existing “form”, asymmetries,
dimensional measurements, and tissue characterization is
mandatory, in addition to documentation of current implant
type, volume, location, and “status”. Any previous or
current pathological concerns should be known, as well as
any diagnostic imaging of the breasts or implants, in
addition to the patient’s overall health, surgeries, and
medications.
• Site change to dual plane if original implant is in a
subglandular pocket.
• Site change to neopectoral pocket if original implant is in a
subpectoral pocket.
• ADM should be handled in the same manner as the
silicone implant. The surgeon should only be handling the
implantable materials, and both the prosthetic device and
ADM are bathed in a solution consisting of 50 000 U of
bacitracin, 1 g of cephazolin, and 80 mg of gentamicin, in
500 mL of normal saline.
• ADM contour shapes, with a geometric contour to engage
the geometry of the implant surface, are exclusively
selected for the lower pole indications (i.e., capsular
contracture and ptosis correction).
• Extra thick ADMs are selected, which are shaped by hand
intraoperatively so that their geometry conforms to that of
the superomedial implant geometric contour for superior
“tissue thickener”.
• Key decisions are made with regard to implants (type,
volume, dimensions, filler, shape, and surface) as well as
treatment of existing capsule, overlying parenchyma, soft
tissue, and skin envelope (mastopexy). We have a
preference for the creation of “site-changed” pockets,
silicone gel implants (generally having a “Biocell texture”),
and ADMs selected by their biomechanical properties,
“design”, indications for use, documented outcomes, as
well as considerations of cost.

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CHAPTER 17 • Secondary procedures following prosthetic breast surgery
A
B
C
D
Fig. 17.6  (A–C) Preoperative views of a 49-year-old woman after augmentation mastopexy. (D–F) Thirty months after revision augmentation mastopexy (inverted T) that
included the development of a neopectoral pocket, lower pole coverage and reinforcement of inferior and lateral walls with acellular dermal matrix (ADM), and replacement
of implants form stable, highly cohesive gel anatomic implants. Successful correction of inferior and lateral malposition was achieved.
E
F

Fig. 17.7  (A–C) Preoperative views of a 38-year-old woman after multiple previous revision augmentations. (D–F) Twenty-six months after revision augmentation through
IMF incision, which included the development of neopectoral pocket, lamellar separation, lower pole coverage with acellular dermal matrix, and replacement of implants
with textured gel implants.
A
B
C
D
E
F

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CHAPTER 17 • Secondary procedures following prosthetic breast surgery
Outcomes, prognosis, and complications
Breast augmentation is the most common aesthetic
procedure performed in the US and perhaps in the
world.45 It is in the nature of plastic surgeons to strive
for perfection and continue to improve surgical tech-
niques to achieve the best aesthetic form. Despite
advances in implant technology and surgical techniques,
undesired outcomes are encountered leading to revi-
sionary surgeries. In preparing for a revisionary breast
augmentation, one must understand patients’ goals and
expectations and evaluate the probability of their
accomplishment, as well as the risk/benefit ratio. When
a decision is made to move forward, the goal should be
to plan and execute the most precise and efficient surgi-
cal correction. To achieve this goal, one must understand
the problem(s) and variables involved and then look for
new solutions.
In the past our options were limited to working with
only the native tissues available to us for these proce-
dures. With the advent of ADM, the indications and the
Fig. 17.8  Patient as seen in Fig. 17.7 demonstrating the softness of implants 26
months following the treatment of her implant malposition, lamellar scarring, and
tissue thinning.
Fig. 17.9  (A–C) Preoperative views of a 45-year-old woman after multiple previous attempts at
correction of capsular contracture.
A
B
C

279
Basic science and disease process
Fig. 17.10  Patient as seen in Fig. 17.9 demonstrating the softness of implants 22
months following the treatment of her capsular contracture.
spectrum of correcting secondary deformities has
improved.
The use of acellular dermal products has been
popularized in both breast and abdominal wall
reconstructions.14–24 In reconstruction cases, ADMs
have been used to replace tissue, extend existing tissue,
or act as a supplement. In aesthetic revisions, the ADM
essentially becomes an outer conforming, regenerative
layer around the implant. They have been used to
correct implant rippling and displacement, ptosis, and
capsular contracture.26,27,37 ADMs are used as an alter-
native to other autologous tissue methods of coverage
and provide camouflage, thus decreasing rippling and
increasing soft-tissue padding.28 In addition to all the
indications described previously, we have also used
ADMs as a mode of treatment for capsular contrac-
ture.25 Breast capsular contracture is similar to lamellar
scarring in the eyelids. At the cellular level, capsular
contracture is most likely caused by any process that
produces increased inflammation, which in turn leads
to the formation of deleterious cytokines within the
periprosthetic pocket. Consequently, in addition to the
D
E
F
(D–F) Twenty-two months after revision augmentation through IMF incision, which
included the development of neopectoral pocket, lower pole coverage with acellular dermal matrix,
and replacement of implants with higher profile, lower-volume textured gel implants.
many techniques described for treating and preventing
capsular contracture,4,5,8,30–36 we believe that the addi-
tion of ADM is another modality in fighting the
evolution of the capsule. An ADM can counteract the
inflammatory process, adding more tissue ingrowth
Fig. 17.9, cont’d

280
SECTION II
CHAPTER 17 • Secondary procedures following prosthetic breast surgery
availability and controlling the interface of the pocket
by providing a regenerative layer between device and
native tissue.
The rising demand for the use of ADM, coupled with
good outcomes in breast reconstructions, has spurred
tremendous interest in its use for aesthetic breast surgery
patients. In the past, revisionary surgeries were gener-
ally performed with a total capsulectomy, removal of
the implant from the subglandular plane, and place-
ment of a new implant in the subpectoral position.5,8,10
This is a fairly simple procedure, involving a change in
implant placement from over the muscle to under the
muscle. More recently, it has become necessary to
perform revisionary surgery on volume-depleted or
severely scarred breasts. In correcting these deformities
as described in the indication section, in addition to the
site change operation, ADMs can provide additional
coverage where the repair is performed.
The recent published series of 197 consecutive patients
who underwent revisionary breast augmentation/
mastopexies with acellular dermal matrices was one of
the largest series to date to address the use of ADM in
revisionary aesthetic breast surgery.46 Reasons for revi-
sion included capsular contracture (61.8%), implant
malposition (31.2%), rippling (4.8%), ptosis (4.8%),
implant exposure (1.6%), and breast wound (0.5%). The
mean follow-up period was 3.1 ± 1.1 years (range: 0.1–6.1
years). The complication rate was 4.8% including Baker
grade III/IV capsular contracture (1.6%), infection
(1.6%), implant malposition (0.5%), hematoma (0.5%),
and seroma (0.5%). Ninety-eight percent of revisions
were successful with no recurrence of the presenting
complaint.
A challenge that plastic surgeons continue to face in
aesthetic revisionary surgery is the cost of these prod-
ucts and their affordability by the patient. On the other
hand, the biggest possible cost of performing a revision-
ary surgical procedure (to patient and surgeon alike) is
the need to perform another surgical revision due to
failure of the planned procedure. No doubt the coming
years will be exciting as we further define the issues,
advance the science, and increase our understanding
via evidence-based medicine, for the benefit of our
patient population.
2. Spear SL, Murphy DK, Slicton A, Walker PS. Inamed silicone breast
implant core study results at 6 years. Plast Reconstr Surg. 2007;120(7
suppl 1):8S–16S, discussion 7S–8S. The authors provide an update on
the postapproval study for Allergan Corporation. The study demonstrates
the safety and effectiveness of Natrelle (formerly Inamed) silicone-filled
breast implants over 6 years, including a low rupture and high
satisfaction rate.
3. Cunningham B, McCue J. Safety and effectiveness of Mentor’s
MemoryGel implants at 6 years. Aesthetic Plast Surg. 2009;33(3):440–
444. The authors provide an update on the postapproval study for Mentor
Corporation. The study shows that Mentor MemoryGel Silicone Breast
Implants represent a safe and effective choice for women seeking breast
augmentation or breast reconstruction following mastectomy.
4. Adams WP Jr, Rios JL, Smith SJ. Enhancing patient outcomes in
aesthetic and reconstructive breast surgery using triple antibiotic
breast irrigation: six-year prospective clinical study. Plast Reconstr
Surg. 2006;117(1):30–36. The authors show the clinical importance for the
use of triple antibiotic breast irrigation. This study shows the lower
incidence of capsular contracture, compared with other published reports,
and its clinical efficacy supports previously published in vitro studies.
Application of triple antibiotic irrigation is recommended for all aesthetic
and reconstructive breast procedures and is cost effective.
8. Maxwell GP, Gabriel A. The neopectoral pocket in revisionary
breast surgery. Aesthet Surg J. 2008;28(4):463–467. The authors describe
in detail (and with multiple illustrations) the operative technique for the
creation of the neopectoral pocket.
13. Maxwell GP, Gabriel A. Use of the acellular dermal matrix in
revisionary aesthetic breast surgery. Aesthet Surg J. 2009;29(6):485–
493. The authors show the largest acellular dermal matrix (ADM) based
revisionary surgeries, including both revisionary augmentation and
revision of augmentation mastopexy. This series shows that the ADM can
be used both safely and effectively in revisionary cases, resulting in
decreased rates of capsular contracture and implant cushioning/
stabilization.
14. Bindingnavele V, Gaon M, Ota KS, et al. Use of acellular cadaveric
dermis and tissue expansion in postmastectomy breast
reconstruction. J Plast Reconstr Aesthet Surg. 2007;60(11):1214–1218.
23. Salzberg CA. Nonexpansive immediate breast reconstruction using
human acellular tissue matrix graft (AlloDerm). Ann Plast Surg.
2006;57(1):1–5.
24. Spear SL, Parikh PM, Reisin E, Menon NG. Acellular dermis-
assisted breast reconstruction. Aesthetic Plast Surg. 2008;32(3):
418–425.
26. Duncan DI. Correction of implant rippling using allograft dermis.
Aesthet Surg J. 2001;21(1):81–84.
43. Harper JR, McQuillan DJ. A novel regenerative tissue matrix (RTM)
technology for connective tissue reconstruction. Wounds. 2007;
2007(6):20–24.
Access the complete reference list online at

280.e1
References
References
1. Maxwell GP, Gabriel A. The evolution of breast implants. Clin Plast
Surg. 2009;36(1):1–13, v.
2. Spear SL, Murphy DK, Slicton A, Walker PS. Inamed silicone breast
implant core study results at 6 years. Plast Reconstr Surg. 2007;120(7
suppl 1):8S–16S, discussion 7S–8S. The authors provide an update on
the postapproval study for Allergan Corporation. The study demonstrates
the safety and effectiveness of Natrelle (formerly Inamed) silicone-filled
breast implants over 6 years, including a low rupture and high
satisfaction rate.
3. Cunningham B, McCue J. Safety and effectiveness of Mentor’s
MemoryGel implants at 6 years. Aesthetic Plast Surg. 2009;33(3):440–
444. The authors provide an update on the postapproval study for Mentor
Corporation. The study shows that Mentor MemoryGel Silicone Breast
Implants represent a safe and effective choice for women seeking breast
augmentation or breast reconstruction following mastectomy.
4. Adams WP Jr, Rios JL, Smith SJ. Enhancing patient outcomes in
aesthetic and reconstructive breast surgery using triple antibiotic
breast irrigation: six-year prospective clinical study. Plast Reconstr
Surg. 2006;117(1):30–36. The authors show the clinical importance for the
use of triple antibiotic breast irrigation. This study shows the lower
incidence of capsular contracture, compared with other published reports,
and its clinical efficacy supports previously published in vitro studies.
Application of triple antibiotic irrigation is recommended for all aesthetic
and reconstructive breast procedures and is cost effective.
5. Spear SL, Carter ME, Ganz JC. The correction of capsular
contracture by conversion to “dual-plane” positioning: technique
and outcomes. Plast Reconstr Surg. 2006;118(7 suppl):103S–113S,
discussion 14S.
6. Cunningham B. The Mentor Core Study on Silicone MemoryGel
Breast Implants. Plast Reconstr Surg. 2007;120(7 suppl 1):19S–29S,
discussion 30S–32S.
7. Adams WP Jr. Capsular contracture: what is it? What causes it?
How can it be prevented and managed? Clin Plast Surg.
2009;36(1):119–126, vii.
8. Maxwell GP, Gabriel A. The neopectoral pocket in revisionary
breast surgery. Aesthet Surg J. 2008;28(4):463–467. The authors describe
in detail (and with multiple illustrations) the operative technique for the
creation of the neopectoral pocket.
9. DFU. Allergan PMA. [Online] Available from: <>.
10. Maxwell GP, Tebbetts JB, Hester TR. Site change in breast surgery.
Presented at the American Association of Plastic Surgeons, St.
Louis, MO, 1994.
11. Maxwell GP, Birchenough SA, Gabriel A. Efficacy of neopectoral
pocket in revisionary breast surgery. Aesthet Surg J.
2009;29(5):379–385.
12. Spear SL, Sher SR, Al-Attar A. Focus on technique: supporting the
soft-tissue envelope in breast reconstruction. Plast Reconstr Surg.
2012;130(5 suppl 2):89S–94S.
13. Maxwell GP, Gabriel A. Use of the acellular dermal matrix in
revisionary aesthetic breast surgery. Aesthet Surg J. 2009;29(6):485–
493. The authors show the largest acellular dermal matrix (ADM) based
revisionary surgeries, including both revisionary augmentation and
revision of augmentation mastopexy. This series shows that the ADM can
be used both safely and effectively in revisionary cases, resulting in
decreased rates of capsular contracture and implant cushioning/
stabilization.
14. Bindingnavele V, Gaon M, Ota KS, et al. Use of acellular cadaveric
dermis and tissue expansion in postmastectomy breast
reconstruction. J Plast Reconstr Aesthet Surg. 2007;60(11):1214–1218.
15. Breuing KH, Warren SM. Immediate bilateral breast reconstruction
with implants and inferolateral AlloDerm slings. Ann Plast Surg.
2005;55(3):232–239.
16. Breuing KH, Colwell AS. Inferolateral AlloDerm hammock for
implant coverage in breast reconstruction. Ann Plast Surg.
2007;59(3):250–255.
17. Cothren CC, Gallego K, Anderson ED, Schmidt D. Chest wall
reconstruction with acellular dermal matrix (AlloDerm) and a
latissimus muscle flap. Plast Reconstr Surg. 2004;114(4):1015–1017.
18. Garramone CE, Lam B. Use of AlloDerm in primary nipple
reconstruction to improve long-term nipple projection. Plast
Reconstr Surg. 2007;119(6):1663–1668.
19. Glasberg SB, D’Amico RA. Use of regenerative human acellular
tissue (AlloDerm) to reconstruct the abdominal wall following
pedicle TRAM flap breast reconstruction surgery. Plast Reconstr
Surg. 2006;118(1):8–15.
20. Kim H, Bruen K, Vargo D. Acellular dermal matrix in the
management of high-risk abdominal wall defects. Am J Surg.
2006;192(6):705–709.
21. Nahabedian MY. Secondary nipple reconstruction using local flaps
and AlloDerm. Plast Reconstr Surg. 2005;115(7):2056–2061.
22. Patton JH Jr, Berry S. Kralovich KA. Use of human acellular dermal
matrix in complex and contaminated abdominal wall
reconstructions. Am J Surg. 2007;193(3):360–363, discussion 3.
23. Salzberg CA. Nonexpansive immediate breast reconstruction using
human acellular tissue matrix graft (AlloDerm). Ann Plast Surg.
2006;57(1):1–5.
24. Spear SL, Parikh PM, Reisin E, Menon NG. Acellular dermis-
assisted breast reconstruction. Aesthetic Plast Surg.
2008;32(3):418–425.
25. Maxwell GP, Gabriel A, Perry LC. Role of Acellular Dermal Matrix in
Inflammation. Unpubls. 2009.
26. Duncan DI. Correction of implant rippling using allograft dermis.
Aesthet Surg J. 2001;21(1):81–84.
27. Baxter RA. Intracapsular allogenic dermal grafts for breast
implant-related problems. Plast Reconstr Surg. 2003;112(6):1692–1696,
discussion 7–8.
28. Gamboa-Bobadilla GM. Implant breast reconstruction using
acellular dermal matrix. Ann Plast Surg. 2006;56(1):22–25.
29. Maxwell GP, Falcone PA. Eighty-four consecutive breast
reconstructions using a textured silicone tissue expander. Plast
Reconstr Surg. 1992;89(6):1022–1034, discussion 35–36.
30. Gancedo M, Ruiz-Corro L, Salazar-Montes A, et al. Pirfenidone
prevents capsular contracture after mammary implantation.
Aesthetic Plast Surg. 2008;32(1):32–40.
31. Ma SL, Gao WC. [Capsular contracture in breast augmentation with
textured versus smooth mammary implants: a systematic review].
Zhonghua Zheng Xing Wai Ke Za Zhi. 2008;24(1):71–74.
32. Scuderi N, Mazzocchi M, Rubino C. Effects of zafirlukast on
capsular contracture: controlled study measuring the mammary
compliance. Int J Immunopathol Pharmacol. 2007;20(3):577–584.
33. Weintraub JL, Kahn DM. The timing of implant exchange in the
development of capsular contracture after breast reconstruction.
Eplasty. 2008;8:e31.
34. Wiener TC. Relationship of incision choice to capsular contracture.
Aesthetic Plast Surg. 2008;32(2):303–306.
35. Wong CH, Samuel M, Tan BK, Song C. Capsular contracture in
subglandular breast augmentation with textured versus smooth
breast implants: a systematic review. Plast Reconstr Surg.
2006;118(5):1224–1236.
36. Zimman OA, Toblli J, Stella I, et al. The effects of angiotensin-
converting-enzyme inhibitors on the fibrous envelope around
mammary implants. Plast Reconstr Surg. 2007;120(7):2025–2033.
37. Colwell AS. Breuing KH. Improving shape and symmetry in
mastopexy with autologous or cadaveric dermal slings. Ann Plast
Surg. 2008;61(2):138–142.
38. Ashikari RH, Ashikari AY, Kelemen PR, Salzberg CA. Subcutaneous
mastectomy and immediate reconstruction for prevention of breast
cancer for high-risk patients. Breast Cancer. 2008;15(3):185–191.
39. Breuing KH, Colwell AS. Immediate breast tissue expander-implant
reconstruction with inferolateral AlloDerm hammock and
postoperative radiation: a preliminary report. Eplasty. 2009;9:e16.
40. Zienowicz RJ, Karacaoglu E. Implant-based breast reconstruction
with allograft. Plast Reconstr Surg. 2007;120(2):373–381.
41. Becker S, Saint-Cyr M, Wong C, et al. AlloDerm versus
DermaMatrix in immediate expander-based breast reconstruction: a
preliminary comparison of complication profiles and material
compliance. Plast Reconstr Surg. 2009;123(1):1–6, discussion 107–108.

280.e2
SECTION II
CHAPTER 17 • Secondary procedures following prosthetic breast surgery
42. Losken A. Early results using sterilized acellular human dermis
(neoform) in post-mastectomy tissue expander breast
reconstruction. Plast Reconstr Surg. 2009;123(6):1654–1658.
43. Harper JR, McQuillan DJ. Extracellular wound matrices: a novel
regenerative tissue matrix (RTM) technology for connective tissue
regeneration. Wounds. 2007;19(6):163–168.
44. Maxwell GP. ADM in Revisionary Breast Surgery. ASPS. 2009.
45. ASPS Procedural Statistics hwpoDM-SAPSSpA. 2014. [Online]
Available from: <
Media/2014-Statistics/ASPS_2010_Plastic_Surgery_
Statistics_20711.pdf>.
46. Maxwell GP, Gabriel A. Non-cross-linked porcine acellular dermal
matrix in revision breast surgery: long-term outcomes and safety
with neopectoral pockets. Aesthet Surg J. 2014;34(4):551–559.

SECTION II • Reconstructive Breast Surgery
18 
The pedicled TRAM flap
Julian J. Pribaz and Simon G. Talbot
SYNOPSIS
■ The pedicled transverse rectus abdominis myocutaneous (TRAM) flap
is a consistent, predictable, and expeditious method of autologous
breast reconstruction.
■ The pedicled TRAM flap was introduced by Dr. Carl Hartrampf1,2 in the
1980s and remains one of the most commonly used autologous
methods of breast reconstruction today.
■ The rectus abdominis muscle is a Mathes and Nahai type III muscle,3
and the pedicled TRAM flap relies on the superior epigastric vessels
and its terminal branches.
■ The key contraindication to a pedicled TRAM flap is injury or absence
of the vascular pedicle (for example, after open cholecystectomy).
■ Many variations on this flap (for example, double pedicled flaps,
supercharged flaps, and delay procedures) make this flap versatile and
reliable.
Access the Historical Perspective section online at

Introduction
The goal of all breast reconstruction is to create a natural
and aesthetically pleasing breast that is stable, long-
lasting, with good symmetry to the opposite side. This
can be most consistently and predictably achieved by
using autologous tissue to perform the reconstruction.
Of course, this entails more complex surgery, additional
scars, and a longer recovery time than implant-based
reconstruction, but in the long run these are often
worthy trade-offs. Autologous breast reconstruction
can be achieved with pedicled or free flaps, and these
flaps can be used for many purposes other than breast
reconstruction. However, the focus of this chapter
will be on the use of the pedicled TRAM flap in breast
reconstruction.
The pedicled TRAM flap remains a commonly used
method of autologous breast reconstruction in the
United States.
Careful patient selection is very important. The
patient must be healthy enough to undergo an approxi-
mately 3-hour operation, have suitable anatomy,
minimal comorbidities, and be aware of the 6–8 weeks
needed for recovery.
Basic science/anatomy
The TRAM flap consists of a transverse island of
abdominal skin and fat that is supplied by periumbilical
perforators that are the terminal branches of the superior
epigastric vascular pedicle. This arises from the internal
thoracic artery and veins (also known as the internal
mammary artery and veins). The superior epigastric
artery and its venae comitantes course along the deep
aspect of the rectus muscles and send perforators from
posteriorly through the muscle just medial to the linea
semilunaris and in the periumbilical area and connect
with the terminal branches of the larger, deep inferior
epigastric vessels, upon which free TRAM flaps and
DIEP flaps are based (also used in breast reconstruction
and described in other chapters). Multiple minor pedi-
cles comprising the intercostal arteries and venae comi-
tantes, supplied by the thoracic aorta and vena cava,
contribute to the muscle perfusion, and may be pre-
served superiorly in the dissection. The rectus abdominis
muscle is a Mathes and Nahai type III muscle.3

281.e1
Historical perspective
Historical perspective
The first description of the use of lower abdominal
tissue for reconstruction of a radical mastectomy defect
was by Millard4 who described the use of a tubed lower
abdominal pedicled flap in 1976. In this procedure he
“waltzed” the tubed flap in stages, firstly to the forearm
and then onto the chest. In 1979, Holmstrom5 reported
the transfer of a free flap based on the inferior epigastric
pedicle, and in the same year, Robbins6,7 described a
pedicled vertical rectus abdominis myocutaneous flap
for breast reconstruction. In 1982 Hartrampf, Scheflan,
and Black1,2 described the increased versatility of having
a transverse abdominal skin island based on the supe-
rior epigastric vessels, giving rise to the pedicled trans-
verse rectus abdominis myocutaneous flap or the
pedicled TRAM flap. Because of the greater abundance
of soft tissue in the abdominal area, the TRAM flap
quickly became the most popular method of autologous
breast reconstruction. The TRAM flap (pedicled or free)
continues to be a very commonly used method of
autologous breast reconstruction in the US, although in
recent years, because of the concern of loss of the rectus
muscle, there has been an increasing use of free tissue
transfers from the abdominal area in the form of the
DIEP flap (based on perforators from the inferior epi-
gastric pedicle with preservation of the rectus muscle).

282
SECTION II
CHAPTER 18 • The pedicled TRAM flap
1. midline of chest and abdomen (including sternal
notch reference point)
2. periareolar incision(s) with lateral extension
3. bilateral inframammary folds
4. limits of the breast mounds.
The flap design and markings are made intraoperatively
after assessment of the mastectomy defect and skin
island requirements:
1. costal margins as a guide where to stop upper flap
elevation
2. abdominal flap incisions
a. upper line approximately 2 cm above umbilicus
to capture periumbilical perforators
b. lower line assessed at where the upper
abdominal flap will reach after the TRAM tissue
is relocated and the patient is flexed
3. periumbilical incision for preservation of the
umbilicus during dissection
4. expected location of the skin paddle(s) of
abdominal skin when relocated to the chest to
allow de-epithelialization of the flap(s) while
remaining taut on the abdomen.
Diagnosis/patient presentation
The TRAM flap may be used for breast reconstruction
stemming from almost any cause. Typically this is
required after mastectomy for breast cancer. However, a
multitude of other indications exist: partial mastectomy
reconstruction, chest wall reconstruction, sternal recon-
struction, congenital asymmetry reconstruction, etc.
The pedicled TRAM flap is a relatively large and very
reliable flap that transfers the redundant soft tissue
present in the mid and lower abdominal region to
reconstruct a breast that has a very natural feel and
shape and without the need for a prosthesis.
Breast reconstruction with a pedicled TRAM flap is
expeditious and reliable with few complications at the
recipient and donor sites if done properly.12 The proce-
dure can be performed either at the time of mastectomy
(which is generally simpler) or secondarily in patients
who prefer to have a delayed reconstruction (or patients
who will need to have postoperative radiation as the
effects of radiation to the flap itself are variable and
unpredictable and may result in a suboptimal result).
The authors typically wait at least 3–6 months after the
completion of radiation and may leave a tissue expander
as a “place-holder” while undergoing radiation to main-
tain breast contour and to make it possible to keep
significantly more native breast skin. When this is
undertaken, the pectoralis is typically elevated for
Motor and sensory innervation to the flap are from
the seventh through twelfth intercostal nerves; however,
these are cut during flap dissection.
The TRAM flap is a very large flap, and an attempt
has been made to quantify the vascularity of different
parts of this flap. The skin island has been subdivided
into four perfusion zones, with the number previously
thought to reflect the degree of vascularity to the overly-
ing skin and fat. Zone 1 overlies the rectus muscle, zone
2 overlies the contralateral muscle, zone 3 is lateral to
the ipsilateral muscle, and zone 4 is lateral to the contra-
lateral rectus muscle (Fig. 18.1).8,9
The best perfused area of the flap is in zone 1, directly
over the perforators. Initially, it was thought that zone
2 over the contralateral muscle was next best perfused,
but it has been shown that zone 3, lateral to zone 1 on
the ipsilateral side, has better perfusion. The least per-
fused part is zone 4 on the contralateral lateral aspect.10
It is best to only use the best-perfused part of the flap
for reconstruction to avoid fat necrosis: zone 1 and the
adjacent parts of zone 3 and 2, depending on the volume
of tissue required.
Ipsilateral versus contralateral TRAM
Although either can lead to a successful reconstruction,
an ipsilateral flap is preferred, as this transfers zone 3
superiorly, which is better perfused than zone 2, which
would be transferred superiorly if a contralateral flap is
used. Use of an ipsilateral flap also helps to maintain
the inframammary fold, a xiphoid hollow, and confers
a potentially lower rate of fat necrosis.11 However, prior
abdominal scars may necessitate the use of a contra-
lateral flap (Fig. 18.2).
Surface markings (Figs. 18.3 & 18.4)
The following markings are made preoperatively in a
standing position for reference and to aid the mastec-
tomy surgeon(s):
Fig. 18.1  Vascular zones (I, II, III, IV) of right sided transverse rectus abdominis
myocutaneous flap.

283
Diagnosis/patient presentation
insertion of a tissue expander, and replaced and re-
suspended at the time of TRAM flap to prevent an
animation deformity over the flap.
The main cited disadvantage of this procedure over
alternative reconstructive options is that part of the
rectus abdominus muscle is harvested with the flap,
possibly resulting in abdominal wall weakness and a
potentially increased incidence of an abdominal wall
hernia. This will be discussed later in the chapter.
Another cited disadvantage is that the pedicled TRAM
flap has a less robust blood supply than the free TRAM
flap or the DIEP flap, with a consequent increased
incidence of fat necrosis. However, as described later in
this chapter, if only the best-perfused parts of the flap
are utilized, this has not been borne out to be a major
problem in the authors’ experience.
B
C
A
D
E
Fig. 18.2  Typical intra- and postoperative results of delayed ipsilateral and contralateral
reconstructions. (A–C) Ipsilateral pedicled transverse rectus abdominis myocutaneous (TRAM)
flap reconstruction. (D,E) Contralateral pedicled TRAM flap reconstruction.
Continued

284
SECTION II
CHAPTER 18 • The pedicled TRAM flap
F
G
H
I
J
K
(F–L) Bilateral immediate pedicled TRAM flap reconstructions.
Fig. 18.2, cont’d

285
Treatment/surgical technique
successful vaginal delivery. Successful pregnancies
(including twins) with vaginal deliveries have been
reported after TRAM flap surgery.
Treatment/surgical technique
The steps involved are demonstrated for both a unilat-
eral (see Fig. 18.3) and bilateral (see Fig. 18.4) breast
reconstruction.
The umbilicus is first incised and dissected down to
the abdominal wall. Although optional, we prefer to de-
epithelialize the parts of the TRAM flap(s) that will later
be buried under the mastectomy skin flap(s), leaving
sufficient intact skin to allow for adjustment at the time
of inset. It is easier to de-epithelialize while the flaps
remain taut on the abdomen, but it is fine to do this later.
The skin island is then incised (beveling superiorly
towards the deep fascia to capture as many perforators
as possible) and dissected down to the abdominal wall.
The abdominal wall is then dissected superiorly to the
epigastric area and connected with the mastectomy site
in the midline, leaving as much of the medial aspect of
the inframammary fold intact as possible. Preserve the
intercostal perforators to this upper abdominal skin flap
by not extending the dissection above the costal margins
laterally. Ensure an adequate width tunnel exists
through which to pass the pedicle(s) into the breast
pocket(s) – approximately large enough to pass a fist
through. This tunnel should not be excessive, as it can
distort the inframammary fold.
The lateral aspect of the TRAM flap is elevated off the
underlying muscles to the lateral aspect of the anterior
rectus sheath, where the lateral row of periumbilical
perforators are seen. Medially, the flap is also elevated
off the linea alba for approximately 1–2 cm. Any perfo-
rators visualized are preserved.
The fascia is then incised down to the muscle. Supe-
riorly, a 2.5 cm strip of fascia is maintained along the
length of the muscle in the central aspect of the muscle.
This protects any vessels immediately beneath and also
facilitates a more expeditious flap harvest.
The muscle is then separated from the fascia medially
and laterally. Laterally, the multiple intercostal neuro-
vascular pedicles are cauterized and divided. The
muscle is divided at approximately the level of the
arcuate line, and the inferior epigastric vessels are also
ligated and divided. The flap is now developed as a
superiorly based flap and dissected superiorly until the
superior pedicle is visualized near the xiphoid process.
The flap is now ready to be introduced into the mas-
tectomy pocket. To help with orienting the flap, it is
marked with an arrow pointing laterally towards zone
Patient selection
The primary goals of breast reconstruction include con-
struction of a natural-appearing breast with contralateral
symmetry, safely, with stability over time. An acceptable
(or even improved) donor site is important.
Patient selection and operative planning should take
into account the size and shape of the breast, plans for
contralateral surgery (in unilateral cases), cancer stage
and need for radiation, appearance of the abdomen,
prior abdominal operations, general health of the
patient, as well as lifestyle, goals, and expectations.
These help in the decision-making between implant
versus autologous techniques and the variety of autolo-
gous techniques available.
Most women are eligible for this method of breast
reconstruction. However, patients with serious medical
problems, psychiatric disorders, morbid obesity, and
patients who continue to smoke heavily are not good
candidates for this form of reconstruction.
Patients may not be candidates if they have insuffi-
cient abdominal tissue to create an adequate mound.
However, thin patients typically also have relatively
small breasts requiring less tissue for reconstruction, so
this is only a relative contraindication.
The pedicled TRAM is contraindicated in patients
with an extensively scarred abdomen. It is also contra-
indicated in patients with severe chronic back pain and
patients with significant fibromyalgia symptoms.
An increasing number of patients who have had prior
implant-based reconstruction are being referred for
conversion to autologous reconstruction, and the pedi-
cled TRAM flap is an excellent option.
Younger women still in their childbearing years,
unfortunately, are also commonly referred for recon-
struction after mastectomy, and they are concerned
about the effects of the abdominal surgery on a
L
Fig. 18.2, cont’d
Text continued on p. 290

286
SECTION II
CHAPTER 18 • The pedicled TRAM flap
A
C
B
D
E
F
G
Fig. 18.3  Technique of unilateral ipsilateral transverse rectus abdominis myocutaneous flap reconstruction. (A) Preoperative markings. (B) Intraoperative markings. (C) Flap
de-epithelialization and tunnel creation. (D) Medial flap elevation. (E) Lateral flap elevation. (F) Markings for anterior rectus sheath incisions. (G) Rectus muscle elevation.
Note that these are of two patients (A,C,E and G are one patient; B,D, and F the other).

287
Treatment/surgical technique
K
H
I
J
L
M
(H) Division of deep
inferior epigastric vessels. (I) Elevated
flap. (J) Mobilization of the flap. (K) The
flap is turned with zone 3 superiorly.
(L) Flap insetting. (M) On-table result.
Fig. 18.3, cont’d

A
B
D
E
C
F
Fig. 18.4  Technique of bilateral transverse rectus abdominis myocutaneous flap reconstruction. (A) Intraoperative markings. (B) Flap de-epithelialization. (C) Tunnel
creation. (D) Medial and lateral flap elevation. (E) Markings for anterior rectus sheath incisions. (F) Rectus muscle elevation.

Fig. 18.4, cont’d
G
H
I
J
K
L
(G) Elevated flaps. (H) Mobilization of the flaps. (I) The flaps are turned with each zone 3 superiorly. (J) Flap insetting. (K) Both leaves of the rectus
sheath are included in the closure. (L) Mesh closure of the abdomen.
Continued
Fig. 18.4, cont’d

290
SECTION II
CHAPTER 18 • The pedicled TRAM flap
dissection has been performed. In delayed reconstruc-
tions, the mastectomy defect must be recreated. It is
often necessary to remove scarred skin from radiation.
The quality of the mastectomy skin flaps is also
assessed, and if these appear ischemic, these are cut
back to where healthy dermal bleeding is evident. The
pedicled TRAM flap is now brought up from the
abdomen and tunneled underneath the upper abdomi-
nal skin into the epigastric region and then introduced
into the mastectomy pocket, bringing zone 3 superiorly.
Twisting is not a problem if zone 3 is grasped and simply
brought superiorly into the pocket. The flap will auto-
matically orient itself into a satisfactory configuration.
Ensure that the flap remains viable and non-congested
3, and the flap is introduced into the breast cavity bring-
ing zone 3 superiorly.
Preparation of mastectomy site and flap inset depends
on the immediate or delayed nature of the reconstruc-
tion. In immediate breast reconstruction after mastec-
tomy, not uncommonly the mastectomy pocket may
have been resected beyond the aesthetic margins of the
breast by the oncologic surgeon, and it is important to
re-define the inframammary fold and the lateral aspect
of the pocket. This is performed with multiple quilting
sutures. A Blake suction drain is then inserted into the
breast pocket along the inframammary fold and exits
laterally and inferior to the fold. An additional drain
into the axilla may be used, especially if an axillary node
M
N
O
P
(M) Completed mesh inset. (N) On-table result. (O) Final result after nipple creation and
tattooing. (P) Final results of abdominal donor site.
Fig. 18.4, cont’d

291
Treatment/surgical technique
fascia is advanced medially to cover a good part of the
mesh. A hole is cut in the mesh over the umbilicus to
allow it to be inset into its new location on the skin. Our
experience has been very favorable with excellent out-
comes and with minimal complications.
Modifications of TRAM flap reconstructions
Double pedicled TRAM flaps for single
mastectomy reconstruction
In some cases where there is very large and/or ptotic
opposite breast and the patient does not wish to have a
reduction procedure, it may be necessary to utilize two
flaps to achieve the necessary volume. In these cases, the
ipsilateral flap is completely de-epithelialized and turned
up first and the contralateral flap contains the skin island
and it is stacked on top of the ipsilateral flap (Fig. 18.5).
Folded TRAM flap
Patients with a very large mastectomy or chest wall
defect require a larger flap to adequately cover
the defect that cannot be achieved with a single pedicle
TRAM flap. Folding the flap expands the area that can
be covered, and folding also produces a conical breast
shape that enhances the reconstruction (Fig. 18.6).
Prior abdominal surgery
Prior abdominal surgery may necessitate modifications
of the TRAM. For example, in cases where an open
cholecystectomy has been performed and there is an
existing scar, it is presumed that the rectus muscle and
its blood supply has been transected, so the contralateral
flap will be used to reconstruct the right mastectomy
defect. Care must also be taken to avoid excessive
undermining of the abdominal flap on the right to
maintain vascularity of the abdominal skin which has
lost the superior pedicle and associated perforators.
TRAM flap delay
In patients who potentially may have compromised
vascularity and diminished perfusion of this flap, such
as in the morbidly obese, smokers, or diabetic patients,
a delay procedure can be performed whereby the infe-
rior pedicle is exposed and ligated. In addition, the
superficial epigastric vessels are also divided. This
should be done two weeks or more prior to elevation of
the flap (Fig. 18.7).
Modifications in flap design in obese patients
or smokers
As an alternative to flap delay, the TRAM flap can be
designed at a higher mid-abdominal level to capture
more perforators from the superior epigastric vessels,
despite being moved to the breast pocket. Additional
widening of the tunnel or dissection to avoid tension or
kinking of the pedicle may be required.
As mentioned, the ipsilateral flap is preferred, and in
doing this transfer, for a right breast reconstruction, the
flap rotates in a clockwise direction. On the left side,
bringing zone 3 superiorly means that the flap rotates
in an anti-clockwise direction. The final inset can then
be performed. The use of an ipsilateral flap has the
added benefit of producing less of a bulge in the epigas-
tric area than a contralateral flap – although in both
instances there is atrophy of the denervated muscle and
the bulge diminishes with time.
Repair of TRAM donor site must be done with care
to avoid the dreaded complication of hernias and bulges.
All cases are best repaired with an inlay of a polypro-
pylene mesh, which is fitted into the defect created by
the muscle harvest, which is larger than the fascial
defect. The mesh stretches in one direction only, and this
stretch should be directed in a superior–inferior orienta-
tion to prevent bulging. The mesh is sutured with buried
sutures to the linea alba in the midline and laterally to
the conjoint fascia of the external and internal oblique
within the anterior rectus sheath. A running polypro-
pylene suture is then inserted advancing the fascia over
the mesh, burying at least 50% of the mesh. This gives
a very sound repair and has greatly reduced the inci-
dence of bulging or hernia.
Finally, in order to close the skin, the patient is flexed
at the hips. Quilting sutures are placed in the midline
above the umbilicus between the linea alba and abdomi-
nal flap. In cases of bilateral TRAM flaps, the umbilicus
is brought through a hole in the spanning mesh. Next,
a vertical ellipse is excised in the abdominal skin overly-
ing the umbilicus, together with some thinning of fat,
and the umbilicus is brought to the surface.
The abdominal incisions are closed with interrupted
and running 2-0 braided absorbable and 3-0 monofila-
ment absorbable sutures and a running 5-0 chromic gut
is used around the umbilicus. Typically three drains are
inserted into the abdominal donor site.
Bilateral mastectomies are becoming increasingly
common, and it is possible to safely perform bilateral
TRAM flap reconstructions in these patients. This can
only be done concurrently, as if only doing a single
TRAM, the contralateral tissue is discarded and cannot
be used subsequently. Each breast is reconstructed with
the ipsilateral TRAM flap, which is dissected in the
same manner as described above. In repairing the
abdominal wall, a larger single piece of mesh is used to
span the gap left by the bilateral muscle harvest. The
mesh is sutured to the linea alba centrally and on each
side to the fascia as described above, and again a running
polypropylene suture on each lateral leaf of the rectus

292
SECTION II
CHAPTER 18 • The pedicled TRAM flap
E
F
C
D
A
B
Fig. 18.5  (A–F) Double-pedicled transverse rectus abdominis myocutaneous flaps stacked for unilateral large breast reconstruction.

293
Treatment/surgical technique
Continued
A
B
C
D
Fig. 18.6  (A–F) Folded bilateral pedicled transverse rectus abdominis myocutaneous flap to give volume and projection.
E
F

294
SECTION II
CHAPTER 18 • The pedicled TRAM flap
G
I
H
J
L
K
Fig. 18.6, cont’d
(G–M) In this patient a no-vertical-scar breast reduction was performed after breast lumpectomy and radiation following breast cancer. Post-operatively,
angiosarcoma was diagnosed and a folded bilateral pedicled TRAM flap was performed with revisions shown here.

295
Treatment/surgical technique
making the transfer safer, but the downside is that this
results in a higher abdominal scar and a less aesthetic
torso contour. This is only a relative disadvantage in
very obese patients.
Secondary procedures
Secondary procedures, which include nipple and areolar
reconstruction, revisions, and contralateral symmetry
procedures, are performed once there has been adequate
time for healing and settling of the initial reconstruction
(Fig. 18.8). This is typically delayed for 4–6 months or
until any adjunctive cancer related therapy is completed.
Fat grafting has become a routine procedure especially
to augment the deficient infraclavicular area and upper
pole of the breast.
Hints and tips
1. Preoperatively, carefully select patients who will benefit
from this procedure and who understand both the benefits
and risks involved.
2. Address the opposite breast, as the goal is to obtain a
symmetrical reconstruction. This may involve a breast
reduction that can be safely done at the same time. The
benefit is that less tissue is transferred with the TRAM flap,
thus reducing the risks of fat necrosis. If the contralateral
breast needs only a mastopexy, this is typically done
secondarily.
3. Carefully assess the mastectomy site in the patients
undergoing an immediate reconstruction. Firstly, the
vascularity of the mastectomy flaps is assessed, and any
compromised flaps are excised and adjustments made
with a larger TRAM skin island. Also, the mastectomy
pocket generally needs to be adjusted due to wide
resection at the site of the inframammary fold and laterally.
4. In patients undergoing delayed reconstruction, the
mastectomy scar is excised and the skin flaps are
elevated off the pectoralis major muscle to recreate the
mastectomy pocket. The skin below the mastectomy scar
is usually excised down to the inframammary fold, as it is
generally too tight to accommodate the flap.
Consequently, a TRAM flap with a larger skin island is
required in delayed reconstruction.
5. Raise the pedicled TRAM flap as described above, and make
a central subcutaneous tunnel that connects with the
mastectomy site and which minimally encroaches into the
inframammary fold of the side being reconstructed. Generally
the tunnel is big enough to allow a hand to traverse, and thus
the pedicled flap can be introduced into the cavity with
minimal trauma. For safe passage through the tunnel, the
TRAM flap should be pushed rather than pulled.
6. Zone 3 of the TRAM is brought superiorly and can be
affixed with an absorbable suture.
7. It is helpful to make the TRAM flap slightly bigger than the
opposite side, to allow for muscle atrophy. If it is still too
large at the time of nipple-areolar reconstruction, it can be
very simply liposuctioned to obtain symmetry.
8. A final assessment is made of the mastectomy flap
vascularity, any tissue with dubious vascularity is excised,
and the final de-epithelialization of the flap is performed
and the inset completed. SPY technology (Novadaq, FL)
may be helpful to evaluate compromised skin, if available.
9. The suturing of a thicker mastectomy flap to the edge of a
de-epithelialized TRAM flap may lead to an uneven repair
with an overriding of the mastectomy flap and relative
depression of the TRAM flap. To avoid this, the use of a
suturing technique that starts deep and takes a vertical
mattress bite of the de-epithelialized side of the flap and a
horizontal mattress of the surrounding mastectomy flap,
results in a more even repair and better result.
10. Great care needs to be taken in repairing the abdominal
wall using mesh as described above. The mesh is inlaid
into the defect created by muscle harvest and attached to
the conjoint tendon laterally and linea alba medially. The
rectus fascia is then advanced with a running
polypropylene suture, thereby covering up a significant
part of the mesh and providing a strong repair. The mesh
is used even if it is felt that the fascial defect can be
closed primarily, as this provides a stronger repair, a
reduced likelihood of hernia, and minimal displacement
of the umbilicus. Care should be taken to ensure that the
polypropylene mesh is inset with the direction of stretch in
a vertical orientation and that the repair is not “too tight”,
as this can cause considerable discomfort postoperatively.
11. Drains are inserted at both the mastectomy site (usually
one drain) and at the abdominal donor site (usually three
drains—one on each lower abdomen and a central drain
the helps drain the epigastric area).
12. The use of long-lasting local anesthesia agents delivered
by an On-Q pump (I-Flow Corporation, CA) can help with
postoperative pain.
13. Overall satisfaction: in the authors’ unit, patients
undergoing pedicled TRAM flap surgery (both unilateral
and bilateral) tend to relate minimal interference with daily
activities and report a satisfaction score of 8.3 out of 10,
with most stating that they would have the surgery
again.13,14 Others, including Moscona et al.,15 report that a
total of 75% of women were satisfied with the operation,
73% declared high satisfaction, and only 12% were
dissatisfied with the results. Also, Veiga et al.16 similarly
found a generic increase in health-related quality of life
after TRAM breast reconstruction.
M
Fig. 18.6, cont’d

296
SECTION II
CHAPTER 18 • The pedicled TRAM flap
Fig. 18.7  (A) TRAM delay performed at time of first unilateral mastectomy (due to high probability for postoperative radiation). (B,C,D) Later contralateral mastectomy and
bilateral delayed pedicled TRAM flaps were performed including revisions and nipple-areolar reconstruction. (E) Straight-leg raising is shown at 6 months postoperative.
A
B
C
D
E

297
Treatment/surgical technique
A
D
B
E
C
F
Fig. 18.8  Revision procedures. (A–C) Ipsilateral pedicled TRAM flap followed by nipple areolar reconstruction and contralateral mastopexy for symmetry.
(D–F) Ipsilateral pedicled TRAM flap in a patient with a prior breast reduction (later revised at the time of nipple-areolar reconstruction).
Continued

G
H
J
K
I
L
(G–J) Delayed ipsilateral pedicled TRAM flap – more difficult due to contracted skin envelope with need to excise scar and skin above the
inframammary fold; contralateral breast reduction at time of initial operation for symmetry. (K–O) Bilateral pedicled TRAM flaps with nipple-areolar reconstruction and fat
grafting at 13 months; long-term appearance at 2.5 years postoperatively.
Fig. 18.8, cont’d

299
Outcomes, prognosis, complications
M
N
O
Fig. 18.8, cont’d
Postoperative care
After a pedicled TRAM flap procedure, patients are cared
for on a regular floor. Typically, they remain in hospital
for 3–5 days. They are treated with appropriate pain
medication, which may include a PCA pump with transi-
tion to oral pain medications in 2–3 days. Additionally,
the use of local anesthetic infusion products, such as the
On-Q, can provide excellent postoperative pain control.
Patients receive DVT prophylaxis (compression boots
during surgery and until fully ambulatory as well as
subcutaneous heparin), and they are mobilized on the
first postoperative day. They also remain on antibiotics
whilst the drains are still in place, and they are instructed
on drain output management in preparation for their
discharge.
They are typically seen as outpatients one week
later, at which time some (or all) of the drains are
removed, if meeting criteria. The patients are reminded
of the core strengthening exercises that were discussed
and initiated at the initial consultation – namely to
tighten their abdominal obliques and transversus
muscles by “pulling in” their umbilicus. This improves
their posture, exercises their core muscles, and hastens
their recovery. These exercises can be safely and pain-
lessly performed in the early postoperative period.
Outcomes, prognosis, complications
Complications may occur at either the recipient site or
the donor site.
Recipient site
The most common complication in breast reconstruc-
tion is native chest flap necrosis. This can be minimized
by initial debridement of compromised tissue. SPY
technology can help determine viability of native skin.
Marginal fat necrosis may also occur. This usually
involves only small areas that can be removed at the
time of nipple-areolar reconstruction. Minor flap loss
can also occur if a large flap extending into the distal
parts of zone 2, 3 and 4 is used, but complete flap loss
is extremely rare, and the authors have never seen this.
There may be transient venous hypertension, which can
be remedied with the insertion of a small angiocath into
a distended peripheral vein or deep inferior epigastric
venous pedicle and intermittent decompression of the

300
SECTION II
CHAPTER 18 • The pedicled TRAM flap
venous hypertension is performed by withdrawing
1–2 cc of blood. This is not common, and the venous
hypertension quickly equilibrates in the subsequent few
hours. The angiocath can be safely removed the next
morning.
The inframammary fold may also need to be revised.
There may be an epigastric bulge medially from the
muscle pedicle, most of which usually atrophies, and
any residual fullness may be treated with liposuction of
the overlying flap. The remaining inframammary fold
may have been overdissected at the initial mastectomy
and may need a formal repair and reconstruction.
At the time of nipple-areolar reconstruction, minor
revisions to correct any asymmetries are usually
required. There may be small areas of hardness due to
fat necrosis that may need to be excised.17 Structural fat
grafting to upper infraclavicular areas or any other
depressed areas are becoming routine to maximize
aesthetic outcomes.
Procedures to the contralateral breast (reduction,
mastopexy, etc.) may be required to obtain symmetry.
Donor site
Abdominal incision problems, when they occur, are
usually minor wound issues that either heal secondarily
or need minor revisions, such as with dog-ears. The
drains are left in place until the output per 24 hours is
less than 25 cc per drain. Premature drain removal can
result in seroma formation.
Patients should be warned that full recovery will take
several months, but typically patients are able to resume
all activities of daily living that they were doing
preoperatively.
Hernias are rare in the authors’ experience, due to
attention to detail with the repair.
Mesh infection is also extremely rare. Obese patients
may experience some bulging despite mesh repair.14,18,19
Some patients complain of a sensation of tightness.
This is typically transient and resolves in time. Care
should be taken not to over-tighten the mesh repair
initially.
General factors
Other factors that may contribute to an increased com-
plication rate at both the recipient and donor sites
include operating on patients who are obese, smokers,
patients with multiple medical problems, psychosocial
disorders, and the elderly. Surgeon inexperience can be
a factor. Interestingly, complication rates do not appear
to be elevated in bilateral versus unilateral TRAM flap
reconstructions.20–28
Secondary procedures
The authors typically wait 3 months before further
procedures to allow time for healing and reduced
inflammation. Timeframes may be adjusted if radiation
or chemotherapy is required until approximately 6
months post-radiation or until blood counts have
returned to normal after chemotherapy.
Secondary procedures may include nipple-areolar
reconstruction, resection of fat necrosis, structural fat
grafting around the breast to improve contour deformi-
ties, and abdominal scar revisions. Nipple-areolar
tattooing is then performed approximately 3 months
following their creation.
1. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with
a transverse abdominal island flap. Plast Reconstr Surg. 1982;69:
216–225. This paper details the early development of the TRAM flap
by Dr. Hartrampf and colleagues and provides an excellent historical
perspective.
2. Scheflan M, Hartrampf CR, Black PW. Breast reconstruction with a
transverse abdominal island flap. Plast Reconstr Surg. 1982;69:908–
909. This letter to the editor details some initial concerns with the TRAM
flap and the article referenced in 1.
3. Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy &
Technique. New York, St. Louis: Churchill Livingstone; Quality
Medical Pub.; 1997. Mathes and Nahai gives an clear and comprehensive
description of the TRAM flap anatomy and classification.
4. Millard DR Jr. Breast reconstruction after a radical mastectomy.
Plast Reconstr Surg. 1976;58:283–291. This paper is the first description
of the use of lower abdominal tissue for reconstruction of a radical
mastectomy defect.
5. Holmstrom H. The free abdominoplasty flap and its use in breast
reconstruction. An experimental study and clinical case report.
Scand J Plast Reconstr Surg. 1979;13:423–427. This paper details the first
use of a “free abdominoplasty flap”, later the free TRAM flap.
6. Robbins TH. Post-mastectomy breast reconstruction using a rectus
abdominis musculocutaneous island flap. Br J Plast Surg.
1981;34:286–290. Prior to the pedicled TRAM, Robbins reported the
pedicled vertical rectus abdominis flap – a further step towards the
TRAM.
7. Robbins TH. Breast reconstruction using a rectus abdominis
musculocutaneous flap: 5 yr follow-up. Aust N Z J Surg. 1985;55:65–
67. The paper is a long-term follow-up of reference 6, showing the results
of the pedicled VRAM flap.
8. Scheflan M, Dinner MI. The transverse abdominal island flap: part
I. Indications, contraindications, results, and complications. Ann
Plast Surg. 1983;10:24–35. These papers (references 8 and 9) show the
early work of Scheflan and colleagues in reporting their experiences with
the pedicled TRAM early in its development.
9. Scheflan M, Dinner MI. The transverse abdominal island flap: Part
II. Surgical technique. Ann Plast Surg. 1983;10:120–129. These papers
(references 8 and 9) show the early work of Scheflan and colleagues in
reporting their experiences with the pedicled TRAM early in its
development.
16. Veiga DF, Sabino Neto M, Ferreira LM, et al. Quality of life
outcomes after pedicled TRAM flap delayed breast reconstruction.
Br J Plast Surg. 2004;57:252–257. Any surgeon performing breast
reconstruction should be familiar with the data regarding patient quality
of life and satisfaction. This paper provides a broad overview of pedicled
TRAM flap outcomes.
Access the complete reference list online at

300.e1
References
References
1. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a
transverse abdominal island flap. Plast Reconstr Surg. 1982;69:216–
225. This paper details the early development of the TRAM flap by Dr.
Hartrampf and colleagues and provides an excellent historical perspective.
2. Scheflan M, Hartrampf CR, Black PW. Breast reconstruction with a
transverse abdominal island flap. Plast Reconstr Surg. 1982;69:908–
909. This letter to the editor details some initial concerns with the TRAM
flap and the article referenced in 1.
3. Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy &
Technique. New York, St. Louis: Churchill Livingstone; Quality
Medical Pub.; 1997 Mathes and Nahai gives an clear and comprehensive
description of the TRAM flap anatomy and classification.
4. Millard DR Jr. Breast reconstruction after a radical mastectomy.
Plast Reconstr Surg. 1976;58:283–291.
This paper is the first description of the use of lower abdominal tissue for
reconstruction of a radical mastectomy defect.
5. Holmstrom H. The free abdominoplasty flap and its use in breast
reconstruction. An experimental study and clinical case report.
Scand J Plast Reconstr Surg. 1979;13:423–427. This paper details the first
use of a “free abdominoplasty flap”, later the free TRAM flap.
6. Robbins TH. Post-mastectomy breast reconstruction using a rectus
abdominis musculocutaneous island flap. Br J Plast Surg.
1981;34:286–290. Prior to the pedicled TRAM, Robbins reported the
pedicled vertical rectus abdominis flap – a further step towards the
TRAM.
7. Robbins TH. Breast reconstruction using a rectus abdominis
musculocutaneous flap: 5 yr follow-up. Aust N Z J Surg. 1985;55:65–
67. The paper is a long-term follow-up of reference 6, showing the results
of the pedicled VRAM flap.
8. Scheflan M, Dinner MI. The transverse abdominal island flap: part
I. Indications, contraindications, results, and complications. Ann
Plast Surg. 1983;10:24–35. These papers (references 8 and 9) show the
early work of Scheflan and colleagues in reporting their experiences with
the pedicled TRAM early in its development.
9. Scheflan M, Dinner MI. The transverse abdominal island flap: part
II. Surgical technique. Ann Plast Surg. 1983;10:120–129. These papers
(references 8 and 9) show the early work of Scheflan and colleagues in
reporting their experiences with the pedicled TRAM early in its
development.
10. 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.
11. Clugston PA, Gingrass MK, Azurin D, et al. Ipsilateral pedicled
TRAM flaps: the safer alternative? Plast Reconstr Surg. 2000;105:
77–82.
12. Beasley ME. The pedicled TRAM as preference for immediate
autogenous tissue breast reconstruction. Clin Plast Surg. 1994;21:
191–205.
13. Chun YS, Sinha I, Turko A, et al. Outcomes and patient satisfaction
following breast reconstruction with bilateral pedicled TRAM flaps
in 105 consecutive patients. Plast Reconstr Surg. 2010;125:1–9.
14. Chun YS, Sinha I, Turko A, et al. Comparison of morbidity,
functional outcome, and satisfaction following bilateral TRAM
versus bilateral DIEP flap breast reconstruction. Plast Reconstr Surg.
2010;126:1133–1141.
15. Moscona RA, Holander L, Or D, Fodor L. Patient satisfaction and
aesthetic results after pedicled transverse rectus abdominis muscle
flap for breast reconstruction. Ann Surg Oncol. 2006;13:1739–1746.
16. Veiga DF, Sabino Neto M, Ferreira LM, et al. Quality of life
outcomes after pedicled TRAM flap delayed breast reconstruction.
Br J Plast Surg. 2004;57:252–257. Any surgeon performing breast
reconstruction should be familiar with the data regarding patient quality
of life and satisfaction. This paper provides a broad overview of pedicled
TRAM flap outcomes.
17. Kim EK, Lee TJ, Eom JS. Comparison of fat necrosis between zone
II and zone III in pedicled transverse rectus abdominis
musculocutaneous flaps: a prospective study of 400 consecutive
cases. Ann Plast Surg. 2007;59:256–259.
18. Mizgala CL, Hartrampf CR Jr, Bennett GK. Abdominal function
after pedicled TRAM flap surgery. Clin Plast Surg. 1994;21:255–272.
19. 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, discussion 88–90.
20. Goldwyn RM. Toward a classification of the chest and breast prior
to immediate reconstruction. Plast Reconstr Surg. 1991;88:876–877.
21. Petit JY, Rietjens M, Garusi C, et al. Abdominal complications and
sequelae after breast reconstruction with pedicled TRAM flap: is
there still an indication for pedicled TRAM in the year 2003? Plast
Reconstr Surg. 2003;112:1063–1065.
22. Paige KT, Bostwick J 3rd, Bried JT, Jones G. A comparison of
morbidity from bilateral, unipedicled and unilateral, unipedicled
TRAM flap breast reconstructions. Plast Reconstr Surg. 1998;101:
1819–1827.
23. Moran SL, Serletti JM. Outcome comparison between free and
pedicled TRAM flap breast reconstruction in the obese patient. Plast
Reconstr Surg. 2001;108:1954–1960, discussion 1961–1962.
24. Wagner DS, Michelow BJ, Hartrampf CR Jr. Double-pedicle TRAM
flap for unilateral breast reconstruction. Plast Reconstr Surg. 1991;88:
987–997.
25. Spear SL, Ducic I, Cuoco F, Hannan C. The effect of smoking on
flap and donor-site complications in pedicled TRAM breast
reconstruction. Plast Reconstr Surg. 2005;116:1873–1880.
26. Ducic I, Spear SL, Cuoco F, Hannan C. Safety and risk factors for
breast reconstruction with pedicled transverse rectus abdominis
musculocutaneous flaps: a 10-year analysis. Ann Plast Surg.
2005;55:559–564.
27. Serletti JM. Breast reconstruction with the TRAM flap: pedicled and
free. J Surg Oncol. 2006;94:532–537.
28. Serletti JM, Moran SL. Free versus the pedicled TRAM flap: a cost
comparison and outcome analysis. Plast Reconstr Surg. 1997;100:
1418–1424, discussion 1425–1427.

SECTION II • Reconstructive Breast Surgery
19 
Latissimus dorsi flap breast reconstruction
Michael S. Gart, John Y. S. Kim, and Neil A. Fine
SYNOPSIS
■ Latissimus dorsi flaps continue to play a significant role in primary and
secondary reconstruction of total and partial mastectomy defects.
■ Relative to other forms of autologous breast reconstruction, the
latissimus flap is reliable, technically simpler, and associated with
fewer and more modest short-term complications.
■ The latissimus flap is an important salvage option following failed
prosthetic or abdominal-based reconstruction.
■ Surgical variations exist – including the extended and minimally-
invasive latissimus flap – that allow the amount of autologous tissue to
be tailored to the clinical situation.
■ Complications at the flap donor site are generally minimal and limited
mostly to seroma formation.
■ The technical ease, favorable complication profile, and short operative/
recovery times will ensure continued use of the latissimus flap in
breast reconstruction.
Access the Historical Perspective section online at

Introduction
The National Cancer Institute estimates nearly 232 000
women will be diagnosed with breast cancer in 2015,
representing 14% of all new cancer diagnoses in the
United States.1 As the indications for external beam
radiation therapy (XRT) and breast-conserving therapy
(BCT) continue to expand, more women will require
total or partial autologous tissue breast reconstruction.
The latissimus dorsi flap is a powerful tool that can be
applied to diverse oncologic defects of the breast, includ-
ing partial mastectomy defects, autologous reconstruc-
tion of modified radical mastectomy defects, expander/
implant coverage prior to radiation therapy, and aug-
menting prosthetic reconstruction to improve symmetry.
It is also important in treating radiation-induced com-
plications and as a salvage flap for patients who have
failed previous forms of reconstruction.
A critical advantage of the latissimus flap is that it
does not require microsurgical techniques and can
thereby afford patients faster recovery. Coupled with
this relative technical ease is the modest frequency and
magnitude of short-term complications.2 Moreover, the
latissimus flap is relatively resistant to the higher com-
plications seen in obese patients undergoing prosthetic
and abdominal-based reconstruction.3,4
Anatomy
The name “latissimus dorsi” is derived from the Latin
latus (broad) and dorsum (back), literally translating to
“the broadest [muscle] of the back”. The latissimus is
the most superficial and largest of the posterior trunk
muscles, measuring approximately 25 × 35 cm (Fig.
19.1). It originates from the lower thoracic spine, the
posterior iliac crest, and the thoracolumbar fascia, where
it forms the roof of the superior lumbar triangle. The
muscle fibers then converge toward the axilla, joining
the teres minor to form the posterior axillary fold before
inserting into the intertubercular groove of the humerus.
The superior extent of the muscle overlies the tip of the
scapula, and superomedially, the inferior trapezius
muscle overlaps the latissimus (Figs. 19.2 & 19.3).
The latissimus myocutaneous flap is a Mathes and
Nahai type V, with one dominant pedicle – the thora-
codorsal artery – and a secondary segmental blood
  Access video content for this chapter online at expertconsult.com

301.e1
Historical perspective
Historical perspective
It has been more than a century since the first descrip-
tion of the latissimus dorsi myocutaneous flap for breast
reconstruction by Iginio Tansini of the University of
Pavia in northern Italy.3 The concept of breast recon-
struction, however, was decried by proponents of radical
mastectomy, and the latissimus flap disappeared from
the literature until the 1970s.3
Olivari reintroduced the latissimus flap to the world
in 1976,4 and in 1977, Schneider and colleagues5 described
their method of latissimus flap breast reconstruction.
Within three years, the latissimus dorsi was considered
“…one of the most versatile and reliable flaps available
in reconstructive surgery…”.3 Its popularity in breast
reconstruction became well documented,6–8 as did
various other uses, including reconstruction of the chest
wall,9,10 head and neck defects,11–13 and the utility of this
flap in free tissue transfer.14–16
Despite the early enthusiasm for this flap, it once
again took a backseat when Hartrampf and colleagues
introduced the pedicled TRAM flap in 1982.17 The TRAM
flap offered total autologous breast reconstruction,
without the need for – and attendant risks of – a pros-
thetic device, a shortcoming of the latissimus flap.
Therefore, indications for the latissimus flap diminished
to include those women who required supplemental
coverage in tissue expander breast reconstruction or
who were not candidates for a transverse rectus abdomi-
nis myocutaneous (TRAM) flap. However, advances in
prosthetic design and flap techniques, coupled with the
relative cost-efficacy, technical ease, and low complica-
tion rate of the latissimus flap vis-à-vis microvascular
flaps, has reinvigorated interest in the latissimus dorsi
flap. Moreover, the latissimus flap plays a role in restor-
ing volume after breast-conserving therapy (BCT).18,19

302
SECTION II
CHAPTER 19 • Latissimus dorsi flap breast reconstruction
viding additional rationale for the use of a split latissi-
mus flap for maintenance of muscle function.
Patient presentation
The preoperative visit should include a discussion with
the patient about her overall health, functional status,
possible donor sites for breast reconstruction, and
desires for reconstruction (pure autologous, pure pros-
thetic, or mixed). The pros and cons of immediate and
delayed reconstruction should also be addressed to
enable the patient to make the most informed decision
possible.
The preoperative work-up generally consists of phys-
ical examination only. Provocative maneuvers – for
example, having the patient place her hand on the
examiner’s shoulder and pull downwards – will allow
assessment of the muscle bulk as well as the borders of
the latissimus muscle. In some patients, this evaluation
may be limited by body habitus. In the preoperative
holding area, the anticipated skin paddle requirement
supply, perforators from the posterior intercostal
(lateral) and lumbar arteries (medial).20 The axillary
artery gives rise to the subscapular artery, which divides
into two branches, the circumflex scapular artery and
the thoracodorsal artery (Fig. 19.4). The thoracodorsal
artery gives off a branch to the serratus anterior just
before it enters the muscle, approximately 10 cm inferior
to the tendinous insertion into the humerus. Within the
substance of the muscle, the thoracodorsal artery bifur-
cates into transverse and lateral branches that demon-
strate extensive intramuscular collateralization.21–23 This
intramuscular arborization forms the anatomic basis for
the split latissimus flap.
The thoracodorsal nerve and vein accompany the
thoracodorsal artery and together comprise the neuro-
vascular bundle. Identifying the nerve positively identi-
fies the thoracodorsal bundle, thus distinguishing it
from other vessels in the area. The innervation to the
latissimus muscle arises from the C6–C8 ventral roots
via the thoracodorsal nerve, which has been shown
to innervate several independent muscle groups,24 pro-
Fig. 19.1  Superficial muscles of the back.
(© Elsevier Inc. All Rights Reserved.)
Superior nuchal line of skull
Spinous process of C2 vertebra
Sternocleidomastoid muscle
Posterior triangle of neck
Trapezius muscle
Spine of scapula
Deltoid muscle
Infraspinatus
fascia
Teres minor
muscle
Teres major
muscle
Latissimus
dorsi muscle
Thoracolumbar fascia
Iliac crest
External
oblique muscle
Internal oblique
muscle in lumbar triangle
(Petit)
Gluteal aponeurosis
(over gluteus medius muscle)
Spinous process
of T12 vertebra
Semispinalis capitis muscle
Splenius capitis muscle
Spinous process of C7 vertebra
Splenius cervicis muscle
Levator scapulae muscle
Rhomboid minor muscle (cut)
Supraspinatus
muscle
Serratus
posterior
superior muscle
Rhomboid
major muscle
(cut)
Infraspinatus
fascia (over
infraspinatus
muscle)
Teres minor
and major
muscles
Latissimus dorsi muscle (cut)
Serratus anterior muscle
Serratus posterior inferior
muscle
External
oblique muscle
Internal
oblique muscle
12th rib
Erector spinae muscle

303
Patient presentation
latissimus flaps in the lateral decubitus position, short-
ening operative times.25
Due to the excellent reliability of this flap and the lack
of variable vascular anatomy, preoperative vascular
imaging studies are not considered necessary. In patients
who have undergone previous axillary dissection, a
weak or non-functional latissimus muscle may herald
is marked and its location determined based on the
anticipated breast skin defect. This allows evaluation of
the quality and elasticity of the back skin and any final
adjustments based on the location of soft-tissue deposits
on the back to be made. This saves time in the operating
room and can also allow surgeons to perform unilateral
Fig. 19.2  Surface anatomy of the latissimus dorsi muscle. (From Wei FC. Flaps
and Reconstructive Surgery. Edinburgh: Saunders; 2009.)
1. Axilla
2. Tip of scapula
3. Anterior margin of latissimus is palpable
4. Midline of back
5. Iliac crest
1
2
3
4
5
X
Fig. 19.3  Intraoperative view showing location of the inferior trapezius fibers
(forceps) following release of the latissimus myocutaneous flap. The fibers should
be identified and protected during flap dissection to avoid iatrogenic injury.
Fig. 19.4  Blood supply to the latissimus dorsi muscle.
6HUUDWXVDUWHU\
7KRUDFRGRUVDO
DUWHU\
/XPEDUSHUIRUDWRUV
,QWHUFRVWDOSHUIRUDWRUV

304
SECTION II
CHAPTER 19 • Latissimus dorsi flap breast reconstruction
latissimus muscle can carry a large skin paddle, up to
30 × 40 cm.32
Primary reconstruction following previous
breast-conserving therapy
The increasing use of BCT in early-stage breast cancers33
has led to the rise of an important patient population,
those who have failed BCT and present for reconstruc-
tion following previous XRT. Despite advances in
radiation protocols, the rates of recurrence following
BCT remain up to 11% at 10 years and up to 22% at 18
years.34,35 The treatment of choice for local recurrence
following BCT is salvage mastectomy. Most would
agree that implants alone in the setting of previous
radiation therapy will lead to a less favorable result,
and autologous tissue is preferred to bring non-
irradiated tissue into the reconstruction.36 While some
studies have reported poor aesthetic outcomes with
latissimus flaps due to the addition of an implant37,38
and others have reported better outcomes with TRAM
flaps,39,40 the latissimus flap remains relevant in patients
who are not candidates for abdominal-based breast
reconstruction. Some authors prefer to use these flaps
primarily when prosthetic reconstruction is desired in
the post-radiation mastectomy setting, citing high
complication rates with prostheses alone,34 while others
use these flaps as a lifeboat if complications are seen
following prosthetic reconstruction.41 A review by
Spear and colleagues showed that 40% of patients who
had implant-based reconstruction in the setting of
previous XRT ultimately required a latissimus flap to
treat radiation-induced complications.42 There have
also been anecdotal reports of direct-to-implant recon-
struction using the latissimus flap in prophylactic
mastectomy and patients considered very low risk to
require adjuvant XRT.43,44
Secondary reconstruction of the
mastectomy defect
Delayed reconstruction allows the final pathologic
status of the tumor and regional lymph nodes to be
known and allows the patient to complete any adju-
vant chemotherapy and/or radiation therapy prior to
definitive reconstruction. Similarly, any mastectomy
skin flap necrosis will have healed, and the amount of
skin required for breast reconstruction can be deter-
mined with precision. The downside to delayed recon-
struction is the formation of scar tissue and breast
envelope skin contracture, which make dissection and
flap inset more technically demanding. Perhaps the
most significant current role of the latissimus dorsi flap
is in secondary breast reconstruction – typically after
prior damage to the neurovascular pedicle. In these
cases, preservation of the serratus branch may still allow
for safe flap transposition.26
Patient selection
Ideal candidates for latissimus dorsi breast reconstruc-
tion include women who desire implant-based recon-
struction but have previously undergone XRT as a
component of their cancer therapy (women with local
recurrence after previous BCT, women with existing
expanders or implants after XRT, or women seeking
delayed reconstruction after XRT who are not candidates
for abdominally based flaps); women who desire fully
autologous breast reconstruction but are not candidates
for abdominal-based reconstruction; and women with
failed prosthetic breast reconstruction. The latissimus
flap can also be used to improve aesthetic outcomes
following partial mastectomy. The use in women who
have not yet undergone XRT should be avoided so as
not to produce a tight, contracted soft-tissue envelope
from the XRT, thus eliminating the latissimus as a
salvage option. This is not a factor in most lumpectomy
reconstructions as implants are not typically employed
for this purpose and the soft tissue-only latissimus flap
will blend with the irradiated breast to avoid severe
contracture.
Mastectomy defects
Primary reconstruction of the
mastectomy defect
The ideal candidate for a latissimus myocutaneous flap
breast reconstruction is one who will undergo a skin-
sparing mastectomy with immediate reconstruction
using a supplemental prosthesis. The back skin can be
used to replace the resected nipple areolar skin, while
the muscle can provide durable coverage for the pros-
thesis. This will predictably lead to a more natural
reconstruction than an implant alone, due to the replace-
ment of a portion of the soft tissues removed with native
soft tissue.
The extended latissimus flap can be used in primary
or secondary reconstruction for complete autologous
reconstruction in women with small to medium sized
breasts,27 and is possible in larger breasts if there is
sufficient adipose tissue at the donor site.28–30 The down-
side to this flap is the increased incidence in donor site
seroma, particularly in obese patients, who often require
larger flaps.31 Lastly, for patients who may require sig-
nificant skin excision to remove their breast cancer – for
example, inflammatory breast cancer patients – the

305
Contraindications
deficiency, potentially preventing some of the sequelae
of radiation therapy.
Secondary reconstruction of the
lumpectomy defect
Lumpectomy defects may not be fully appreciated in
the early postoperative setting, while the cavity remains
filled with hematoma or seroma fluid. These defects,
particularly when large (>10–20% of the breast volume),
become more pronounced with time and radiation
therapy. In these patients, a muscle-only latissimus flap
can be used to restore lost breast volume, or a myocu-
taneous flap with a small skin paddle may be used to
remove the constricted, radiated tissues.
Other specific indications
Patients who are not candidates for
abdominal-based reconstruction
Patients who require autologous tissue as a component
of their breast reconstruction may not be candidates for
abdominal-based flaps. This includes women who lack
sufficient abdominal skin and adipose tissue, either
naturally or from previous surgery (abdominoplasty or
abdominal-based breast reconstruction) and women
who prefer to avoid the abdominal donor site due to its
attendant morbidity. In these women, the latissimus flap
is a clear choice.47 In women who are active smokers,
are morbidly obese, or have other medical comorbidi-
ties that would preclude the use of a pedicled or free
abdominal-based flap, the latissimus may be a safer
option and result in fewer complications while still
providing a high degree of patient satisfaction.2,48
Limited availability of microsurgery
Those of us who work in academic medical centers
may take for granted the availability of microsurgeons,
microsurgical instruments, and appropriate postopera-
tive care units with equipment and personnel to monitor
a free tissue transfer. In a recent review of nationwide
trends in breast reconstruction, 81.5% of all reconstruc-
tions were pedicled TRAM (48.8%) or latissimus (32.7%)
flaps, with free flaps representing less than one in five
reconstructions.2 When microsurgical techniques are
not available or feasible, the latissimus flap is an excel-
lent autologous option.
Contraindications
The primary contraindication to latissimus dorsi flap
breast reconstruction is a previous posterolateral
radiation-induced problems with the primary recon-
structive method.
At the authors’ institution, they largely practice
delayed-immediate breast reconstruction,45 which mini-
mizes the number of patients who present for secondary
reconstruction following mastectomy alone. Placement
of a tissue expander at the time of mastectomy preserves
the skin envelope and limits scar contracture. For
patients who have not undergone delayed-immediate
reconstruction, the authors prefer to use abdominal-
based reconstruction, but utilize the latissimus flap for
patients who are not candidates for abdominal-based
reconstruction. When a latissimus flap is used for sec-
ondary reconstruction, the possible need for supple-
mental breast prosthesis to optimize aesthetics is
routinely discussed.
The latissimus dorsi flap also plays an important role
in salvage reconstruction of the breast after previous
failed reconstruction. Patients who have been radiated
prior to or following prosthetic breast reconstruction are
at increased risk for implant infection and exposure,
both of which have successfully been treated with the
latissimus.41 Moreover, in patients with partial failure of
abdominal-based flaps who require additional autolo-
gous tissue, the latissimus flap is an obvious choice.46
Fortunately, the rates of free tissue transfer success are
high; however, for patients with complete flap loss, the
use of a latissimus flap with breast prosthesis can often
provide a cosmetically acceptable result.
Lumpectomy defects
Increasingly, women are choosing to undergo breast-
conserving therapy when possible, with one study
showing a 2 : 1 preference for lumpectomy over mastec-
tomy in women with early-stage breast cancer.33 The
plastic surgery literature is replete with articles detail-
ing the deleterious effects of radiation therapy on the
breast, including contracture, delayed wound healing,
and skin hyperpigmentation. The latissimus flap plays
an important role in both primary and secondary recon-
struction of these defects.
Primary reconstruction of the
lumpectomy defect
When a lumpectomy defect is of sufficient size to pre-
clude the use of local, parenchymal-based techniques,
the addition of a latissimus dorsi flap can improve
aesthetic outcomes despite larger lumpectomy resec-
tions. For patients undergoing BCT, a muscle-only
latissimus dorsi flap or a myocutaneous flap with a
small skin paddle can be used to reconstruct the volume

306
SECTION II
CHAPTER 19 • Latissimus dorsi flap breast reconstruction
branch. Therefore, the most reliable skin territory over-
lying the muscle is vertically oriented over the lateral
aspect of the muscle, corresponding to the course of the
lateral branch of the thoracodorsal artery.21–23
A number of skin paddle designs for the latissimus
myocutaneous flap have been described, each with its
own set of advantages and disadvantages. Which
pattern is best for a patient depends on a number of
factors, including surgeon and patient preference,
anticipation of final scar location, the distribution of any
excess soft-tissue deposits on the back, and, most impor-
tantly, the skin paddle requirements (see Video 19.3
).
The mid-back transverse scar (Fig. 19.5) provides
excellent exposure of the latissimus muscle, particularly
near its humeral insertion, which facilitates its division
and dissection around the pedicle; however, the final
scar may be visible with a low-cut top. When possible,
the authors prefer to have patients bring a bra from
home to note the location of the strap and make efforts
to place the final scar in this location. Moreover, this
skin paddle has a tendency to be vertically oriented
after transposition, which may make inset challenging,
depending on the location of the breast skin defect.
However, it is possible to safely elevate the corners of
the flap to assist with skin paddle orientation at inset.
The low transverse or low oblique incision (Fig. 19.6)
results in a final scar that is very well concealed with
most clothing and can take advantage of any soft-tissue
redundancy, increasing potential flap volume and pro-
viding the patient with contour improvement. This skin
thoracotomy, in which the latissimus muscle has been
divided, making it unsuitable for use. Many thoracic
surgeons will use a muscle-sparing approach that may
leave this option open even with previous thoracotomy.
The operative note and physical exam can clarify if the
latissimus muscle has been spared. Some have sug-
gested that an atrophic muscle may not provide adequate
coverage or may herald damage to the neurovascular
pedicle during a previous axillary dissection and con-
sider this a relative contraindication. However, Fisher
and colleagues demonstrated that even in patients with
previous axillary dissection in which the thoracodorsal
pedicle has been divided, reverse flow through the ser-
ratus branch can provide adequate blood supply for flap
transposition.26
The other contraindication is a suspected or known
need for postoperative XRT along with the need for a
prosthetic device. If the latissimus flap will be used with
a prosthetic device, XRT may cause significant and
unpredictable contracture and having used it, it is not
available for salvage.42 The frequency with which the
latissimus flap is used to improve or salvage prosthetic
reconstructions that have been radiated makes this
contraindication self-evident.
Surgical technique (see Video 19.1 )
Marking
Patients are marked in the preoperative holding area in
the standing position. When possible, immediate recon-
structions should be marked in conjunction with the
breast surgeon to appreciate the skin paddle require-
ments and identify important landmarks to be preserved
during the mastectomy, including the inframammary
fold. When reconstruction with a latissimus flap is
planned, the nipple areolar complex can be excised in a
circle rather than the standard ellipse to maximize the
final aesthetic outcome of the reconstruction.19
At the donor site, important landmarks are the tip of
the scapula, corresponding to the superior extent of the
latissimus dorsi muscle, the posterior iliac crest, and the
dorsal midline (see Fig. 19.2). As these are marked in
the standing position, they must be rechecked once the
patient is positioned on the operating table as landmarks
may change (see Video 19.2
).
Skin paddle design
Both the lateral and transverse branches of the thora-
codorsal artery give off numerous perforating vessels to
the overlying skin, making harvest of a skin paddle safe
within the confines of the muscle borders; however, the
most robust of these perforators arise from the lateral
Fig. 19.5  High transverse skin paddle design. The final scar location (dashed line)
is often well concealed beneath a bra strap, but will be visible in low-back tops.
This incision pattern allows excellent access to the cephalad component of the
muscle at the expense of more difficult dissection caudally.

307
Surgical technique
underlying muscle for implant coverage. These incision
patterns are also less preferred by patients.49
In a recently published study, Bailey and colleagues
surveyed 250 women to determine their preferences
for incision placement and reasoning behind their
preference.49 The low, transverse incision was the
most preferred (54% of respondents), followed by the
paddle is ideal for skin defects located at or near the
inframammary fold and provides nearly complete
muscular coverage of an associated expander or implant.
However, this design provides suboptimal exposure of
the latissimus muscle, particularly near the axilla. A
small axillary counter incision greatly facilitates this
dissection and is well tolerated by patients (Fig. 19.7).
The vertical skin paddle (Fig. 19.8) provides excellent
exposure of the latissimus muscle, but the final scar is
oriented perpendicular to the relaxed skin tension lines.
The oblique skin paddle (Fig. 19.9) has similar issues
with the final scar and may not make efficient use of the
Fig. 19.6  Low transverse skin paddle design. The final scar location (dashed line)
is well concealed in most clothing and often falls into a natural skin crease. This
incision pattern can take advantage of any excess soft-tissue deposits, improving
lower back contour. With this incision pattern, visualization of the cephalad portion
of the muscle is limited, often requiring an axillary counter-incision.
Fig. 19.7  Low transverse skin paddle design and marking for axillary counter
incision.
Fig. 19.8  Vertical skin paddle design. The final scar location (dashed line) may be
concealed in clothing; however, it travels perpendicular to relaxed skin tension lines
and is often noticeable. This incision pattern provides excellent exposure to the
entire latissimus muscle, but is less preferred by patients.
Fig. 19.9  Oblique skin paddle design. The final scar location (dashed line) is
concealed in most clothing; however, depending on the location of the breast skin
defect, this pattern may require adjustments to maximize muscle coverage of the
expander. This incision pattern, like the vertical skin paddle, provides excellent
exposure to the entire latissimus muscle, but is less preferred by patients.

308
SECTION II
CHAPTER 19 • Latissimus dorsi flap breast reconstruction
a constant thickness of the cutaneous flaps of the
back.
The lateral border of the latissimus flap is identified
first and then separated from the underlying serratus
anterior muscle. This plane of dissection proceeds
toward the caudal extent of the latissimus muscle, which
is then divided, taking care not to violate the paraspi-
nous or external oblique fascia. Doing so can make
dissection more difficult and potentially risk lumbar
herniation.50
mid-transverse skin paddle (22%); the vertical (3%) and
oblique (9%) were the least preferred options. The most
common reasons behind these preferences were the
ability to conceal the scar in a low-back top and aesthetic
contour improvement at the donor site. In this study,
younger women were more concerned with concealing
the scar, whereas older women were more concerned
with contour improvement. These preferences for inci-
sion placement were not influenced by age, body mass
index, body image, or preferred clothing.
Unilateral reconstruction
A unilateral latissimus flap is elevated with the patient
under general anesthesia, in the lateral decubitus posi-
tion. An IV bag wrapped in a thin towel makes a
convenient axillary roll. In the case of immediate recon-
struction, hemostasis is achieved in the mastectomy site
and the incision temporarily closed with staples and
covered with a sterile, adhesive dressing (Tegaderm or
Ioban) before repositioning. The ipsilateral arm is
prepped into the field and an extra, sterile mayo stand
– or simply pillows stacked on the arm board – can be
used to support the arm during flap harvest (Fig. 19.10).
If using a mayo stand, it is important to make sure the
edge is adequately padded to avoid excessive pressure
on the arm. It is critical to confirm the landmarks, par-
ticularly the scapular tip, after patient positioning, as
changes in arm movements can alter these markings
and the location of the latissimus muscle relative to the
skin paddle design on the back.
After confirming its location, the skin paddle is
incised and dissection carried out through the superfi-
cial (Scarpa’s) fascia, being careful to bevel away from
the edges of the skin paddle to maintain flap volume
and perfusion to the overlying skin. In the case of a
purely autologous reconstruction or a patient who
requires a large volume of tissue in addition to a
prosthesis, all of the sub-Scarpa’s fat is maintained with
the muscle, and elevation proceeds directly beneath this
layer (Fig. 19.11). This technique is also helpful in
avoiding donor site contour defects, by maintaining
Fig. 19.10  The patient is positioned in the lateral decubitus position with the
ipsilateral arm on a mayo stand. This allows access to the entire muscle and its
insertion.
Fig. 19.11  In purely autologous reconstructions, all of the fat
beneath the Scarpa’s fascia is maintained on the muscle surface
to provide additional flap volume. Care is taken not to undercut
the skin paddle.
Skin
Superficial fat layer
Deep fatty layer
Muscle
Superficial fascia

309
Surgical technique
Dissection then proceeds cephalad to the skin paddle,
in a plane superficial to the latissimus muscle towards
the axilla until the tendinous portion of the humeral
insertion can be visualized. Depending on the location
of the skin island, this dissection may require the use of
a counter-incision placed near the axilla (see Fig. 19.7).
This dissection can proceed rapidly, as the pedicle is
located beneath the muscle, and there are no structures
at risk in this plane. It is important to clearly define the
latissimus muscle from the teres minor muscle, which
converges toward the same insertion point and can be
very closely associated with the latissimus.
The latissimus is then progressively freed from its
midline attachments in a caudal to cephalad direction.
During this part of the dissection, several large perforat-
ing vessels, representing the secondary segmental blood
supply, will be encountered. Prospective hemostasis
with bipolar electrocautery or clips will greatly facili-
tate dissection and prevent postoperative hematoma
formation.
During the cephalad dissection beneath the latissimus
muscle, the surgeon must be very careful to avoid iat-
rogenic injury to the serratus muscle, which can be
easily incorporated by mistake if the dissection proceeds
in an incorrect plane. The large perforating lumbar
vessels will signal the inferior border of the serratus
muscle. Superomedially, the fibers of the trapezius
muscle that overlap and are superficial to the latissimus
are identified and protected (see Fig. 19.3). Once the
superior border of the muscle is reached, dissection
continues in a medial to lateral direction, taking care to
separate the latissimus from the teres minor muscle.
Once all borders of the muscle are freed, the dissection
proceeds beneath the latissimus muscle towards its
neurovascular pedicle until the desired axis of rotation
is achieved. We do not routinely skeletonize the pedicle
to the latissimus, and prefer simply to visualize its
pulsation beneath its protective fat pad to avoid iatro-
genic injury.
Once the entire muscle is freed on its superficial
and deep surfaces, the tendinous insertion is divided,
taking care not to injure the insertion of the teres minor
muscle or the underlying neurovascular pedicle (see
Video 19.4
). The authors prefer to disinsert the muscle
completely and do not routinely divide the thoracodorsal
nerve (Fig. 19.12). We find that leaving the tissue sur-
rounding the pedicle avoids the concern of putting
undue tension on the neurovascular pedicle and limits
potential twisting of the pedicle. Patients do not complain
of animation deformity from an intact nerve due to the
complete division of the insertion into the humerus, as
there is no “pulling” sensation without an origin or
insertion to the muscle, just a central bunching or firming
Fig. 19.12  Intraoperative photo demonstrating complete division of the humeral
insertion of the latissimus muscle.
of the muscle. Moreover, we find that complete division
of the insertion minimizes the axillary bulge that is some-
times seen after flap transposition.51 We do feel that it is
important to either divide the insertion completely or
divide the nerve in order to avoid a disconjugate “pulling”
sensation.
Flap transposition and inset
Depending on the lateral extent of the mastectomy
defect, the mastectomy space may be inadvertently
entered during dissection of the lateral muscle. This
should be avoided when possible, and suture repair
may be necessary if the space is entered too far caudally.
The flap should be transposed through a subcutaneous
tunnel high in the axilla to avoid a prominent axillary
bulge (Figs. 19.13–19.14) (see Video 19.5
). Once the
flap is transposed, the muscle is secured at the anterior
axillary line with interrupted 2-0 polydioxanone sutures
to prevent lateral migration of the flap as well as dis-
placement of the expander/implant to the axillary
space. This maneuver also prevents excessive tension on
the vascular pedicle when the humeral insertion of the
latissimus muscle is completely divided.
The inset of the flap is dictated by the preoperative
skin paddle markings, the location of the breast skin
resection, and the need for muscular coverage of the
associated implant (see Video 19.6
). For immediate
reconstruction of a modified radical mastectomy, a
transverse mid-back incision is often useful, as this pro-
vides muscular coverage both above and below the skin
paddle, which is often placed in the mid-breast (Fig.
19.15). When this skin paddle is transposed and the
muscle secured medially to cover the prosthesis, there is
a tendency for the medial skin paddle to be oriented
superiorly. If necessary, the skin can be elevated off of the
underlying flap at the level of the subcutaneous tissues
to rotate the medial aspect into the proper location
(Fig. 19.16). With immediate reconstruction following

310
SECTION II
CHAPTER 19 • Latissimus dorsi flap breast reconstruction
Fig. 19.14  (A) Flap transposed through axillary counter incision. (B) Transposition
of flap through mastectomy space. (C) Final inset of latissimus muscle and skin
paddle.
A
B
C
Fig. 19.13  (A) Elevation of the latissimus dorsi flap, attached only by the humeral
insertion. (B) After division of the humeral insertion, the flap is transposed
anteriorly through a subcutaneous tunnel high in the axilla.
$
%
skin-sparing mastectomy, an areolar-sized cutaneous
circle will be preserved and the remainder of the skin
island will be de-epithelialized (Fig. 19.17). In this
instance the authors score the de-epithelialized dermis
surrounding the areolar skin paddle to provide an edge
to inset the mastectomy flaps and minimize indentation
at the periphery of the areola.
When reconstruction is combined with the use of a
tissue expander or implant, the authors find it more
efficient to leave the pectoralis muscle down, attached
to the chest wall, and inset the latissimus flap to its
superficial surface. Tabbed expanders are used and
secured in place, followed by interrupted 2-0 polydioxa-
none sutures to define the dimensions of the breast

311
Surgical technique
pocket. Securing the flap superiorly helps to provide
additional upper pole fullness to the reconstructed
breast and provides some camouflage of the transition
from the chest wall to the breast prosthesis.
In the case of unilateral reconstructions, we have
found that the use of tabbed tissue expanders have
allowed us to accurately place the prosthesis and inset
the flap with the patient in the lateral decubitus posi-
tion, eliminating one position change and making the
operation significantly more efficient.25 An assistant
closes the back while the latissimus flap is inset into the
mastectomy space.
At this point, once the muscle is sutured in place, we
will fill the expander to the desired level. We have found
that waiting until the flap is inset completely is prohibi-
tive due to the thickness of the back skin overlying the
integrated expander port. Moreover, the thin latissimus
muscle makes palpation of the fill port simple
Fig. 19.15  (A) Mid-transverse skin paddle, showing muscle bulk above and below
the skin paddle. (B) Flap inset, showing coverage of the inferior and superior
expander with latissimus muscle.
A
B
A
B
Fig. 19.16  Adjustment of the medial skin paddle. (A) Flap in situ after
transposition and muscle inset. (B) Elevation of the medial corner of the skin
paddle. (C) Final inset.
C