Aesthetic and Reconstructive Surgery of the Breast- E Book
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Description

Drs. Hall-Findlay and Evans’ new Aesthetic and Reconstructive Surgery of the Breast has a purely surgical focus that covers the full scope of breast surgery. Coverage of hot topics includes new implant types, gel implants, fat injections to the breast for aesthetic enhancement, and fat injections for reconstruction.The book is organized into seven sections including reduction, mastopexy, augmentation, and more. Expert, international contributors deliver practical advice on the latest techniques, with a special emphasis on what can go wrong and how to avoid it. This full-color, templated reference comes with case studies and 16 video clips with approximately three hours of footage demonstrating key procedures. Video coverage includes form-stable high cohesive silicone gel implants, short scar with inferior pedicle, and sub-fascial breast augmentation. Expert Consult access enables you to search full text online and download images.

  • Get practical advice on handling problems that occur in both reconstructive and aesthetic surgery
  • Study various operative steps in depth with real-life clinical detail
  • Avoid and/or deal with complications by referencing case examples and analyses with expert international counsel

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Publié par
Date de parution 14 septembre 2010
Nombre de lectures 0
EAN13 9780702050091
Langue English
Poids de l'ouvrage 5 Mo

Informations légales : prix de location à la page 0,0855€. Cette information est donnée uniquement à titre indicatif conformément à la législation en vigueur.

Exrait

Aesthetic and Reconstructive Surgery of the Breast

Elizabeth J. Hall-Findlay, MD FRCSC
Private Practice, Banff Plastic Surgery, Consulting Staff, Mineral Springs Hospital, Banff, AB, Canada

Gregory R.D. Evans, MD FACS
Professor of Surgery and Biomedical Engineering, Chief, Aesthetic and Plastic Surgery Institute, The University of California, Irvine, Orange, CA, USA
Saunders Ltd.
Front Matter

AESTHETIC AND RECONSTRUCTIVE SURGERY OF THE BREAST
Editors:
Elizabeth J. Hall-Findlay MD FRCSC Private Practice, Banff Plastic Surgery, Consulting Staff, Mineral Springs Hospital, Banff, AB, Canada
Gregory R. D. Evans MD FACS Professor of Surgery and Biomedical Engineering, Chief, Aesthetic and Plastic Surgery Institute, The University of California, Irvine, Orange, CA, USA
Video Editor:
Kenneth K. Kim MD FACS Board Certified Plastic Surgeon, Beverly Hills, CA, USA

Commissioning Editor: Sue Hodgson
Development Editor: Sharon Nash
Editorial Assistant: Kirsten Lowson
Project Manager: Frances Affleck
Design: Charles Gray
Illustration Manager: Merlyn Harvey
Illustrator: EPS Inc.
Marketing Manager (USA): Radha Mawrie
Copyright

An imprint of Elsevier Limited.
© 2010, Elsevier Limited. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions .
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).
Dr Joan Lipa retains the copyright to the images used in Chapter 9.
Dr Aldona Spiegel retains the copyright to the SIEA film used in Chapter 10.
Dr Craig Rubinstein retains the copyright to the images used in Chapter 36.
Dr J. Peter Rubin retains the copyright to the video images accompanying Chapter 41.


Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
ISBN: 9780702031809
British Library Cataloguing in Publication Data
Aesthetic and reconstructive surgery of the breast.
1. Mammaplasty.
I. Hall-Findlay, Elizabeth J. II. Evans, Gregory R. D.
618.1′90592 – dc22
ISBN-13: 9780702031809
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress


Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Preface
When we were asked to create a breast book for Elsevier, we were both concerned that this text had to have a different approach to similar books recently released. We hope that we have done this.
Our purpose is to focus on breast surgery – all aspects – from aesthetic to reconstructive. Instead of giving the reader variations on other texts, this book has authors whose work is respected around the world. These authors have important ideas to impart which will be very useful to plastic surgeons.
The book is outlined in several different sections and each chapter is designed to follow a pattern which makes finding relevant information easy. We have tried to include more controversial and future directions such as fat grafting and alternatives to traditional breast reduction techniques.
It is our hope that this comprehensive breast book will give the reader some broader insights into breast surgery along with a better understanding of appropriate concepts and principles. Techniques are clearly outlined in both the text and the illustrations to allow the reader to use this as a reference to improve and alter their own assessment and surgical approach to the breast.
E.J.H-F
G.R.D.E
2010
List of Contributors

Affonso Accorsi, Jr MD, Plastic Surgeon Private practice Rio de Janeiro Brazil

Siamak Agha-Mohammadi, BSc MB BChir PhD, Plastic Surgeon Hurwitz Plastic Surgery Newport Beach CA USA

Jamil Ahmad, MD, Resident Department of Plastic Surgery University of Texas Southwestern Medical Center Dallas TX USA

Vicenzo Argencio, MD, Plastic Surgeon Private practice Rio de Janeiro Brazil

Yuko Asano, MD, Department of Plastic Surgery The University of Tokyo Tokyo Japan

Hilton Becker, MD FACS FRCS, Private practice Boca Raton FL USA

Thomas M. Biggs, MD, Clinical Professor of Plastic Surgery College of Medicine Baylor University Houston TX USA

Kristin A. Boehm, MD FACS, Plastic Surgeon Paces Plastic Surgery Atlanta GA USA

James Boehmler, MD, Assistant Professor Plastic Surgery Division of Plastic Surgery The Ohio State University Columbus OH USA

Patricia A. Bortoluzzi, MD FRCS, Pediatric Plastic and Reconstructive Surgeon Hospital Sainte Justine Director Craniofacial Clinic Montreal QC Canada

Nathalie Bricout, MD, Plastic Surgeon Member of the French Society of Plastic Reconstructive and Aesthetic Surgery Member of the National Academy of Surgery Paris France

Mitchell H. Brown, MD FRCSC, Associate Professor of Plastic Surgery Department of Surgery University of Toronto Toronto ON Canada

Charles E. Butler, MD FACS, Professor of Plastic Surgery Department of Plastic Surgery University of Texas M.D. Anderson Cancer Center Houston TX USA

Charbel Chalfoun, MD, Plastic Surgeon Aesthetic and Plastic Surgery Institute UC Irvine Medical Center Orange CA USA

Bernard W. Chang, MD, Chief of Plastic Surgery, Mercy Medical Center, Associate Professor of Surgery, Johns Hopkins School of Medicine Plastic and Reconstructive Surgery at Mercy Baltimore MD USA

David W. Chang, MD FACS, Professor of Surgery Department of Plastic Surgery University of Texas M.D. Anderson Cancer Center Houston TX USA

Ming-Huei Cheng, MD MHA, Associate Professor and Chief Division of Reconstructive Microsurgery Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital Chang Gung Medical College Chang Gung University Taipei Taiwan Xiamen Chang Gung Hospital Fujing China

Brendan J. Collins, MD, Staff, Plastic and Reconstructive Surgery Center at Mercy Weinberg Center for Women’s Health & Medicine Baltimore MD USA

Renee C. Comizio, MD, Assistant Professor of Surgery Dartmouth Hitchcock Medical Center Lebanon NH USA

Niamh Corduff, FRACS, The Jack Brockhoff Reconstructive Plastic Surgery Research Unit Royal Melbourne Hospital Department of Anatomy and Cell Biology University of Melbourne Melbourne Victoria Australia

Melissa A. Crosby, MD, Assistant Professor Department of Plastic Surgery The University of Texas M.D. Anderson Cancer Center Houston TX USA

Bruce L. Cunningham, MD MS, Professor of Surgery Chief, Division of Plastic and Reconstructive Surgery University of Minnesota Minneapolis MN USA

Emmanuel Delay, MD PhD, Head, Plastic and Reconstructive Department Centre Léon-Bérard Lyon France

Joseph J. Disa, MD FACS, Associate Attending Surgeon Plastic and Reconstructive Surgery Service Memorial Sloan Kettering Cancer Center Assistant Professor of Surgery Weill Cornell Medical College New York NY USA

Liron Eldor, MD, Fellow in Plastic Surgery Institute For Reconstructive Surgery The Methodist Hospital Houston TX USA

Robyn Fio, MD, Resident Physician Emory University Atlanta GA USA

Gilbert P. Gradinger, MD FACS, Clinical Professor of Surgery Division of Plastic and Reconstructive Surgery University of California, San Francisco (UCSF), School of Medicine San Mateo CA USA

Ruth M. Graf, MD PhD, Professor of the Plastic Surgery Department of Hospital de Clínicas Federal University of Paraná Curitiba-PR Brazil

Örjan Gribbe, MD PhD, Plastic Surgeon Victoriakliniken Saltsjöbaden Sweden

Jeffrey A. Gusenoff, MD, Assistant Professor of Surgery Division of Plastic and Reconstructive Surgery University of Rochester Medical Center Rochester NY USA

Dennis C. Hammond, MD, Clinical Assistant Professor Department of Surgery Michigan State University College of Human Medicine East Lansing MI Associate Program Director Plastic and Reconstructive Surgery Grand Rapids Medical Education and Research Center for Health Professions Grand Rapids MI Center for Breast and Body Contouring Grand Rapids MI USA

Per Hedén, MD PhD, Associate Professor in Plastic Surgery Akademikliniken Stockholm Sweden

Charles K. Herman, MD FACS, Chief, Division of Plastic and Reconstructive Surgery Pocono Health Systems East Stroudsburg PA Assistant Clinical Professor Division of Plastic and Reconstructive Surgery Albert Einstein College of Medicine New York NY USA

Oscar Ho, MD, Plastic Surgery Resident Dartmouth Hitchcock Medical Center Lebanon NH USA

Jung-Ju Huang, MD, Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital Chang Gung Medical College Chang Gung University Taipei Taiwan

Dennis J. Hurwitz, MD FACS, Clinical Professor of Surgery (Plastic) University of Pittsburgh Medical Center Attending Plastic Surgeon Magee Women’s Hospital Hurwitz Center for Plastic Surgery Pittsburgh PA USA

Carolyn L. Kerrigan, MD FRCSC, Professor of Surgery Chief and Residency Program Director Section of Plastic Surgery Dartmouth Hitchcock Medical Center Lebanon NH USA

Louise Caouette Laberge, MD, Pediatric Plastic Surgeon Professor Department of Surgery University of Montreal Chief of Plastic Surgery Hospital Sainte Justine QC Canada

Don Lalonde, MD FRCSC, Professor of Plastic Surgery Dalhousie University Saint John NB Canada

Jan Lalonde, RN, CPN(C), CPSN, Saint John NB Canada

Karen Lane, MD FACS, Clinical Director UCI Breast Health Center Orange CA USA

Joan E. Lipa, MD MSc FRCS(C) FACS, Associate Professor Division of Plastic and Reconstructive Surgery David Geffen School of Medicine at UCLA Los Angeles CA USA

Frank Lista, MD FRCS(C), Medical Director The Plastic Surgery Clinic Mississauga ON Canada

Albert Losken, MD, Assistant Professor Emory Division of Plastic and Reconstructive Surgery Atlanta GA USA

Jonathan D. McCue, MD, Plastic Surgery Resident University of Minnesota Minneapolis MN USA

Mark Migliori, MD, Adjunct Assistant Professor of Surgery University of Minnesota Minneapolis MN USA

A Aldo Mottura, MD PhD, Plastic Surgeon Private Practice Cordoba Argentina

Egle Muti, MD, Professor of Plastic Surgery Department of Plastic Surgery University of Turin Turin Italy

Foad Nahai, MD FACS, Clinical Professor of Plastic Surgery Emory University Paces Plastic Surgery Atlanta GA USA

Maria Cecília Closs Ono, MD, Plastic Surgery Resident of the Hospital de Clínicas Federal University of Paraná Curitiba-PR Brazil.

Andrea L. Pusic, MD MHS FRCSC, Assistant Professor of Plastic Surgery Plastic and Reconstructive Service Department of Surgery New York NY USA

Charles Randquist, MD, Plastic Surgeon Victoriakliniken Saltsjöbaden Sweden

Scott L. Replogle, MD, Private Practice Replogle Plastic Surgery PC Louisville CO USA

Liacyr Ribeiro, MD, Plastic Surgeon Private practice Rio de Janeiro Brazil

Roberto Rocha, MD, Plastic Surgeon Private practice Rio de Janeiro Brazil

Craig Rubinstein, MBBS(Melb) FRACS(Plast) Master of Surgery(Melb), Epworth Medical District Richmond Melbourne Australia

J Peter Rubin, MD, Director of Body Contouring Program Associate Professor of Surgery Division of Plastic Surgery University of Pittsburgh Pittsburgh PA USA

Kenneth C. Shestak, Professor of Plastic Surgery University of Pittsburgh School of Medicine Chief of Plastic Surgery Magee Womens Hospital Pittsburgh PA USA

Aldona J. Spiegel, MD, Director, Center for Breast Restoration Assistant Professor, Cornell University Institute for Reconstructive Surgery The Methodist Hospital Houston TX USA

Berish Strauch, MD FACS, Professor and Chairman Emeritus Division of Plastic and Reconstructive Surgery Albert Einstein College of Medicine New York NY USA

André Ricardo Dall’Oglio Tolazzi, MD MSc, Plastic Surgeon Member of the Brazilian Society of Plastic Surgery Curitiba-PR Brazil

Henry C. Vasconez, MD FACS FAAP, Professor of Surgery and Pediatrics, Chief of Plastic Surgery Division of Plastic Surgery KY Clinic Lexington KY USA

Paul R. Weiss, MD, Clinical Professor of Plastic Surgery Albert Einstein College of Medicine New York NY USA

Elisabeth Würinger, MD, Plastic Surgeon Private Practice Vienna Austria

Kotaro Yoshimura, MD, Assistant Professor Department of Plastic Surgery University of Tokyo School of Medicine Tokyo Japan

Toni Zhong, MD FRCSC, Clinical Fellow in Microsurgery and Reconstructive Surgery Plastic and Reconstructive Surgery Service Memorial Sloan Kettering Cancer Center New York NY USA
Dedication
Dedication from Elizabeth Hall-Findlay
To my three children, Jamie, David and Elise, who have become truly enjoyable young adults.
Dedication from Gregory Evans
To Ruth, Brandon and Brogan – Thank you for your continued love, support and patience. You make it all worthwhile.
Acknowledgments
To my partners for their tireless contributions and to my mentors for their wisdom and teaching.
GE
I would like to thank my staff for all their support. I have appreciated all those who have challenged me both in my thinking and my performance.
EH-F
Table of Contents
Instructions for online access
Front Matter
Copyright
Preface
List of Contributors
Dedication
Acknowledgments
Chapter 1: History and Anatomy
Part 1: Breast Reconstruction
Chapter 2: Oncologic Considerations for Breast Reconstruction
Chapter 3: Adjuvant Therapy and Breast Reconstruction
Chapter 4: Expanders and Breast Reconstruction with Gel and Saline Implants
Chapter 5: Latissimus Dorsi Flap Breast Reconstruction
Chapter 6: TRAM Flap Breast Reconstruction
Chapter 7: TRAM Flap Variations in Breast Reconstruction
Chapter 8: Muscle-Sparing and Free TRAM Flap Breast Reconstruction
Chapter 9: DIEP Flap Breast Reconstruction
Chapter 10: SIEA Flap Breast Reconstruction
Chapter 11: Gluteal Flap Breast Reconstruction
Chapter 12: Fat Injections to the Breast: The Lipomodeling Technique
Part 2: Breast Reduction
Chapter 13: An Overview of the Modern Era of Breast Reduction
Chapter 14: The Central Septum in Breast Reduction and Mastopexy
Chapter 15: Breast Reduction with a Central Mound
Chapter 16: Subglandular Breast Reduction
Chapter 17: No Vertical Scar Breast Reduction and Mastopexy
Chapter 18: Inferior Pedicle Breast Reduction Using a Circumvertical Pattern
Chapter 19: Superomedial Pedicle Breast Reduction Using a Vertical Pattern
Chapter 20: Superior and Medial Pedicle Breast Reduction Using a Vertical Pattern
Chapter 21: Superolateral Pedicle Breast Reduction with Vertical and Inverted T Patterns
Part 3: Augmentation
Chapter 22: Saline Implants: Getting a Good Result
Chapter 23: Highly Cohesive Textured Form Stable Gel Implants: Principles and Technique
Chapter 24: Form Stable Shaped High Cohesive Gel Implants
Chapter 25: Subfascial Breast Augmentation
Chapter 26: Fat Injections
Part 4: Mastopexy and Mastopexy-Augmentation
Chapter 27: Primary and Secondary Mastopexy-Augmentation
Chapter 28: Circumvertical Breast Reduction and Mastopexy
Chapter 29: Rotation Mastopexy
Chapter 30: Superior Pedicle Extension Mastopexy
Chapter 31: Superomedial Pedicle Extension Mastopexy
Chapter 32: Inferior-central Flap Mastopexy with Pectoralis Strip
Chapter 33: Periareolar V-T Parachute Mastopexy
Chapter 34: Mastopexy after Implant Removal
Part 5: Developmental Breast Deformities
Chapter 35: Adjustable Breast Implants for Asymmetry and Ptosis
Chapter 36: Breast Asymmetries
Chapter 37: Inferior Flaps for Tuberous Breasts
Chapter 38: Local Flaps for Tuberous and Asymmetric Breasts
Chapter 39: Correction of Breast Asymmetry in Teenagers
Chapter 40: Surgery of the Breast in Poland’s Syndrome
Part 6: Breast Reshaping after Massive Weight Loss
Chapter 41: Dermal Suspension and Parenchymal Breast Reshaping after Massive Weight Loss
Chapter 42: Autologous Flap Use in Breast Reshaping after Massive Weight Loss
Index
CHAPTER 1 History and Anatomy

History
Gregory R.D. Evans and Elizabeth J. Hall-Findlay

Breast Reconstruction
Breast cancer diagnosis and management have always been an issue in society. If Cleopatra had developed breast cancer, it would have been treated with cauterization in the hope of burning out the disease.
Even when breast cancer could be diagnosed, treatment was prevented by a lack of adequate anesthesia. William Halsted would not have been able to develop his radical mastectomy procedure without the advent of anesthesia. Unfortunately, breast cancer recurrence presented in spite of this disfiguring and invasive operation.
In the 1970s most breast surgeons began to favor the modified radical mastectomy when they realized that removing the pectoralis muscle did not improve the outcome. This became the gold standard for breast cancer treatment and any suggestions of an even more ‘modified’ approach were met with derision.
Finally, surgeons began to accept that segmental resections and lumpectomies combined with chemotherapy and radiation offered realistic alternatives.
Patient requests were rarely considered in the past, but surgeons can now offer patients several different options that suit their disease, their genetic and family predisposition status, their own self body image, and their personal lifestyles.
Initially, diagnosis and treatment were aggressively combined so that patients had their biopsies booked as possible mastectomies and lymph node dissections. Today, core sampling can establish the diagnosis and imaging and sentinel node biopsy can further clarify the extent of the disease.
Chemotherapy can be given before and/or after definitive treatment and radiation and, if used, can be given before or after the reconstruction. Surgery, chemotherapy, and radiation decisions are not separate issues but can be combined to suit the disease and patient desires.
Reconstruction following breast cancer was slow to develop. In fact today, even though our options for reconstruction are multiple and women have significant choices, only about one-third of the women seeking surgical options for their breast cancer seek reconstruction. Probably the most common method of reconstruction today occurs with the placement of a silicone or saline implant. Reconstruction options today are numerous and there is no correct answer. This is so different from the days when anyone who questioned radical mastectomy was treated as a pariah. Reconstruction was not even discussed back then as a future possibility.
The evolution of the use of autogenous tissue led to more options for women seeking reconstruction. Further, some women concerned about the use of implants turned to autogenous reconstruction as a viable alternative. Numerous techniques have evolved to allow for reconstruction using natural tissues. The earliest utilized muscles to provide blood flow to the skin and create a breast mound. The latissimus dorsi flap was the most popular form of autogenous tissue reconstruction in the 1970s. Although there are currently still limitations to this form of reconstruction, this option is still utilized today for patients seeking improved reconstructive outcomes. 1 - 5
In 1982 the first transverse rectus abdominis flap (TRAM) flap procedure was performed. This transfer of the lower abdominal muscle, fat, and tissue improved the shape of the breast and allowed a more acceptable donor site for autogenous breast reconstruction. The flap has remained a workhorse for reconstruction but is still complicated by issues related to blood supply and donor site morbidity. As microsurgical techniques evolved, our ability to improve the vascular supply of the TRAM flap also increased. As our microsurgical skills improved, further refinements of flap harvest were performed. The goal was to continue to decrease the potential for donor site morbidity. Initial attempts included techniques of muscle sparing. This allowed the harvest of part of the rectus muscle while sparing other components, leaving the rectus muscle intact in certain locations. Perforator flaps were introduced in the late 1990s and early 2000s as a mechanism to decrease the abdominal donor site morbidity. The deep inferior epigastric perforator flap and the superficial inferior epigastric flap allowed transfer of these autogenous tissues while sparing the harvest of the rectus abdominis muscle. With improved microsurgical skills, additional locations for reconstruction were examined. The gluteal artery perforator flap allows the use of skin from the buttocks. The gracilis myocutaneous flap allows the use of skin and a portion of muscle from the inner thighs. The latissimus dorsi was again utilized without harvesting of muscle to supply bulk in the creation of a breast mound. 1 - 5
Issues today still concern primarily control of the disease. Treatment now needs to be integrated with various reconstructive decisions, coverage and types of implants when used, as well as treatment of the skin envelope (excision, skin sparing, mastectomy, and even nipple-sparing mastectomy).
Plastic surgeons were seeking new options because some of the initial procedures were disappointing. Now plastic surgeons have a vast array of options available, but there is still resistance from the general surgeons and oncologists. Not enough patients are being given the opportunity to participate in decision making and they are not being presented with all the treatment and reconstructive options available.

Breast Reduction
It has long been recognized that overly large breasts can be a significant burden for women. Treatment was delayed until the advent of anesthesia.
Initially, amputation techniques were used because they were relatively simple and straightforward. Surgeons began to understand that resection of parenchyma and skin should be designed to preserve nipple and areolar circulation. Numerous techniques were described over the years to reduce bulk, preserve the nipple and achieve an aesthetically desirable effect. Preservation of sensation and breast feeding potential were secondary.
No perfect design was achieved, but plastic surgeons persisted in trying to improve the cosmetic results while maintaining some of the successes achieved in the past with combining resection with preservation of nipple viability. Surgeons attempted to reduce scars while achieving a good shape and today the controversy persists as to which procedure or technique is superior.
As with many other decisions in plastic surgery, the answer comes down to surgeon experience and comfort along with individual patient indications and desires.

Mastopexy
The history of mastopexy surgery follows that of breast reduction. Plastic surgeons need to be able to combine lifting of the breast parenchyma with a reduction of the skin envelope while still preserving nipple and areolar viability.
There has long been controversy over the use of skin and dermis as a brassiere versus suture techniques in the parenchyma to hold up the breast. This issue has not been resolved.

Breast Augmentation
Patients have long desired an augmentation in breast size because of inadequate development, asymmetry, or loss of volume after pregnancy.
Breast implants were first introduced in the 1960s and numerous shells and fillers have been tried over the years. Some have been more successful than others in providing a good shape, acceptable consistency and long lasting results. The FDA in the United States placed a moratorium on silicone gel filled breast implants in the 1990s, and for over 10 years Americans were restricted to using saline-filled implants. The ban was lifted when studies were finally accepted showing that silicone did not cause disease.
Surgical techniques for breast augmentation are as varied as those for reconstruction and reduction. No one technique has proven to be superior. Incision location and implant placement continue to be debated. Implants can be placed above the muscles or in numerous variations under the muscle. Even subfascial placement has its advocates.
It became accepted over the years that direct injection of even medical grade silicone was contraindicated because of migration and interference with both clinical diagnoses and imaging techniques. Injection of various non-medical substances by non-physicians (such as paraffin and various oils) was a disaster. These days, however, fat injections are not only becoming acceptable, but proper techniques are proving them to be clinically viable. The initial prohibition against fat injection because of the possibility of interfering with diagnosis is being recognized as a non-issue. Mammographers are now consistently saying that any sequelae of fat injections are not difficult to distinguish from more ominous finding suggestive of malignancy.

Mastopexy–Augmentation
All of the controversies surrounding mastopexy procedures and breast augmentation techniques are magnified when both are combined. Potential complications are increased and the surgery is less straightforward.
Lifting the breast tissue and adding an implant are processes that work against each other, especially over time. The same controversies about skin brassieres and suture techniques are continuing.
The history of breast surgery is not simple. New techniques are sometimes embraced too quickly (soybean oil filled implants) and some standard techniques are only slowly being adopted (the general surgery resistance to reconstruction). We can look at history to give us perspective and to help us continue to search for solutions to unsolved problems.

Anatomy
The adult female breasts lie on each side of the anterior thorax with their bases extending from about the second to sixth ribs. 1 - 8 The breasts lie on a substantial layer of fascia overlying the pectoralis major muscle superomedially, the serratus anterior muscle in the lower third, and the anterior rectus sheath in the lower medial area. Although these appear to be the boundaries of the breast, the duct system often extends more widely than this. In about 15% of the cases, breast tissue extends below the costal margins. It is critical when performing breast reconstruction that the inframammary fold is maintained or at least identified and reconstructed if surgical removal of additional breast tissue below this fold is required. Considerable asymmetry is frequently found among normal women and the patient may not be aware of this asymmetry or may accept this as a normal variant. This is important to point out to the patient as autogenous reconstruction with preservation of the skin envelope may lead to further asymmetry postoperatively. One-half of the women have a volume difference of 10% or more and one-quarter have a volume difference of 20% or greater ( Fig. 1.1 ). 1

Fig. 1.1 Anterior view of breast.
From Drake RL, Vogl AW, Mitchell AWM, et al. Gray’s atlas of anatomy . Edinburgh: Churchill Livingstone; 2008.
The precise position of the nipple–areola complex varies widely with the fat content of the breast and the age of the patient. In the nulliparous breast, the nipple position lies approximately 19–21 cm from the sternal notch. 2 The amount of fat within the breast varies widely, as one would expect. The intimacy with which it is mixed with glandular tissue also varies. Microscopic examination demonstrates that the nipple is composed of the terminal ducts with a supporting stroma of smooth muscle that are mainly arranged in a circular fashion with a few arranged radially. Contraction of the circular muscles causes nipple projection; contraction of the radial fibers causes retraction.
Breast tissue consists of lobes separated from each other by fascial envelopes, usually 15–20 in number. Each lobe is drained by a ductal system from which a lactiferous sinus opens on the nipple and each lactiferous sinus receives up to 40 lobules. Each lobule contains 10–100 alveoli which comprise the basic secretory unit ( Fig. 1.2 ).

Fig. 1.2 Lateral view and sagittal section of breast.
From Drake RL, Vogl AW, Mitchell AWM, et al. Gray’s atlas of anatomy . Edinburgh: Churchill Livingstone; 2008.
The blood supply is from the axillary artery via its thoracoacromial, lateral thoracic and subscapular arteries, and from the subclavian artery via the internal thoracic artery. The internal thoracic artery supplies the three large anterior perforating branches through the second, third and fourth intercostal spaces. The veins form a rich subareolar plexus and drain to the intercostals and axillary veins and to the internal thoracic veins ( Fig. 1.3 ).

Fig. 1.3 Left, arteries and innvervation of breast. Right, lymphatic drainage of breast.
From Drake RL, Vogl AW, Mitchell AWM, et al. Gray’s atlas of anatomy . Edinburgh: Churchill Livingstone; 2008.
The lymphatic drainage of the breast is of great importance in the spread of malignant disease. Several lymphatic plexi issue from the parenchymal portion of the breast and the subareolar region which drain to the regional lymph nodes, the majority of which lie within the axilla. Most of the lymph from each breast passes into the ipsilateral axillary nodes along a chain which begins at the anterior axillary nodes and continue into the central axillary and apical nodal groups. Further drainage occurs into the subscapular and interpectoral node groups. A small amount of lymph drains across to the opposite breast and also downward into the rectus sheath. Some of the medial part of the breast is drained by lymphatics, which accompany the perforating internal thoracic vessels and drain into the internal thoracic groups of nodes in the thorax and into the mediastinal nodes ( Fig. 1.3 ). 3
The innervation of the breast is principally by somatic sensory nerves and autonomic nerves accompanying the blood vessels. In general, the areola and nipples are richly supplied by somatic sensory nerves while the breast parenchyma is mostly supplied by autonomic nerves, which appear to be solely sympathetic. No parasympathetic activity has been demonstrated in the breast. Detailed histological examination has failed to demonstrate any direct neural end terminal connections with breast ductal cells or myoepithelial cells, suggesting that the principal control mechanisms of secretion and milk ejections have a humoral rather than nervous mechanism. (Although personal experience would intuitively be in conflict with this statement. EH-F) It appears that the areolar epidermis is relatively poorly innervated whereas the nipple and lactiferous ducts are richly innervated. The somatic sensory nerve supply is via the supraclavicular nerves (C3, C4) superiorly and laterally from the lateral branches of the thoracic intercostal nerves. The medial aspects of the breast receive supply from the anterior branches of the thoracic intercostal nerves which penetrate the pectoralis major to reach the breast skin. The major supply of the upper outer quadrant of the breast is via the intercostobrachial nerve (C8, T1), which gives a large branch to the breast as it traverses the axilla ( Fig. 1.3 ).
The fascial framework of the breast is important in relation to clinical manifestations of disease and surgical technique. Ligaments of Cooper provide the supporting framework to the breast lobes. The skin overlying the breast has been shown to vary in thickness from 0.8 mm to 3 mm on mammograms of normal breasts and tends to decrease proportionally with increasing breast size.
Although these anatomical points are well delineated, they may change throughout the woman’s lifetime. Development of the breast during reproductive life, menstrual cycle, pregnancy, and postlactational involution can change the basic structure of breast tissue.
The breast is a complex organ that undergoes multiple changes throughout a woman’s life based on hormonal and temporal variations. This complex organ, however, establishes the femininity identified with women. Our efforts to reconstruct and restore form and function can maintain this feminine identity.

References

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2 Brandberg Y, Malm M, Blomqvist L. A prospective and randomized study, ‘SVEA,’ comparing effects of three methods for delayed breast reconstruction on quality of life, patient-defined problem areas of life, and cosmetic result. Plast Reconstr Surg . 2000;105:66.
3 Breuing KH, Warren SM. Immediate bilateral breast reconstruction with implants and inferolateral AlloDerm slings. Ann Plast Surg . 2005;55(3):232-239. PMID: 16106158
4 Salzberg CA. Nonexpansive immediate breast reconstruction using human acellular tissue matrix graft (AlloDerm). Ann Plast Surg . 2006;57(1):1-5.
5 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.
6 Loughry CW, Shelffer DB, Price TE, et al. Breast volume measurments in 598 women using biostereometric analysis. Ann Plast Surg . 1989;22:380-385.
7 Westreich M. Anthropomorphic breast measurements: protocol and results in 50 women with aesthtically perfect breasts and clinical application. Plast Reconstr Surg . 1997;100:468-479.
8 Suami H, Pan WR, Mann GB, et al. The lymphatic anatomy of the breast and its implications for sentinel lymph node biopsy: a human cadaver study. Ann Surg Oncol . 2008;15:863-871.

Further Reading

Bostwick J. Plastic and reconstructive breast surgery . St. Louis MO: Quality Medical Publishing; 2000.
Drake RL, Vogl AW, Mitchell AWM, et al. Gray’s atlas of anatomy . Edinburgh: Churchill Livingstone; 2008.
Mansel RE, Webster DJT, Sweetland HM. Benign disorders and diseases of the breast , 3rd ed. New York: Saunders; 2009.
Moses KP, Banks JC, Nava PB, et al. Atlas of clinical gross anatomy . St. Louis: Mosby; 2005.
Standring S, et al. Grays anatomy , 40th ed. Edinburgh: Churchill Livingstone; 2009.
Part 1
Breast Reconstruction
CHAPTER 2 Oncologic Considerations for Breast Reconstruction

Charbel Chalfoun, Karen Lane

Introduction
Breast cancer currently affects one in eight women in the United States. A diagnosis of breast cancer presents the patient not only with physical challenges but emotional concerns with respect to body image and sexuality. With improved screening and early detection, approximately 80% of these women present with small tumors that are amenable to breast conservation. Until the 1970s, breast cancer was treated with radical mastectomy involving removal of the breast, axillary lymph nodes, and pectoralis muscle. This was extremely disfiguring for patients and did not lend itself to optimal reconstructive options. In the 1970s, modified radical mastectomy was introduced, which preserved the pectoralis muscle and improved the contour of the chest wall, as well as increased the reconstructive possibilities. In the 1980s, a large randomized study conducted by the National Surgical Adjuvant Breast and Bowel Project (NSABP) was able to prove that breast conservation plus radiation had equivalent outcome to mastectomy.
Since that time, breast conservation has become increasingly popular. As a personal choice, however, some patients with small tumors still opt for mastectomy. Many of these women are resistant to radiation as part of therapy and seek to avoid that by choosing mastectomy. For women with recurrent or multifocal cancer, or a history of radiation therapy to the breast, mastectomy remains the gold standard. With the discovery of the BRCA genes and the up-to 85% lifetime incidence of breast cancer associated with a gene mutation, women carrying a BRCA mutation often opt for bilateral prophylactic mastectomies. Women with a diagnosis of breast cancer that are found to carry a BRCA mutation are usually offered bilateral mastectomies at the time of diagnosis. It is clear, that in certain cases, mastectomy is the best surgical option for a subset of patients, and the development of improved breast reconstruction techniques has significantly reduced the psychological stress faced by patients who often see mastectomy as losing a part of their body image. It is critical that all breast cancer patients who require a mastectomy are given the opportunity to consult with a plastic surgeon to discuss reconstructive options. This chapter will address the oncologic considerations for women who opt for breast reconstruction.

Background on the Diagnosis and Treatment of Breast Cancer
Breast cancer may initially present as a mammographic finding or a palpable mass. It is always optimal to obtain a tissue diagnosis with a core needle biopsy rather than an open excisional biopsy if at all possible. In this way the diagnosis can be discussed with the patient prior to any surgical procedures and also no unnecessary incisions are made in the breast or tissue removed that might impact both the oncologic and cosmetic outcome. All of our new breast cancer patients undergo breast magnetic resonance imaging (MRI). This is much more sensitive than mammogram in measuring the extent of disease as well as multifocal or contralateral breast cancer. This information is important as it affects the surgical recommendations for patients.
Up until the 1970s, breast cancer was treated with radical mastectomy, which involved removal of the breast, pectoralis muscle, and axillary lymph node levels I to III. This was quite disfiguring for the patient and so in the 1970s, modified radical mastectomy came in to use, which preserved the pectoralis muscle, thereby improving somewhat the contour of the chest wall. In addition, only level I and II axillary lymph nodes were removed, which reduced the incidence of lymphedema in these patients. In the 1980s breast conservation (lumpectomy or partial mastectomy) combined with radiation therapy to the breast was found to be equivalent in survival to modified radical mastectomy. Today, approximately 80% of patients are found to be candidates for breast conservation.
In the 1990s, the technique of sentinel lymph node dissection was adopted in efforts to spare women with negative lymph nodes the morbidity of a full axillary lymph node dissection. The technique involves injecting radiolabeled colloid and/or lymphazurin blue dye into the breast and allowing it to travel to the axillary lymph nodes. All the radioactive and/or blue lymph nodes are removed and, in our institution, evaluated by frozen section. If these sentinel lymph nodes do not contain tumor on frozen section, then the patient is spared a complete axillary lymph node dissection. If the frozen section does reveal cancer in the sentinel lymph nodes, then a complete axillary lymph node dissection is performed during the same operation. If a patient has clinically positive lymph nodes before surgery, a sentinel lymph node dissection is not performed and the patient undergoes a complete axillary lymph node dissection.

Timing of Reconstruction
Although many patients are able to be treated with breast conservation, a subset of patients will either require a mastectomy or choose mastectomy as their surgical option. For these patients, the plastic surgeon is critical in helping the patient determine whether they wish to have breast reconstruction. However, controversy exists regarding the timing of breast reconstruction – immediate versus delayed. Immediate reconstruction employs the skin-sparing mastectomy technique that was developed by Toth and Lappert in 1991 1 and offers several advantages. The reconstructed breast has an improved cosmetic outcome following immediate reconstruction due to preservation of the skin envelope. Psychologically, the patient wakes up with a breast mound rather than a flat chest wall. The patient has one hospital stay and one anesthetic for the majority of the surgery followed by additional outpatient procedures for revisions, nipple reconstruction, etc. The skin-sparing mastectomy technique has been evaluated from an oncologic perspective and there does not appear to be any increased risk for local or distant recurrence. 2 - 7 Rozen et al performed a Medline literature review to evaluate the psychosocial need for immediate breast reconstruction and the issues surrounding oncologic safety. The authors’ review of previous studies concluded that immediate reconstruction does not increase local recurrence rates and does not delay the initiation of adjuvant chemotherapy or radiation. There was not a higher rate of complications in the setting of chemotherapy although there was a higher rate of complications in patients receiving adjuvant radiation therapy. Immediate breast reconstruction did have a positive effect on psychosocial outcomes including depression, anxiety, body image, self-esteem, self-image, emotional function, social function and sexual function. 8
The oncologic safety of immediate reconstruction was also reviewed by Taylor et al. 9 This was also a literature review and included analysis of 84 papers. The authors’ analysis concluded that there was not an increased risk of local or distant recurrence (although the studies reviewed were small and retrospective), and that detection of recurrence was not impaired by immediate reconstruction. In addition, no delay in the delivery of adjuvant chemotherapy was identified. With respect to radiation, there was a significantly higher rate of complications (capsular contracture, implant rupture, wound infections) in patients undergoing mastectomy and expander or implant placement who had radiation before or after reconstruction. With respect to autologous tissue reconstruction, complication rates were similar between patients undergoing radiation followed by TRAM reconstruction versus patients undergoing immediate reconstruction followed by radiation. However, fat necrosis and flap volume loss were more common in the immediate reconstruction group. 9
As outlined above, there are several concerns regarding immediate reconstruction. The major issue involves postmastectomy radiation, which will be discussed in greater detail in the following section. Immediate reconstruction still may be undertaken in patients who will more than likely require postmastectomy radiation. However, the oncologic surgeon and plastic surgeon need to discuss this preoperatively and inform the patient of the possible cosmetic sequelae from this approach. Another concern regarding immediate reconstruction is the possibility of delay in adjuvant chemotherapy. If a patient undergoes autologous tissue reconstruction and develops postoperative wound complications, the chemotherapy may need to be delayed until the wound problems are resolved. Although the studies detailed above have not found any significant delays in adjuvant chemotherapy, it is unknown what type of impact this might have on a patient’s overall survival. In our practice, many of our patients with Stage II and certainly Stage III breast cancer, undergo neoadjuvant chemotherapy, which negates this concern. We feel that most patients should be considered for immediate reconstruction and that this should be a joint decision made by the oncologic surgeon, plastic surgeon, and patient. Inflammatory breast cancer, with its poor prognosis and rapidity of recurrence, is a subtype of breast cancer that should not be considered suitable for immediate reconstruction. Additionally, patients with locally advanced breast cancer who do not undergo neoadjuvant therapy, or those with a poor response to chemotherapy, may also need to delay their reconstruction.
Delayed reconstruction is a more commonly employed technique. These patients typically complete their adjuvant therapy and then are evaluated by plastic surgeons for their reconstruction options. The advantage to this approach is that the final pathology is known prior to any reconstructive procedures. If any additional surgery is required, this can be undertaken without the anatomic or technical considerations that would result following reconstruction. Patients have time to consider whether or not they want reconstruction without the uncertainty of their stage of disease and following completion of therapy. They are able to use a prosthesis and decide if that is adequate for them.
The disadvantages are the advantages stated above for immediate reconstruction: possible inferior cosmetic result, additional anesthetic/hospital stay and the psychological distress of absence of a breast. Postmastectomy radiation does impact the outcome of the reconstruction and needs to be discussed with the patient.

Postmastectomy Radiation
Current recommendations for postmastectomy radiation include four or more positive lymph nodes or advanced tumors (T3, T4, skin involvement). Close or positive margins are another indication for postmastectomy radiation. Based on recent Danish and Canadian trials, postmastectomy radiation for patients with one to three positive lymph nodes is becoming more common and therefore the overall use of postmastectomy radiation is increasing. 10 - 12 The radiation may adversely affect the cosmetic outcome of the immediate reconstruction ( Fig. 2.1 ) and there is some concern that the reconstructed breast may result in technical difficulties in the delivery of radiation therapy. This includes increased doses of radiation to the lungs or reduced radiation delivery to the internal mammary lymph nodes. If breast reconstruction is delayed until after radiation, however, the mastectomy skin is often compromised, and the shape of the native breast skin envelope lost. Delayed breast reconstruction with implants following postmastectomy radiation can result in wound healing problems, capsular contracture with subsequent implant displacement, and painful constriction against the chest wall. 10 Many plastic surgeons will opt for autologous tissue when delayed reconstruction after radiation is performed.

Fig. 2.1 Radiated TRAM reconstruction.
To address this problem, surgeons at MD Anderson have described and published their experience with a two-stage approach that they have termed ‘delayed-immediate reconstruction.’ Stage 1 consists of a skin-sparing mastectomy with subpectoral insertion of a completely filled saline tissue expander to preserve the shape of the breast skin envelope. After review of the final pathology, patients who do not need radiation undergo immediate reconstruction within two weeks from the time of mastectomy (Stage 2). Patients who require radiation undergo therapy with the expander deflated to the chest wall. After radiation is complete, patients undergo re-expansion of the preserved breast skin. 13
Nahabedian and Momen analyzed the local recurrence rate and survival of patients undergoing radiation therapy either before or after breast reconstruction. The patient cohort included 146 women who underwent breast reconstruction and radiation with a follow-up of at least 12 months. Tumor recurrence, survival, loss of implant and total flap necrosis were analyzed. 14 The 59 women who underwent radiation after breast reconstruction had a higher local recurrence rate versus the 87 women who underwent radiation therapy prior to breast reconstruction (27% versus 15%). In addition there was a higher loss of life in the group undergoing breast reconstruction before radiation versus the group undergoing reconstruction after radiation (12% versus 7%). This raises concerns regarding the potential impact of immediate reconstruction on radiation delivery. This is a small study and it is difficult to draw definitive conclusions from this data. These questions may be better answered by a prospective trial.

BRCA Positive Patients
Women who carry a BRCA1 or BRCA2 mutation have an up-to 85% chance of developing breast cancer in their lifetime. In addition, there is up to a 65% cumulative lifetime risk that these women will develop ovarian cancer. The management of these women involves a multidisciplinary approach among breast surgeons, plastic surgeons and gynecologists. While many of the patients opt for aggressive clinical follow-up including physical exams, breast MRI, pelvic ultrasounds, serum CA-125 levels and possibly tamoxifen, prophylactic surgery is a reasonable approach that is effective in significantly reducing the risk of breast and ovarian cancer.
In these women who choose prophylactic surgery, consideration should be given to a coordinated approach for the mastectomies and bilateral salpingo-oophorectomies (BSO). Batista et al identified 12 patients who underwent combined mastectomies and BSO between 1996 at 2003. Ten of these patients underwent bilateral autologous tissue reconstruction. Six of these ten patients also underwent total abdominal hysterectomy during the same procedure. In this small retrospective study, there were no significant complications related to the gynecologic procedures. 15 Therefore, it is important that these patients are cared for by a multidisciplinary team who can determine whether a combined approach is feasible.
Many of the BRCA positive patients are quite young, and given this is a prophylactic procedure, they are most concerned with the cosmetic results. In this group, it is critical that the plastic surgeon be able to offer these women any and all reconstructive options. This should include autologous tissue reconstruction with latissimus dorsi, transverse rectus abdominis, or possibly gluteal flaps. Tissue expanders or immediate implant placement are other options to discuss. These patients need to be counseled that based on their genetic predisposition, there is a chance that occult cancer will be found at the time of surgery. Therefore, all these patients should receive preoperative MRI to look for abnormalities and bilateral axillary sentinel lymph node dissections at the time of mastectomies. It is critical that the patient and her oncologic and plastic surgeons discuss this preoperatively in case adjuvant therapy is required that might impact the reconstruction performed.
Many patients have a strong family history of breast cancer but test negative for the BRCA mutation. This could mean that they have another hereditary cancer syndrome such as Cowden or Li–Fraumeni, or carry a genetic mutation that has not yet been discovered. Further, some patients have watched relatives undergo breast cancer treatment and possible recurrence and wish to have prophylactic surgery to reduce their risk as much as possible. In these patients, it is important to have a long discussion about prophylactic surgery and the reconstructive options. If the patient elects to pursue this option, then it is reasonable to have them meet with the plastic surgeon. All patients need to know that mastectomy removes approximately 97% of the breast tissue not 100% of the breast and so they will still need clinical exams in follow-up for the small amount of tissue remaining.

Young Patients Considering Future Child-Bearing
Young women with breast cancer present additional challenges with respect to surgical options and reconstruction. Some of these patients will carry a BRCA mutation and may consider undergoing bilateral prophylactic mastectomy as discussed earlier. There also exists the issue of future pregnancy after autologous tissue reconstruction. Collin and Coady reported a case of a 33-year-old female who underwent a free transverse rectus abdominis myocutaneous (TRAM) reconstruction and subsequently became pregnant 1 year later. She was able to successfully carry her infant to term without any abdominal wall complications including width of donor site scar. 16 Patients need to be counseled about the potential risks of pregnancy after TRAM including fascial tears, herniation, and scar widening. The exact safe time interval between TRAM and pregnancy is unknown. For breast cancer patients, we generally advise them to wait 2 years post treatment prior to considering pregnancy.

Locally Advanced Breast Cancer/Inflammatory Breast Cancer
Many patients have concerns regarding the oncologic safety of immediate reconstruction in the face of locally advanced breast cancer. This was addressed in a study by Newman et al, in which 540 patients undergoing immediate reconstruction following mastectomy were evaluated. Fifty of these patients had locally advanced breast cancer and all underwent postoperative chemotherapy. Forty percent of these patients underwent postoperative radiation therapy. At median follow-up of 58.5 months, there was no difference in local or distant recurrence between these 50 patients and 72 matched controls with locally advanced breast cancer who did not undergo reconstruction. 17
In today’s paradigm, most patients with locally advanced breast cancer are treated with neoadjuvant chemotherapy. This allows not only for evaluation of how the chosen chemotherapy regimen is working on a patient’s particular tumor type, but it may shrink the tumor such that subsequent surgery is technically easier to perform. It also eliminates the concern about postoperative wound complications delaying the delivery of chemotherapy. Patients who develop wound infections or necrotic tissue must be completely healed prior to commencing chemotherapy. 18 In patients with aggressive tumors, this can lead to concern regarding spread of disease.
Inflammatory breast cancer is a very aggressive subtype of cancer with involvement of the dermal lymphatics. Despite multi-modality treatment of chemotherapy followed by mastectomy and then radiation, the overall 5-year survival is 46%. 19 These patients tend to have a high-rate of local recurrence, which is why they have traditionally not been considered candidates for immediate breast reconstruction. Two studies have recently challenged this recommendation. Slavin et al evaluated 10 patients with inflammatory breast cancer who underwent immediate reconstruction with a myocutaneous flap. Six of these patients developed local recurrence, however there was no effect on patient survival. 20 In another study by Chin et al, 23 women underwent breast reconstruction after surgery for inflammatory breast cancer. Fourteen patients had immediate reconstruction while 9 patients had delayed reconstruction. At median follow-up of 44 months, there were no differences in outcome between the two treatment groups. 21
Despite these small studies with positive results, we are currently not offering immediate reconstruction to our patients with inflammatory breast cancer. If the patient shows no evidence of disease one to two years post treatment, they are then referred to a plastic surgeon for discussion of possible reconstruction.

Nipple-sparing Mastectomy
A recent phenomenon is the increased use of nipple-sparing mastectomy or total skin-sparing mastectomy in patients undergoing either prophylactic surgery or treatment for breast cancer. This procedure involved ‘coring-out’ the ductal tissue from within the nipple–areola complex to reduce the likelihood of a recurrence in the area of the nipple. Recent studies have addressed the concerns regarding nipple–areola recurrences as well as technical issues related to nipple necrosis. Sacchini et al analyzed data on 123 patients who underwent nipple-sparing mastectomy with breast reconstruction. Forty-four patients had invasive cancer, 20 had ductal carcinoma in situ (DCIS), and four had phylloides tumors. There were two local recurrences with one being DCIS and the other invasive cancer. Two patients developed breast cancer after prophylactic mastectomy. None of these recurrences or new cancers was in the nipple–areola complex. Eleven percent of patients developed nipple necrosis but this was minimal in 59% of patients. 22 The authors concluded that local relapse after nipple-sparing mastectomy was very low and that this procedure might be feasible in select patients.
Garwood et al recently compared the first 64 patients undergoing total skin-sparing mastectomy at University of California, San Francisco between 2001 and 2005 to 106 patients undergoing total skin-sparing mastectomy between 2005 and 2007. The first cohort was analyzed in 2005 and techniques were altered to minimize risk factors for complications. An incision involving 30% or less of the nipple areolar complex resulted in improved nipple viability. Between cohort 1 and cohort 2, nipple survival rates rose from 80% to 95% and complication rates declined. These included necrotic complications, implant loss and wound infections. Local recurrence at median follow-up of 13 months was 0.6% with no recurrences in the nipple–areolar complex. 23 The authors concluded that total skin-sparing mastectomy is oncologically safe with high nipple viability.
Patients should be counseled regarding the potential risks and benefits of proceeding with nipple-sparing mastectomy. Clearly, technique is critical in obtaining an optimal cosmetic result. It seems reasonable to be conservative when offering this option to women who have a diagnosis of breast cancer as no definitive long term data is currently available for this technique. Nipple-sparing mastectomy appears to be a safe alternative for prophylactic surgery providing that the ductal tissue within the nipple is removed.

Breast Imaging Following Breast Reconstruction
Confusion exists regarding the role for mammography following bilateral mastectomies with reconstruction. Many primary care physicians are unclear about the necessity of routine screening mammography in a patient who clinically appears to have breasts but has undergone mastectomy and reconstruction particularly in the case of autologous tissue transfer. A study by Lee et al aimed to determine the role of mammography after TRAM reconstruction in women treated for breast cancer. In this retrospective review, 264 patients who had undergone mastectomy with TRAM reconstruction and subsequent bilateral screening mammograms were evaluated. Over a median follow-up period of 4.9 years, the rate of detection of recurrent non-palpable cancer in TRAM reconstructions was 0%. 24 In our practice, we do not perform routine mammograms of a breast that has undergone mastectomy followed by reconstruction. These patients should have yearly mammograms on the contralateral breast if prophylactic mastectomy has not been performed. Women who have undergone mastectomy with reconstruction have clinical breast exams and diagnostic imaging of any areas of concern. This imaging may include mammogram, ultrasound or MRI. The management of breast cancer local recurrence after mastectomy with reconstruction can be challenging and usually involves a combination of wide local excision, chemotherapy and radiation.

Conclusions
The treatment of breast cancer has become increasingly complex as more options have become available to patients. A multidisciplinary approach to breast cancer care, including the involvement of an oncologic surgeon, plastic surgeon, medical oncologist, radiation oncologist, mammographer, and often genetic counselor, is critical to ensure that the patient achieves an optimal outcome. The role of breast reconstruction often plays a crucial role in the patient’s recovery and has a significant positive impact on their psychological well-being.

References

1 Warren AG, Morris DJ, Houlihan MY, Slavin SA. Breast reconstruction in a changing breast cancer treatment paradigm. Plast Reconstr Surg . 2008;121(4):1116-1126.
2 Toth BA, Forley BG, Calabria R. Retrospective study of the skin-sparing mastectomy in breast reconstruction. Plast Reconstr Surg . 1999;104(1):77-84.
3 Simmons RM, Fish SK, Gayle L, et al. Local and distant recurrence rates in skin-sparing mastectomies compared with non-skin-sparing mastectomies. Ann Surg Oncol . 1999;6(7):676-681.
4 Carlson GW, Bostwick J, Styblo TM, et al. Skin-sparing mastectomy: oncologic and reconstructive considerations. Ann Surg . 1997;225(5):570-575.
5 Newman LA, Kuerer HM, Hunt KK, et al. Presentation, treatment, and outcome of local recurrence after skin-sparing mastectomy and immediate breast reconstruction. Ann Surg Oncol . 1998;5(7):620-626.
6 Kroll SS, Khoo A, Singletary SE, et al. Local recurrence risk after skin-sparing and conventional mastectomy: a 6 year follow-up. Plast Reconstr Surg . 1999;104(2):421-425.
7 Slavin SA, Schnitt SJ, Duda RB, et al. Skin-sparing mastectomy and immediate reconstruction: Oncologic risks and aesthetic results in patients with early-stage breast cancer. Plast Reconstr Surg . 1998;102(1):49-62.
8 Rozen WM, Ashton MW, Taylor GI. Defining the role for autologous breast reconstruction after mastectomy: social and oncologic implications. Clin Breast Cancer . 2008;8(2):134-142.
9 Taylor CW, Horgan K, Dodwell D. Oncological aspects of breast reconstruction. Breast . 2005;14(2):118-130.
10 Kronowitz SJ, Kuerer HM. Advances and surgical decision-making for breast reconstruction. Cancer . 2006;107(5):893-907.
11 Overgaard M, Hansen PS, Overgaard J, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. N Engl J Med . 1997;337(14):956-962.
12 Ragaz J, Jackson SM, Le N, et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med . 1997;337(14):956-962.
13 Kronowitz SJ, Robb GL. Breast reconstruction with postmastectomy radiation therapy: current issues. Plast Reconstr Surg . 2004;114(4):950-960.
14 Nahabedian MY, Momen B. The impact of breast reconstruction on the oncologic efficacy of radiation therapy. Ann Plast Surg . 2008;60(3):244-250.
15 Batista LI, Lu KH, Beahm EK, Arun BK, Bodurka DC, Meric-Bernstam F. Coordinated prophylactic surgical management for women with hereditary breast-ovarian cancer syndrome. BMC Cancer . 2008;8:101-106.
16 Collin TW, Coady MSE. Is pregnancy contraindicated following free TRAM breast reconstruction? J. Plast Reconstruct Aesthet Surg . 2006;59(5):556-559.
17 Newman LA, Kuerer HM, Hunt KK, et al. Feasibility of immediate breast reconstruction for locally advanced breast cancer. Ann Surg Oncol . 1999;6(7):671-675.
18 Ananthakrishnan P, Lucas A. Options and considerations in the timing of breast reconstruction after mastectomy. Cleve Clin J Med . 2008;75(S1):S30-3.
19 Singletary E. Surgical management of inflammatory breast cancer. Semin Oncol . 2008;35(1):72-77.
20 Slavin SA, Love SM, Goldwyn RM. Recurrent breast cancer following immediate reconstruction with myocutaneous flaps. Plast Reconstr Surg . 1994;93(6):1191-1204.
21 Chin PL, Andersen JS, Somlo G, Chu DZ, Schwarz RE, Ellenhorn JD. Esthetic reconstruction after mastectomy for inflammatory breast cancer: is it worthwhile? J Am Coll Surg . 2000;190(3):304-309.
22 Sacchini V, Pinotti JA, Barros A, et al. Nipple-sparing mastectomy for breast cancer and risk reduction: oncologic or technical problem? J Am Coll Surg . 2006;203(5):704-714.
23 Garwood ER, Moore D, Ewing C, et al. Total skin-sparing mastectomy: complications and local recurrence rates in 2 cohorts of patients. Ann Surg . 2009;249(1):26-32.
24 Lee JM, Georgian-Smith D, Gazelle GS, et al. Detecting nonpalpable recurrent breast cancer: The role of routine mammographic screening of transverse rectus abdominis myocutaneous flap reconstructions. Radiology . 2008;248(2):398-405.
CHAPTER 3 Adjuvant Therapy and Breast Reconstruction

Melissa A. Crosby, David W. Chang

Key Points

1. The safety, efficacy, and timing of breast reconstruction in patients who require adjuvant therapy must be evaluated to ensure that reconstruction does not delay adjuvant therapy or negatively affect disease-free interval or overall survival.
2. Neoadjuvant chemotherapy generally is not a contraindication to immediate breast reconstruction and does not increase the complication rate or significantly delay further adjuvant therapy. At our institution, we recommend delaying reconstruction for 3–4 weeks following neoadjuvant chemotherapy to allow the immunosuppressive effects of the chemotherapy to resolve.
3. Adjuvant chemotherapy: most oncologists prefer to initiate therapy 4–6 weeks after mastectomy or breast-conservation surgery. Immediate breast reconstruction does not seem to delay adjuvant chemotherapy or affect overall survival and recurrence rates.
4. Hormone therapy: because tamoxifen presents a theoretical risk of thrombosis, it may be appropriate to have the patient stop tamoxifen therapy 10–14 days prior to undergoing free-flap reconstruction and restart the therapy after breast reconstruction.
5. Radiotherapy: most agree that autologous tissue-based reconstruction tolerates radiation better with more pleasing aesthetic outcomes and fewer complications than implant-based reconstruction.
Advances in adjuvant therapies for breast cancer have significantly reduced the disease’s recurrence rate and associated mortality rate. Adjuvant therapies may include systemic therapy including cytotoxic, endocrine, or biologic modulators and/or localized treatment such as radiation therapy.
When considering breast reconstruction for patients who need adjuvant therapy, surgeons must take into account the potential effects of breast reconstruction on adjuvant therapy, and vice versa. The safety, efficacy, and timing of breast reconstruction in patients who require adjuvant therapy must be evaluated to ensure that reconstruction does not delay adjuvant therapy or negatively affect disease-free interval or overall survival. The impact of adjuvant treatment on the approach and overall outcome of breast reconstruction also merits clarification.

Systemic Therapy

Cytotoxic chemotherapy
Cytotoxic chemotherapy generally causes myelosuppression, which may interfere with wound healing and increase the risk of infections. Several studies have evaluated the efficacy of breast reconstruction in patients who are scheduled to receive adjuvant chemotherapy. Wound healing problems tend to occur when drugs are delivered during the 2 weeks before reconstruction or during the first week following reconstruction. As the interval between reconstruction and chemotherapy increases, the risk of developing wound healing complications decreases. 1 - 3

Neoadjuvant chemotherapy
Although it has not been shown to provide survival benefit compared with postoperative adjuvant chemotherapy, neoadjuvant chemotherapy has become a widely accepted treatment option for breast cancer patients. Neoadjuvant chemotherapy has been shown to reduce tumor size in some patients with large tumors, thereby facilitating breast-conservation surgery and enabling in vivo assessment of the tumor’s response to chemotherapy. 4 - 6 Many studies have shown that neoadjuvant chemotherapy followed by mastectomy and immediate breast reconstruction is safe and viable, does not delay other adjuvant treatment, and can be used to identify patients who do not respond to chemotherapy, which enables oncologists to modify post-surgical treatment. 7 - 9 In addition, studies have shown that the complication rate after implant- or autologous tissue-based reconstruction is not significantly higher in patients who have undergone neoadjuvant chemotherapy, nor are the local recurrence and disease-free survival rates affected. 7, 9 - 13
Generally, neoadjuvant chemotherapy is not a contraindication to immediate breast reconstruction and does not increase the complication rate or significantly delay further adjuvant therapy. At our institution, we recommend delaying reconstruction for 3–4 weeks following neoadjuvant chemotherapy to allow the immunosuppressive effects of the chemotherapy to resolve ( Fig. 3.1A, B ).

Fig. 3.1 A This is a 54-year-old woman with left breast multicentric invasive ductal carcinoma. The patient’s clinical stage at presentation is stage II-A with T2, N0, M0. She received neoadjuvant chemotherapy consisting of 12 weekly cycles of Taxol followed by four cycles of FAC. Four weeks after the completion of her chemotherapy, the patient underwent left mastectomy and immediate reconstruction with free DIEP flap. Her postoperative course was uneventful. B At 8 weeks following mastectomy and reconstruction.

Adjuvant chemotherapy
Postoperative chemotherapy is a common adjuvant treatment for breast cancer because it reduces the risk of local and systemic recurrence due to occult micrometastatic disease. Randomized trials and meta-analyses have shown that post-mastectomy adjuvant chemotherapy reduces recurrence and death rates in breast cancer patients. 14 - 16
Many researchers have studied whether immediate breast reconstruction affects the timely delivery of adjuvant chemotherapy and whether adjuvant chemotherapy after reconstruction affects wound healing. Allweiss et al compared 49 patients who underwent mastectomy, immediate breast reconstruction with various autologous tissue techniques, chemotherapy with 308 patients who underwent mastectomy alone followed by chemotherapy and found that the type of reconstruction did not significantly delay chemotherapy and that the time to chemotherapy was in fact significantly longer in patients who did not undergo immediate reconstruction. 17 In addition, Wilson et al compared patients who had undergone mastectomy with immediate reconstruction, mastectomy with no reconstruction, or breast-conservation surgery, all followed by adjuvant chemotherapy, and found no significant differences in the time to chemotherapy among the three cohorts. 18 At our institution, Mortenson et al found that patients who underwent immediate breast reconstruction followed by adjuvant chemotherapy had a higher incidence of wound complications (22.3%) than patients who did not undergo immediate reconstruction (8.3%) but did not find that immediate breast reconstruction delayed postoperative chemotherapy. 19
With regard to implant-based reconstruction, most researchers have found that adjuvant chemotherapy typically does not increase implant infection or complication rates or affect cosmetic outcomes. 2, 20 - 22 In addition, no significant delays in receiving chemotherapy or changes in dose intensity have been observed. 3 , 20 Based on these studies and our experience with implant-based reconstruction and tissue expansion during chemotherapy, we recommend that patients undergo tissue expansion and implant placement before starting chemotherapy. If tissue expansion is not complete before a patient starts chemotherapy, absolute neutrophil counts should be assessed to make certain that the patient’s immune system can fight the bacteria that are introduced during the expansion process.
Although whether delaying adjuvant chemotherapy affects cancer-related outcomes is not yet definitively known, most oncologists prefer to initiate therapy 4–6 weeks after mastectomy or breast-conservation surgery given concerns that longer periods may increase recurrence or diminish survival. 23 Immediate breast reconstruction may increase the risk of complications as a result of the additional surgical procedures performed, but it does not seem to delay adjuvant chemotherapy or affect overall survival and recurrence rates.

Hormone therapy

Selective estrogen receptor modulators
Tamoxifen has been shown to reduce the risk of recurrence and death in women with early-stage, hormone receptor-positive invasive breast cancer; reduce the risk of invasive and non-invasive recurrences in women who undergo breast-conserving surgery for ductal carcinoma in situ; and reduce the risk of breast cancer in women who have a high risk for the disease because of personal characteristics or family history. 16 , 24 Despite tamoxifen’s benefits, 1–2% of patients may experience thromboembolic events such as deep vein thromboses, pulmonary embolisms, and cerebrovascular thrombi. Although the mechanisms by which tamoxifen causes thromboembolic events are not totally understood, the events are thought to be related to tamoxifen’s reduction of levels of antithrombin III, and factor V, and protein C. 25 - 27
Because tamoxifen presents a theoretical risk of thrombosis, it may be appropriate to have the patient stop tamoxifen therapy 10–14 days prior to undergoing free-flap reconstruction and restart the therapy after breast reconstruction. (This time frame is based on the pharmacokinetics and the 9–14-day terminal half-life of tamoxifen’s major metabolite. 28 ) However, we recommend consulting with the patient’s medical and surgical oncologists to confirm that tamoxifen therapy can be stopped safely without negatively affecting the patient’s cancer treatment.

Aromatase inhibitors
The most common aromatase inhibitors studied in breast cancer patients are anastrozole and letrozole. In comparison trials, anastrozole was associated with higher disease-free survival rates, lower breast cancer event rates, and fewer incidences of contralateral breast cancer than tamoxifen. Also, significantly fewer venous thrombolic events occurred in the anastrozole group than in the tamoxifen group. 29 We currently do not routinely stop aromatase inhibitor therapy prior to breast reconstruction.

Biological therapy
Trastuzumab, a humanized monoclonal antibody directed against the HER-2 receptor, has been shown to significantly improve survival rates in metastatic breast cancer patients when used alone or in combination with chemotherapy. Trastuzumab also has been shown to reduce recurrence rates and improve survival in early-stage breast cancer patients. 30
Patients who receive trastuzumab alone or in combination with other chemotherapy may experience neutropenia and an increased incidence of infections. An increase in the incidence of thrombotic events has also been reported. 31 Because of these potential complications, we recommend that patients complete trastuzumab therapy and undergo immune status evaluation before undergoing breast reconstruction. And as always, we recommend consulting with the patient’s medical and surgical oncologists.

Radiotherapy
Giving adjuvant radiotherapy following mastectomy has been shown to significantly reduce the risk of locoregional recurrence in early-stage breast cancer patients with positive lymph nodes. 32 , 33 Furthermore, recent prospective trials have demonstrated improved locoregional control, disease-free survival, and overall survival rates in node-positive breast cancer patients who receive adjuvant radiotherapy in addition to mastectomy and chemotherapy. 34 , 35 Currently, post-mastectomy adjuvant radiotherapy is recommended for patients with locally advanced tumors or four or more involved lymph nodes. 36 , 37 However, many institutions are evaluating the efficacy of radiotherapy in patients who have T1 or T2 disease and one to three involved nodes. 33

Breast reconstruction in a previously irradiated breast
The negative effects of radiation on implant-based breast reconstruction have been particularly well documented; studies of implant-based reconstruction of previously irradiated breasts have reported complications including infection, extrusion, capsular contracture, and failed reconstruction in 20–60% of cases. Thus, most prefer to use autologous tissue only for breast reconstruction in a previously irradiated breast. However, recent reports may support that when autologous tissue flap and implant are used together in a previously irradiated breast for breast reconstruction, an autologous tissue flap may protect the implant from the negative effects of radiotherapy. Spear et al evaluated 28 patients with previously irradiated breasts who underwent latissimus dorsi (LD) flap/implant breast reconstruction and found a 14% implant-related complication rate with a mean cosmetic satisfaction rating of 8.5 of 10 and mean overall satisfaction rating of 8.8 of 10. The authors concluded that although breast reconstruction with autologous tissue alone may be the best choice following radiotherapy, LD flap/implant reconstructions provide cosmetically acceptable results and acceptable complication rates. 38 In a study from our institution, of patients who received radiotherapy prior to mastectomy and reconstruction, significantly fewer reconstructions failed in patients with LD flap/implant reconstructions (15%) or transverse rectus abdominis myocutaneous (TRAM) flap/implant reconstructions (10%) than in patients with expander/implant-only reconstructions (42%; p  < 0.03). 39
In our experience, an autologous tissue flap combined with an implant for breast reconstruction appears to reduce the incidence of implant-related complications in previously irradiated breasts. A well-vascularized flap may improve wound healing and thus reduce the risk of wound breakdown and infection. The flap also provides a well-vascularized pocket for the implant, which minimizes the implant’s direct contact with the surrounding irradiated tissue. Although the implant sits on the chest wall, covering the implant with well-vascularized tissue may reduce the risk of capsular contracture associated with radiotherapy. Because free TRAM flaps and deep inferior epigastric artery perforator (DIEP) flaps typically provide more well-vascularized tissue than LD flaps, covering the implant with a free TRAM or DIEP flap may provide better protection.

Immediate breast reconstruction followed by radiotherapy
There are conflicting results in the literature regarding almost all aspects of immediate reconstruction and radiotherapy. This conflict has clinical ramifications, since the first step after diagnosing breast cancer is offering a patient the best possible treatment in accordance with her and the tumor’s characteristics. Such treatment may include immediate breast reconstruction in cases in which mastectomy is indicated.
The mechanisms and clinical effects of radiation on the reconstructed breast depend on the radiation dose, the use of compensating filters and wedges, the use of bolus dosing to the skin, and the boost to the radiation bed. 40 The variability among radiation oncologists and centers makes it difficult to predict the effects radiotherapy will have on a reconstructed breast. Incompletely understood intrinsic patient factors can also alter the effects of radiotherapy. Immediate breast reconstruction can create technical challenges in administering adjuvant radiotherapy and may increase radiation exposure in the mediastinum. A flat chest – that is, one without a reconstructed breast – allows for beam angulations that minimize radiation doses to the heart and lungs while treating the internal mammary lymph nodes; however, the sloped contour of a reconstructed breast contributes to less precise geometric matching of the lateral and medial radiation fields, resulting in greater radiation doses in the mediastinum. 33, 41 - 43

Autologous tissue-based reconstruction followed by radiotherapy
Most authors agree that autologous tissue-based reconstruction tolerates radiation better with more pleasing aesthetic outcomes and fewer complications than implant-based reconstruction. 44 , 45 Jhaveri et al performed a retrospective analysis of the long-term complication rates and cosmetic results in 69 patients who underwent immediate tissue expander/implant-based reconstruction with adjuvant radiotherapy and 23 patients who underwent autologous tissue-based reconstruction with adjuvant radiotherapy. The authors found that the tissue expander/implant group had a significantly higher rate of severe complications – those that required surgical intervention or removal and/or replacement of the implants (33.3%) – than the group who underwent autologous tissue-based reconstruction (0%). The autologous tissue group also had a higher rate of acceptable cosmesis (83%) than the tissue expander/implant group (51%). 46
However, many feel that irradiating a reconstructed breast may diminish the aesthetic outcome and thus advocate delay reconstruction in patients who require adjuvant radiotherapy. Tran et al reported on a series of 41 patients undergoing immediate TRAM flap reconstruction (9 pedicled and 32 free) followed by radiation. No flap loss was reported; however, 10 patients (24%) required an additional flap to correct contracture, and only 9 patients (22%) maintained normal breast volumes. Hyperpigmentation occurred in 15 patients (37%), palpable fat necrosis in 14 patients (34%), and a loss of symmetry in 32 patients (78%). 47 In a later study, Tran et al evaluated 32 patients who underwent immediate reconstruction followed by radiotherapy and 70 patients who underwent reconstruction after radiotherapy. No significant difference was found in early flap complications between the two groups but significantly higher (87.5% versus 8.6%) rates of late complications (fat necrosis, flap volume loss, and flap contracture) were noted in patients who received immediate reconstruction prior to radiotherapy, with 28% requiring an additional flap to correct deformities ( Fig. 3.2A–E ). 48 Other studies have found similar results with higher rates of fat necrosis and necessary additional surgeries or flaps due to volume loss in patients who undergo autologous tissue-based reconstructions before adjuvant radiotherapy. 49 - 52

Fig. 3.2 A The patient is a 53-year-old woman with left breast invasive mixed ductal lobular carcinoma and ductal carcinoma in situ. B The patient underwent left modified radical mastectomy and right prophylactic mastectomy with immediate reconstruction with free TRAM flaps. C Pathology review revealed close surgical margin and patient was treated with 50 Gy in 25 fractions to the left chest wall and reconstructed breast followed by a 14 Gy electron boost to the skin overlying the TRAM flap. D At 12 months following completion of the radiation therapy. E At 4 years after mastectomy and free TRAM breast reconstruction, and 45 months following completion of the radiation therapy.
Meanwhile, for some surgeons, immediate reconstruction with autologous tissue remains the preferred approach in patients who require adjuvant radiotherapy. In a series of 25 patients, Soong et al found that radiotherapy did not increase the rate of complications after immediate reconstruction with TRAM flaps. The authors concluded that radiotherapy after reconstruction with TRAM flaps is well tolerated and that cosmetic outcome and local control of the breast cancer are satisfactory. 53 Other authors have reported similar results with good to excellent cosmetic outcomes and minimal flap loss and complications. 54 - 57

Implant-based breast reconstruction followed by radiotherapy
Among patients who had immediate implant-based breast reconstruction followed by radiotherapy, Cordeiro et al found that 68% experienced capsular contracture after radiotherapy, a rate significantly higher than in patients who did not receive radiotherapy. Also, the patients who did not receive radiotherapy had a higher percentage of very good to excellent outcomes of the reconstructed breast than patients who did receive radiotherapy. Nevertheless, the authors concluded that immediate reconstruction with expanders and implants is an acceptable option when adjuvant radiotherapy is necessary. 58 Hazard et al reached the same conclusion in a retrospective study in which 85% of patients had good or excellent cosmetic outcomes, with an acceptable rate of capsular contracture. 59
Other authors have reported higher complication, reoperation, and capsular contracture rates in patients with implant-based reconstructions followed by adjuvant radiotherapy, resulting in poor cosmetic outcome. Spear et al evaluated outcomes in 40 patients undergoing two-stage reconstruction with saline implants and adjuvant radiotherapy with 40 patients undergoing two-stage reconstruction without radiation and found that the group who received radiation had significantly more complications (52.5% versus 10.0%), capsular contractures (32% versus 0%), and additional procedures (47% versus 10%). 40 Other authors have come to the same conclusion and even consider the need for radiotherapy to be a relative contraindication to immediate breast reconstruction with tissue expanders and implants. 60 - 66

Delayed-immediate breast reconstruction
It remains unclear whether radiation will be required after mastectomy in many patients. The inability to consistently identify patients who require adjuvant radiotherapy complicates the decision about whether to perform immediate reconstruction in many early-stage breast cancer patients.
Because of this dilemma, Kronowitz et al described the ‘delayed immediate’ technique, in which a completely filled textured saline tissue expander is placed during mastectomy to preserve the skin envelope. 42 Once the final pathology results are received, patients can undergo delayed reconstruction after they complete radiotherapy or immediate reconstruction if radiotherapy is unnecessary. The advantage of this technique is that it preserves the skin to achieve superior aesthetic outcomes in immediate reconstruction and it enables delay of final reconstruction in patients who are found to need postmastectomy radiation, thereby avoiding most effects of irradiating a reconstructed breast.

Summary
Given reports of the increased risk of capsular contracture associated with radiotherapy and implant reconstruction and the need for removal or reoperation despite reported acceptable cosmetic results, we recommend autologous tissue-based reconstruction instead of implant reconstruction in patients who have received or will receive radiotherapy. Ideally, delaying reconstruction until after radiotherapy is prudent and results in less morbidity. In addition, if a patient receives radiotherapy and desires delayed reconstruction, we believe that autologous tissue provides the most reliable and best aesthetic results. Although many centers have reported minimal complications and acceptable cosmetic results in patients who receive radiotherapy after autologous tissue-based reconstruction, we believe this risk is unnecessary. Delaying reconstruction until after radiotherapy decreases the risk of fat necrosis, volume loss, and the need for additional flaps. Furthermore, immediate reconstruction may cause technical problems when designing the radiation fields necessary to deliver adjuvant radiotherapy.

Conclusion
The current approach to breast cancer is multidisciplinary. Breast reconstruction has become a routine aspect of treatment, and many breast cancer patients who undergo reconstruction after partial or total mastectomy also require adjuvant therapy. To plan and provide effective multidisciplinary care for breast cancer patients, plastic surgeons must understand how adjuvant therapy and breast reconstruction impact each other.

References

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38 Spear SL, Boehmler JH, Taylor NS, et al. The role of the latissimus dorsi flap in reconstruction of the irradiated breast. Plast Reconstr Surg . 2007;119:1-9.
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CHAPTER 4 Expanders and Breast Reconstruction with Gel and Saline Implants

Jonathan D. McCue, Mark Migliori, Bruce L. Cunningham

Key Points

1. The optimal result in implant-based breast reconstruction requires a team approach.
2. With careful selection and preoperative education, the irradiated patient may have a successful result with implant reconstruction.
3. The base diameter of the breast is the primary determinant of implant selection.
4. Preservation of the inframammary fold or its re-establishment is crucial to appropriately positioned implants.
5. Starting at the time of tissue expander placement, the implant pocket should be of a size and position that would be desirable as a final result.

Introduction
Clinical use of tissue expansion dates back to 1957 where expanded postauricular skin was used to reconstruct a traumatic ear defect. 1 Subsequent interest in this technique, and specifically its application to breast reconstruction, did not flourish until 20 years later when Radovan and Austad developed silicone tissue expanders, independently presenting their results in 1978 2 and 1979. 3 Radovan described a saline-filled implantable silicone expander utilizing a port; Austad described a self-inflating tissue expander 4 including a description of the histological features of expanded tissue. 5 , 6 As the safety and efficacy of submuscular tissue expansion has improved, implant-based breast reconstruction has become one of the most frequently employed reconstructive techniques in eligible patients. Today, an understanding of implant reconstruction results through careful planning of tissue expander placement and judicious modification of the pocket at the time of permanent implant exchange is resulting in a more realistic appearance to the reconstructed breast, while technologic advances in implant design and biologic substitutes are providing improved soft tissue coverage, contour and a more realistic feel to implant-based breast reconstruction.

Team Approach to Implant-Based Breast Reconstruction
Achieving an optimal result in implant-based breast reconstruction is dependent on the skill and diligence of other physicians who ideally have a good understanding of reconstructive priorities. A mastectomy surgeon who is able to perform a sound oncologic procedure, while preserving anatomic landmarks that define the contours of the original breast, is critical to overall success. Unnecessarily aggressive surgical resection compromises the ability to reconstruct a natural appearing breast, limiting aesthetic results and taints the patient’s perception of the plastic surgeon’s abilities. With respect to the radiation oncologist, proper titration of therapy is critical to avoid excessive injury that limits tissue expansion and increases the incidence of complications. A good working relationship with all disciplines involved allows coordination of care to minimize the inconvenience for the patient in terms of multiple office visits and unnecessary delays in receiving adjuvant therapy.

Indications and Patient Selection
The ideal candidate for implant-based reconstruction is the patient with durable, non-redundant soft tissue coverage desiring a moderate sized non-ptotic breast ( Fig. 4.1 ). This allows for flexibility in final size, tends to create a more stylized contour of the breast, and is particularly well suited to bilateral reconstruction. In unilateral reconstruction the patient must be willing to entertain the possibility of contralateral breast augmentation, reduction, or mastopexy. These considerations hold true for immediate or delayed reconstruction patients. However, the delayed reconstruction patient who has received postmastectomy radiation therapy should be approached very cautiously as the complication rate in this setting may be exceedingly high 7 ( Fig. 4.2 ). Also, large-breasted patients who wish to maintain a large size in their reconstruction may not be able to achieve this with tissue expansion and implants. Tissue expansion may altogether be avoided in carefully selected patients who have received a skin-sparing mastectomy (e.g., prophylactic mastectomy) with unequivocally viable skin flaps. However, in those patients with significant soft tissue loss at the time of tumor extirpation, tissue expansion is usually necessary.

Fig. 4.1 A, B Thin patient with a petite frame and non-ptotic breasts prior to mastectomy and at completion of C, D first and E, F second stage reconstruction with nipple reconstruction.

Fig. 4.2 Patient with history of right mastectomy and radiotherapy. An adherent, fibrotic skin envelope makes this patient unsuitable for tissue expansion and a latissimus flap with implant is planned.

Radiation Therapy and Implant-Based Reconstruction
Radiation therapy may be administered before mastectomy in the instance of prior breast conservation therapy, immediately following mastectomy but before reconstruction, coincident with tissue expansion, or after completion of tissue expansion. Radiation therapy has traditionally been avoided in patients with T0, T1 or T2 tumors after mastectomy, based on the patient’s choice, rather than lumpectomy with radiation as defined in the NSABP-B-06 trial. 8 However, an increasing number of patients desiring breast reconstruction are eligible for radiotherapy due to the increasing prevalence of breast cancer and expanding indications for adjuvant therapy. 9 In 1999 the indications for radiation therapy for breast cancer after mastectomy were expanded to include patients with stage II disease having either a primary tumor diameter greater than 5 cm (T3) and/or four or more involved lymph nodes ( Table 4.1 ). 10 Currently the efficacy of radiation therapy in patients with one to three affected lymph nodes is in phase III trials (NSABP-B-39). 11
Table 4.1 Indications for postmastectomy radiation
Tumor >5 cm
T4 tumor
Involvement of 4 or more axillary lymph nodes
Gross extracapsular nodal disease
Residual disease after mastectomy
Additional considerations
Involvement of 1–3 axillary lymph nodes
Gross multifocality
Extension into the nipple or skin
As such, an understanding of the effects of radiation therapy on the reconstructive surgeon’s strategy has become increasingly important. Radiation therapy by itself is no absolute contraindication to implant-based reconstruction, but its limitations must be realized, and some surgeons may wish to avoid attempting to expand skin with anticipated irradiation. While the need for radiation may be determined prior to mastectomy in a subset of patients, an increasing number are offered postoperative radiation therapy following analysis of the permanent pathology of lymph nodes or tumor margins. Delayed primary reconstruction, in which the tissue expander is placed 3 or 4 days after mastectomy, may be performed to ensure negative pathology and no indication for radiation. In those patients where radiation therapy is indicated based on intraoperative findings such as tumor size, narrow margins or sentinel lymph node status, the reconstructive surgeon should reserve the option to ‘walk away’ from an immediate reconstruction. Some authors have suggested the use of a delayed-immediate reconstruction technique, where a partially inflated expander is placed immediately with interval deflation for the duration of radiation therapy, if indicated. 12 In this circumstance of postoperative radiation, we prefer to expedite the expansion process to completion within 4 to 5 weeks, before radiation therapy is started.
In most centers, radiation oncologists do not perceive the tissue expander as a hazard to good treatment. If oncologic considerations require radiation prior to that time, delayed reconstruction is preferred. Those patients who have received even appropriately titrated radiation therapy are at greater risk for mastectomy flap necrosis, implant exposure or inability to complete tissue expansion ( Fig. 4.3 ). However, a successful result can nonetheless be obtained ( Fig. 4.4 ). As such, we often allow patients to ‘prove’ the expander will not work before resorting to autologous forms of reconstruction. Ultimately, autologous tissue coverage may be required to achieve an acceptable contour. Spear reviewed a series of saline implant-reconstructed women receiving radiation therapy at various time points relative to reconstruction and found autologous tissue was needed in 19 out of 40 (47.5%) patients primarily as a consequence of contracture or unsatisfactory implant position. 13 These secondary operations still make use of the expanded tissue, and may be thought of as an adjunct to implant-based reconstruction, rather than salvage for a failed operation. No additional operations are required than if the patient had proceeded to autologous tissue transfer, initially or at a later date; the only disadvantage is the time and inconvenience for the patient having undergone an expansion process that does not progress to completion or ultimately fails. In those secondary or delayed reconstruction patients who have received very high doses of radiotherapy, we do not attempt tissue expansion alone, and proceed directly to autologous tissue transfer with or without the use of an implant and expander.

Fig. 4.3 Patient after bilateral mastectomy and radiation therapy to the right side, followed by bilateral tissue expansion. Goal tissue expansion could not be achieved in the irradiated side. Volume has been removed from the right tissue expander and a latissimus flap is planned.

Fig. 4.4 Implant-based reconstruction shown A preoperatively and B following right mastectomy with tissue expansion and radiation therapy. C Second stage reconstruction with good result without autologous tissue transfer. A contralateral augmentation for symmetry has been performed. Note the constricted envelope of the irradiated breast has been lowered to match the inframammary fold of the left breast.

Preoperative Marking and Tissue Expander Selection
Preoperative coordination with the surgical oncologist is critical for obtaining a favorably placed mastectomy scar that can be concealed by clothing with preservation of as much skin envelope as needed. The importance of preserving the inframammary fold should be appreciated by the oncologic surgeon. With greater acceptance of skin-sparing and areola-sparing mastectomies, incisions other than a standard periareolar ellipse may affect surgical exposure ( Fig. 4.5 ). In the large-breasted patient who wants significantly smaller breasts and has no indication for radiation, a mastectomy scar incorporating a vertical component, or based on an inverted ‘T’ incision as seen in Wise pattern breast reductions, may be considered (see Fig. 4.27 ).

Fig. 4.5 Second-stage reconstruction after nipple-sparing mastectomy.
Preoperative marking for the reconstructive surgeon involves outlining all borders of the breast to approximate the planned implant or expander pocket space dissection. Any asymmetries are noted, and the inframammary fold is marked while the patient is in the upright position. The meridian of the breast is marked at the level of the inframammary fold. At this point it is critical for the reconstructive surgeon to visualize how the final reconstruction should appear with respect to breast diameter and volume, including any planned symmetry procedure. The surgeon should aspire to estimate the position and size of the permanent implants prior to tissue expander placement.
With the final result in mind, tissue expanders of appropriate dimensions are ordered prior to the surgery. A range of tissue expanders are currently available, including round and contoured expanders, the latter offering the benefit of differential, greater lower pole expansion, and an increasing slope from the upper pole. Most expanders utilize an integrated valve that is located using a magnetic port finder ( Fig. 4.6 ). If expander positioning is ideal, a remote port expandable implant provides an option of explanting only the port and interconnecting catheter, leaving the implant in place as a permanent device. Each tissue expander has a specific base diameter, height, contour profile (e.g., low, moderate, and tall), and maximum recommended volume ( Fig. 4.7 ). We use base diameter as the primary determinant of implant choice with volume as the second consideration. The choice of profile is largely based on the habitus of the patient, with narrow-chested, thinner patients appearing proportional with low or medium profile expanders and heavier patients requiring a tall profile to offer projection commensurate with their larger size.

Fig. 4.6 Use of a magnet to locate the integrated filling port on a tissue expander.

Fig. 4.7 Packaging label on a Mentor tissue expander indicating the base diameter, implant contour and maximum recommended filling volume.
Surgeon preference does play a role in the choice; some prefer a tall profile expander that can be used to ‘recruit’ superior pole tissue during expansion. While it is aesthetically desirable to have upper pole fullness, achieving this through initial tissue expansion may result in poorer, more fibrotic, tissue quality. For this reason it may be preferable to expand the lower pole and ‘recruit’ unexpanded tissue superiorly by dissecting upwards into the expander pocket at the time of second stage reconstruction. Although each expander has a recommended fill volume, strictly limiting expansion to this number is of little importance as the base diameter does not change significantly with increasing fill, and the devices can easily exceed the stated fill volume.

Operative Technique: Immediate Reconstruction

Patient positioning
Implant-based reconstruction can begin immediately after tumor extirpation with the patient having been under general anesthesia for anywhere between 1 to 3 hours. Surgical margins of the tumor specimen would be negative on preliminary examination and sentinel or formal lymph node dissection would be performed, if indicated, at this point. Although proof of efficacy has not been established, additional wound infection precautions such as re-administration of prophylactic antibiotics and a second application of surgical prep around the incision may be done. The arms may be extended or at the sides, depending on preference. We prefer placing the arms at the sides as this decreases tension on the pectoralis major, facilitating retraction of the muscle during pocket dissection.

Pocket dissection
As previously mentioned, the option for immediate placement of a permanent implant may be reasonable only if the mastectomy flaps are viable and can accommodate the appropriate implant size without creating excessive tension on the skin closure. It also necessitates accurate positioning of the implant and reconstructing the important landmark of the inframammary fold. In the majority of cases, a staged expansion process is necessary to achieve optimal results.
With the deficiency of soft tissue coverage resulting from the mastectomy, partial or complete muscle coverage is necessary to limit implant visibility or exposure. We prefer complete muscular coverage of the expander to maximize the vascularity of the pocket and exclude the implant from the overlying mastectomy incision. In this technique, the lateral edge of the pectoralis major muscle is elevated and a submuscular pocket is dissected medially to the sternal edge and superiorly to the second rib. The superior dissection is made in a relatively avascular plane between the pectoralis major and minor muscles. Care should be taken to avoid injury to the thoracoacromial pedicle located on the undersurface of the pectoralis major muscle. A systemic paralytic may be administered to make the superior dissection easier, as powerful contractions of the pectoralis major may result from electrocautery dissection near its dominant neurovascular pedicle. Superior dissection may be made bluntly, and while technically easy, excess dissection in this direction may lead to implant malposition, as the expander is wider than it is tall. When possible, the large perforator in the medial second interspace is preserved because of its contribution to the mastectomy flap blood supply ( Figs 4.8 and 4.9A–C ).

Fig. 4.8 Schematic illustration for raising pectoralis major, serratus anterior and pectoral-serratus fascia to achieve complete coverage for the implant.

Fig. 4.9 A Technique of submuscular pocket dissection: periareolar ellipse mastectomy incision, B elevation of lateral edge of pectoralis major, C superior pole dissection between pectoralis major and minor, D elevation of serratus anterior, E elevation of bridging fascia between pectoralis major and serratus anterior, F local anesthetic injection into pectoralis major pedicle.
Inferiorly, the pocket dissection is carried down to the top of the sixth rib at the meridian of the breast. In general, the inframammary fold (IMF) can be reliably reconstructed in this location. Although the anatomy of the IMF is not firmly established and may vary with age and body habitus, it is an anatomic landmark with gross anatomic dissections and histologic reports suggesting a confluence of organized collagen fibers in the dermis 14 and/or an actual ligament arising from periosteum and intercostal fascia. 15 With the normal curve of the ribcage, the medial IMF is predictably located at the bottom of the fifth rib and the lateral extent of the fold is located at the top of the seventh rib ( Fig. 4.10 ). Avoidance of dissection below the fold is the preferred strategy. Because the pectoralis major muscle inserts at the fifth rib, cephalad to the IMF, it is necessary to detach its inferior origins to position the expander appropriately. When the mastectomy has not violated the IMF, this release may be carried into the subcutaneous tissue of the IMF without compromising the expander coverage inferiorly. However, it is often necessary to elevate a portion of the anterior rectus fascia in continuity with the released pectoralis to maintain complete expander coverage.

Fig. 4.10 Landmarks on the fifth, sixth and seventh ribs to re-establish the inframammary fold.
The lower slips of the serratus anterior are elevated to cover the infralateral expander ( Fig. 4.9D ). Maintaining the bridging fascia between the pectoralis major and the serratus anterior is very helpful in this dissection ( Fig. 4.9E ). Care must also be taken to avoid dissection through the intercostal spaces. A complementary adjunct to complete elevation of the serratus anterior is to elevate the lateral edge of the pectoralis minor in continuity with the lower slips of the serratus ( Fig. 4.11 ). This has the benefit of better retention of the implant at the superolateral pocket border, helping to prevent any late migration towards the axilla, particularly after lymph node dissection. These dissections are performed to match the footprint of the desired expander, respecting the desired landmarks of the future reconstructed breast. Proper control of the pocket dimensions will limit the potential for expander malposition or malrotation. When possible, muscle relaxation provided by the anesthesia team will facilitate the pocket dissection. As an adjunct to post-operative pain management and to prevent muscle spasms, 0.25% bupivacaine can be injected near the thoracoacromial pedicle and as a field block around the perimeter of the pocket ( Fig. 4.9F ).

Fig. 4.11 Technique for raising lateral slips of pectoralis minor to achieve superolateral muscular coverage.
An alternative to complete muscle coverage of the expander has emerged. An acellular dermal matrix may be used as a hammock for the expander to avoid the necessity of elevation of the rectus fascia, serratus and/or pectoralis minor muscle. 16 It is also useful in those situations where complete muscle coverage was desired but the mastectomy resulted in loss of fascia or muscle integrity in the inferior pocket. Typically, an 8 × 16 cm sheet of dermal matrix is sutured superiorly to the detached pectoralis major muscle edge and medially at the sternal edge ( Fig. 4.12 ). We use interrupted 2-0 silk sutures for this purpose. Inferiorly and laterally, it is sutured to the underlying fascia. The IMF landmarks and the desired lateral contours determine the position. It is recommended that the dermal side of the graft is directed towards the undersurface of the mastectomy flaps to promote vascular ingrowth. While an effective technique without a known increase in complications, the acellular dermal matrix adds considerable cost and may increase the risk of seroma. In the setting of an ischemic mastectomy flap, expander protection from infection or exposure may be compromised. Additionally, the effect of post-expansion radiation on the vascularization of the acellular dermal graft is not fully known. Although it has been successfully used in this scenario, deliberate patient selection is necessary to achieve optimal results.

Fig. 4.12 Illustration of dermal matrix in position with underlying implant. Drains may be placed deep and superficial to the graft.

Expander placement
The expander is removed from the sterile internal packaging only when ready for placement to reduce the possibility of implant contamination. Hemostasis within the pocket should be assured: perforating vessels, if visible at the medial pocket edges should be cauterized for risk of avulsion following future expansion. Prior to the insertion of the expander or a permanent implant, the pocket is irrigated to remove cautery char, loose fat, and to visualize any remaining bleeding. Many different irrigant solutions have been proposed: the ‘triple antibiotic’ solution popularized by Adams contains gentamicin (80 mg), cefazolin (1 g) and bacitracin (50,000 U) in 500 ml of normal saline, with vancomycin substituted for bacitracin at some institutions. 17 It must be noted that the endpoint of this study, capsular contracture in breast augmentation patients, was based on an etiologic assumption of subclinical pocket infection, which has not been firmly established. No comparative efficacy has been established with any popular irrigation choices including triple antibiotic, single antibiotic, diluted povidone–iodine or normal saline alone, particularly in breast reconstruction patients, and the additional cost of these measures should be considered if implementing them systematically. We do employ well-established barrier precautions – the operating surgeon applies new sterile gloves and is the only team member to handle the implant. Some air is present in the expander when removed from the packaging. We typically evacuate the air maximally to minimize risk of tearing tissues during pocket insertion. The expander is then positioned so that the integrated valve is at the upper pole. Some additional pocket dissection may be required to achieve this; however, effort is made to keep within the appropriate base diameter. Certain tissue expander models have a reinforced orientation tab at the posterior aspect where an absorbable stitch can temporarily secure the implant to rib periosteum or intercostal fascia to prevent malposition. The expander is then filled with 60–120 cc of saline from a closed system, based on the condition of the overlying skin and muscle. This intraoperative expansion allows the lower pole of the implant to unfurl, facilitating positioning and has the secondary benefit of obliterating any dead space within the pocket.
Once expander position is satisfactory and it is apparent that the implant pocket can be closed without excessive tension, the lateral free edge of the pectoralis major is sewn to the free edge of the serratus anterior and pectoral-serratus fascia in the case of total submuscular placement, or to the free edge of the dermal matrix if used. The overlying muscle is closed and additional saline is added using the sterile magnetic port finder to achieve an acceptable amount of tension on skin and muscle closure ( Fig. 4.13 ). Total intraoperative expansion may range widely depending on overlying soft tissue laxity, but approximately 20% of the implant volume should be tolerated in most patients. The use of dermal matrix approximately doubles the intraoperative volume expansion possible.

Fig. 4.13 A Tissue expander placement technique: complete deflation of expander, B positioning of deflated expander into submuscular pocket, C closure of edge or pectoralis major and serratus anterior, D partial intraoperative inflation.

Delayed Reconstruction
Implant-based reconstruction may be delayed to facilitate completion of chemo- or radiation therapy, but subsequent tissue expansion is usually necessary. Patient marking is done preoperatively to estimate the boundaries of the ideal implant pocket that will provide the final desired result ( Fig. 4.14 ). If the contralateral breast is used as a template, any planned symmetry procedure should be accounted for in estimation of pocket size. The surgical approach is similar to that of primary reconstruction. The scar is excised and the skin flaps are elevated although not to the same extent as would be seen immediately after a mastectomy. After exposure of the inferior portion of the pectoralis major it is possible to create the submuscular pocket in the same fashion as previously described by identifying and reflecting its lateral border. Another option is to create the pocket through a pectoralis muscle-splitting incision ( Fig. 4.15 ). This has the benefit of preserving functional muscle fibers with a natural tendency to close the incision upon contraction and is less likely to disrupt the inframammary fold. The muscle fibers are oriented perpendicular to the skin incision, providing more durable coverage in the event of skin necrosis, but more extensive dissection of the skin flaps is required. Because the skin flaps are functionally delayed by the prior mastectomy, it is less critical to achieve complete lateral muscular coverage. It is usually not necessary to elevate the anterior rectus fascia, serratus anterior muscle, or pectoralis minor muscle to maintain satisfactory coverage of the expander. The same landmarks are utilized in dissecting the pocket for delayed reconstruction as are used in immediate reconstruction in terms of the location of the IMF in relation to the underlying ribs. Accurate pocket dissection is equally important here to reduce the risk of malposition and malrotation. Primary closure of the muscle splitting incision is performed and expansion under direct visualization is performed to assess tension. Despite loss of skin domain in the setting of delayed reconstruction, it can be combined successfully with immediate reconstruction for a reasonably symmetric result ( Fig. 4.16 ).

Fig. 4.14 Preoperative markings for delayed first stage bilateral breast reconstruction. With the exception of the inframammary fold placement, the planned pocket dissections outlined are not based on any remaining breast but a goal volume and a base diameter appropriate for the patient’s chest diameter and habitus.

Fig. 4.15 Use of muscle-splitting incision to access implant pocket in delayed reconstruction. The superior (small arrow) and inferior (large arrow) edges of the pectoralis major are retracted.

Fig. 4.16 Second stage result shown A preoperatively, and B-D following delayed reconstruction of right modified radical mastectomy and immediate reconstruction of left prophylactic mastectomy.

Drain Management
Drains are typically placed after immediate reconstruction, especially after axillary dissection, but rarely in delayed or second stage reconstruction. Prior to skin closure, a closed bulb suction drain is placed over the pectoralis muscle so that it is not in contact with the implant. If dermal matrix is used, often a well-tunneled drain placed inside the implant pocket may be advisable due to reports of increased drainage volumes 18 ( Fig. 4.12 ). Drains are typically removed when drainage is less than 30 ml over a 24-hour period, with many surgeons removing drains at 7–14 days irrespective of output. Any reaccumulation of fluid can be removed postoperatively during the expansion process by aspirations over the area of the fill port. Patients should not get the drain sites wet and should sponge bath rather than shower. Good patient education and meticulous care is essential to prevent an ascending infection originating at the drain site. A first-generation cephalosporin or other empiric coverage for skin organisms is administered for 7–10 days.

Expansion
The tissue expansion process may begin intraoperatively with 60–1200 cc, or more if dermal matrix is used. Outpatient expansion begins at 10–14 days postoperatively with each fill ranging from 60 to 120 cc ( Fig. 4.17 ). The magnetic port finder is used to locate the integrated valve and a 21-gauge needle attached to IV tubing is used to transfix the valve. Early in the expansion process, the interposed soft tissue may be thick and a long needle length (5 cm or greater) is necessary. As more expansion is achieved, the soft tissue thins considerably and a shorter butterfly needle is suitable. Tissue expansion results in temporary ischemia and inflammation that is minimized with smaller, more frequent fills. Expansion is repeated at 1 to 4 week intervals and often the patient will determine the rate of expansion, as there is some discomfort with each fill.

Fig. 4.17 Record of intraoperative and postoperative expansion.
We generally add volume until the patient is satisfied with the size and do not limit them or encourage them to the complete recommended expander fill volume. One method of determining this in unilateral reconstructions with planned mastopexy is to see if the expanded breast matches the volume of the contralateral breast when wearing a bra. We often make note of this volume if overexpansion is planned. The practice of overexpansion at 110–120% of the patient’s desired size is intended to create a more natural appearing ptosis resulting from an implant smaller than the expanded pocket. This rationale may be based on the high prior incidence of implant contracture. With a lower rate of capsular contracture in modern implants, excess overexpansion may also contribute to a loss of implant pocket dimensions and orientation. Expansion to within 10% of the goal volume is likely all that is necessary with current implants, especially if capsulotomy will be tolerated by the inferior pocket skin and soft tissue. Overexpansion is both more necessary and more difficult in previously irradiated patients.


Adjuvant therapy and tissue expansion
Chemotherapy often coincides with the tissue expansion process and is no contraindication to continued expansion. We have not had significant concerns continuing the expansion between cycles on non-chemotherapy weeks. It is important to make sure the patient has an adequate absolute neutrophil count.
Radiation therapy is associated with an increased risk of infection, contracture and wound complications when combined with prosthetic implants 19 and ongoing expansion places considerable risk of dehiscence on an irradiated incision. Ideally, tissue expansion should proceed to completion before initiation of radiation therapy. In our center, radiation therapy typically begins 6–8 weeks after mastectomy, allowing adequate time for full expansion.

Second Stage Reconstruction

Timing of second stage reconstruction
Generally, second-stage reconstruction is anticipated 6 months after the mastectomy. The process of tissue expansion, usually taking 2–3 months, results in inflammation that subsides with time. Patience in this process allows for a more pliable capsule that requires less capsular modification. Additionally, recipients of chemotherapy should have their second stage delayed for 2 months after their final treatment. In those patients who have been irradiated, the second stage may be delayed 1 month for each week of radiation therapy, or 6 months in most cases.

Preoperative markings and implant selection
Ideally, the position of the permanent implant should be no different from that of the tissue expander, and little or no modification is required, but this is rarely the situation. Most patients benefit from a minor revision of the pocket. In the event of expander migration or rotation, areas of capsulotomy or capsulorraphy are marked ( Fig. 4.18 ). A superomedial capsulotomy to enhance cleavage and lateral capsulorraphy to medialize the pocket in the event of lateral migration are typical adjustments. The base diameter of the breast is again confirmed and is a primary deciding factor in choice of permanent implants to have in the operating room. It is important to realize that the tissue expander comprises approximately 65–100 cc of volume and this should be factored in the permanent implant volume selection.

Fig. 4.18 Second stage marking: Preoperative marking in expanded patient prior to permanent implant placement. Capsulotomies are planned to provide superomedial fullness. The inframammary folds are marked, noting a lower fold on the right.
The choice of saline or silicone implants is left to the patient. Saline implants may offer greater projection in the larger patient, while the thin patient likely will prefer the surface camouflage and feel of silicone-filled implants. With respect to adverse events, we use the product information data provided by the Food and Drug Administration (FDA) on saline and gel implants to educate the patient regarding risks with emphasis on rupture, Baker grade III/IV contracture and overall reoperation ( Table 4.2 ). 20 In preoperative counseling we quote a 1% per year per breast reoperation rate for contracture, based on the Mentor CPG MemoryGel study that showed 5.2% rate of Baker grade III/IV contractures at 2 years in 251 primary reconstruction patients. 21 For those patients that use a silicone implant, the FDA recommendation of 3 year post-implant magnetic resonance imaging (MRI) with follow up MRI every 2 years is explained to the patient, but we candidly recognize the clinical and practical limitations and controversy of using MRI as a screening tool for asymptomatic implant reconstructions. 22 In absence of MRI screening, yearly follow up with clinical exam should be sufficient and may be the best clinical practice.

Table 4.2 Comparison of 3-year cumulative first occurrence Kaplan-Meier adverse event risk rates a by implant type
The issue regarding the choice of textured versus smooth implants warrants mention. Although once believed to reduce the incidence of capsular contracture, textured round implants have been shown to have no better outcomes than smooth devices in this respect, and are regarded by many to have an increased rate of palpability, rupture, visible wrinkling, and lack of dynamic motion. 23 Form-stable textured implants have been used internationally and are currently under evaluation in the United States. Although these devices offer the theoretic advantage of a more realistic shape, the textured surface necessary to anchor the implant in position may present aesthetic issues. Also, the form-stable design may be unforgiving of slight degrees of malposition, and the importance of precise pocket dissection to avoid rotation should be emphasized.

Surgical approach
The second stage approach begins by excising the mastectomy scars that have often widened after the expansion process. If an identifiable muscle layer is present, the muscle-splitting approach described previously may be used. Often the muscle is attenuated and difficult to identify as a layer distinct from the capsule. In this case the muscle and capsule are divided as far inferiorly as possible by raising the inferior mastectomy skin flap. This results in optimal coverage by ‘staggering’ the skin and muscle/capsule layers ( Fig. 4.19 ). A secure multi-layer closure is particularly critical in patients with poor healing capabilities following radiation. The expander port is transfixed and partially deflated to allow intact removal without excessive stretch or tearing of the capsulotomy. This is an important precaution because while the expander and permanent implant fill volumes may be equivalent, the expander shell is somewhat bulkier with stiff components, such as the integrated port. The expander shell also adds approximately 65–100 cc to the fill volume, in comparison to the negligible volume of the permanent implant silicone shell. Actual total expansion volume can be confirmed by volume displacement in saline, in addition to what was aspirated from the expander to facilitate its removal.

Fig. 4.19 Layered technique of entering capsule for second stage reconstruction. The muscle layer incision is a muscle-splitting incision that is directed perpendicular to the skin incision and is placed as inferior as possible.
Complete capsulectomy at the time of second stage reconstruction is not recommended because of the loss of soft tissue coverage, possible injury to the blood supply of the overlying skin and increased inflammation. Rather, directed capsulotomy and/or capsulorrhaphy are used to provide optimal positioning and shaping. In general, a circumferential capsulotomy into the subcutaneous fat is performed around the base of the pocket. A ‘zigzag’ inferior pole capsulotomy will allow for lower pole distension and overhang ( Fig. 4.20 ). When performing inferior capsulotomies, it is necessary to divide any remaining pectoralis muscle fibers to gain the necessary relaxation. When acellular dermal matrix has been used to provide lower pole coverage, it has functionally become a part of the lower pole capsule. It should be incised similarly if needed to provide the desired contour of the lower pole. In those patients with extremely thin lower pole soft tissue coverage, care should be taken to avoid dermal injury or ‘button-hole’ perforation. Upper pole capsulotomies are performed sparingly to prevent bulging in the upper breast. Additional directed capsulotomies are performed as needed to allow for expansion of the pocket to achieve the desired contour. Conversely, capsulorrhaphy sutures of 2-0 silk may be necessary to correct areas of overexpansion and meet the needs of the desired permanent implant dimension. Accurate pocket positioning is necessary for optimal results. Control of the pocket with the initial expander placement will obviate the need for significant pocket manipulation at the second stage.

Fig. 4.20 A Schematic of capsulotomy with ‘zigzag’ pattern along inferior pole to allow natural-appearing ptosis; upper pole capsulotomy is represented, if needed. B Preoperative capsulotomy markings at second stage reconstruction.

Re-establishing the inframammary fold
Ideally the inframammary fold is preserved following the original mastectomy and, if not, it is re-established at the time of tissue expander placement. A fold that appears too high may be a result of insufficient inferior pocket dissection and inferior capsulotomy will address this. If the fold has been lowered by expander migration, it should be re-established internally. From within the pocket, the undersurface of the mastectomy flap is sutured internally to the expander capsule at the bottom of the fifth rib medially, the middle of the sixth rib at the meridian and the top of the seventh rib laterally ( Fig. 4.10 ). These static landmarks can be located by identifying the second rib at the manubriosternal joint (Angle of Louis). Four to five sutures are needed; braided sutures such as Vicryl or silk are preferred as they are softer and will be in direct contact with the prosthesis.
A range of implants should be available, although the base diameter and goal volume should be known preoperatively. We find the use of implant sizers helpful to be certain of the correct volume prior to committing to a permanent device. The recently FDA-approved limited-use silicone sizers are particularly helpful as they feature the various base diameter and projection profiles to most closely approximate the appearance of the permanent implant. After final pocket preparation, the permanent implants are removed from their packaging and inserted ensuring correct orientation of the implant base. The muscle/capsule layer is closed with interrupted absorbable monofilament stitches and the skin is closed with a running strong absorbable stitch. If a contralateral symmetry procedure (e.g., augmentation, reduction, or mastopexy) is planned, it is important to finalize the implant positioning first to establish the ideal breast mound position against which to match the balancing procedure.

Postoperative Care
Patients are placed on a first generation cephalosporin for 5 days after second stage reconstruction. Drains should not be needed unless extensive capsular modifications have been made. The wound is checked at 1–2 weeks postoperatively. Implant massage has been employed in the past to discourage capsular contracture but is likely less important as rates of capsular contracture decline in incidence and severity. Massage may promote increased discomfort and seroma formation and may alter the pocket configuration created intraoperatively. A soft underwire bra is comfortably fitted and maintained for 3 weeks postoperatively to support the internal suturing. Nipple reconstruction, if the overlying soft tissue is adequate, is planned for 2 months after second stage reconstruction when the mastectomy scar has matured and is less of a barrier to local flap perfusion. Tattooing may be delayed approximately 6 weeks after nipple reconstruction.

Complications and Pitfalls

Asymmetric breasts
Unilateral reconstruction or separately timed reconstruction procedures may result in significant differences in size or ptosis that can be corrected at the time of second stage reconstruction. A contralateral breast reduction, mastopexy ( Fig. 4.21 ), or augmentation mastopexy may be required and patients should be informed of the likelihood of future revisions to maintain symmetry. Achieving symmetry with respect to the inframammary fold, nipple position and overall breast size is challenging, particularly in those patients requiring contralateral augmentation mammaplasty. One of the more difficult scenarios is the expanded breast that has received radiation therapy and has a somewhat constricted envelope ( Fig. 4.4 ). This may also be a result of insufficient pocket dissection inferiorly and can be addressed by inferior capsulotomy with avoidance of dissection below the internal rib landmarks.

Fig. 4.21 Left-sided mastectomy shown A preoperatively and B after second stage reconstruction with contralateral mastopexy for symmetry.

Loss of pocket control
The implant pocket may be made too large due to excessive tissue expansion or pocket dissection at either first or second stage reconstructive procedures ( Fig. 4.22 ). This should be avoided by adherence to dissection within the breast diameter when performing mediolateral dissection and preservation of the inframammary fold with its re-establishment at the static rib landmarks if necessary. Capsulorraphy may be needed for medial or lateral support.

Fig. 4.22 Poorly positioned permanent implants due to pocket size mismatch.

Implant exposure
In immediate reconstruction, tension and mastectomy flap overdissection are associated with skin flap necrosis at the incision. One of the benefits to complete submuscular placement is that local wound care is all that is necessary provided skin necrosis is minor and healthy muscle is beneath ( Fig. 4.23 ). When radiation over an expanded implant is poorly titrated, full thickness skin loss remains a possibility. In severe cases, the expander may need to be removed ( Fig. 4.24 ). When the underlying device is a tissue expander, continued expansion to the desired volume or to match a contralateral implant may not be possible and volume must be removed to allow healing subsequent to any necessary debridement. In the event of permanent implant exposure, debridement and immediate wound closure is necessary. If enough skin is lost so that primary closure is not possible, the implant should be removed and additional skin is transferred by autologous reconstruction ( Fig. 4.25 ).

Fig. 4.23 Minor skin necrosis in this patient after first stage reconstruction. This was managed with local wound care without need for implant removal or autologous tissue transfer.

Fig. 4.24 Skin necrosis during tissue expansion in a breast with prior radiation. Debridement and autologous tissue transfer were required for salvage.

Fig. 4.25 Implant exposure after second stage reconstruction in a patient who had received radiation to the left breast. The left implant was removed and a latissimus dorsi flap was performed to replace irradiated skin on the breast mound.

Contracture and visible wrinkling
Capsular contracture is generally regarded to be a more frequent complication in reconstructive than in primary augmentation mammaplasty, presumably because of the significantly reduced soft tissue coverage likely increasing the sensitivity for detection if not the primary incidence. Currently patients are advised that they will likely require a reoperation for contracture at 15 years with an incidence of 1% per breast per year. 21 Visible wrinkling may occur with silicone as well as saline implants ( Fig. 4.26 ), but can be best avoided by adequate submuscular implant coverage.

Fig. 4.26 Visible wrinkling in a submuscularly placed silicone permanent implant.

Implant infection
Implant infection ( Fig. 4.27 ) is quoted at 0.2–7% in recent literature. 24 It is presumably higher than in primary augmentation mammaplasty because of the decreased soft tissue coverage, longer operating times, and the effects of chemoradiation therapy on the host defense system. Implant removal with drainage and reoperation in 6 months is recommended for severe implant infection. There are reports of implant salvage in circumstances where no frank pus is identified in the implant pocket, and copious antibiotic irrigation and prolonged postoperative targeted antibiotic therapy is used. 25 , 26 The presence of cellulitis near the incision does not necessarily mandate operative exploration, and a trial course of antibiotics is reasonable. Antibiotics cannot be expected to resolve an infected prosthesis or periprosthetic fluid, however. In our institution with a 30% incidence of methicillin-resistant Staphylococcus aureus (MRSA), empiric antibiotic therapy consists of prolonged (2–6 weeks) of intravenous vancomycin therapy with the addition of a penicillin for greater bactericidal effect in sensitive organisms. Ultimately, empiric therapy should be tailored according to the prevalence of methicillin resistance at individual institutions. Intraoperative cultures or periprosthetic fluid withdrawn during expansion in the clinic provide a basis for any directed therapy. A trial of implant salvage with antibiotic therapy can be exhausting for the clinician and patient alike, requiring many clinical visits for surveillance of the breast as well as home intravenous antibiotic therapy. While there is occasional success, efforts at salvaging an implant may result in a tremendous expense of time and resources only to result in explantation. Establishing an ‘end point’ at the initiation of therapy, where the implant will be removed if certain goals are not achieved is highly recommended for the sake of everyone involved.

Fig. 4.27 Clinical infection following immediate second stage reconstruction. Note the breast reduction (Wise-pattern) mastectomy incision.

Conclusions
The refinement of surgical technique, implant technology and a better understanding of candidate selection are improving the result of the implant-reconstructed breast. The team approach to implant-based reconstruction is evident as results improve when reconstructive priorities are observed whenever possible. Of primary importance is the understanding of the concept of pocket control . Appropriate pocket positioning must be maintained from the time of mastectomy and expander placement to the placement of the final implant. The improved contour and feel of recently FDA-approved silicone gel implants with cohesive gels, as well as innovative biologic substitutes such as dermal matrix to improve implant coverage are providing a more realistic reconstruction even in patients with more aggressive surgical resections. Autologous reconstruction may be considered the gold standard of breast reconstruction with respect to soft tissue characteristics, and is often necessary in the setting of radiation injury, where the limitations of implant reconstruction with respect to wound healing, limited expansion and late contracture must be realized. Implant-based reconstruction, however, should not be considered a second line of therapy, and in certain characteristic patients might represent the best option for reconstruction. Indeed, many patients insist upon implant-based reconstruction to avoid a donor defect, limit recovery time and potential morbidity, and to exercise choice in the size of the reconstructed breast. With its increasingly patient-driven popularity, it is important for the reconstructive surgeon to understand the best application of this technique to achieve ideal results. The ultimate goal of achieving balance and symmetry and of reducing the patient’s awareness of the mastectomy defect is no less important in expander reconstruction and no less achievable provided there is a meticulous and well-planned approach.

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9 Smigal C, Jemal A, Ward E, et al. Trends in breast cancer by race and ethnicity: update 2006. CA Cancer J Clin . 2006;56(3):168-183.
10 Harris JR, Halpin-Murphy P, McNeese M, Mendenhall NP, Morrow M, Robert NJ. Consensus statement on postmastectomy radiation therapy. Int J Radiat Oncol Biol Phys . 1999;15:989.
11 Goldhirsch A, Wood WC, Gelber RD, et al. Progress and promise: highlights of the international expert consensus on the primary therapy of early breast cancer 2007. Ann Oncol . 2007;18(7):1133-1144.
12 Kronowitz SJ, Hunt KK, Kuerer HM, et al. Delayed immediate breast reconstruction. Plast Reconstr Surg . 2004;113(6):1617-1628.
13 Spear SL, Onyewu C. Staged breast reconstruction with saline-filled implants in the irradiated breast: recent trends and therapeutic implications. Plast Reconstr Surg . 2000;105(3):930-945.
14 Muntan CD, Sundine MJ, Rink RD, Acland RD. Inframammary fold: a histologic reappraisal. Plast Reconstr Surg . 2000;105(2):549-556.
15 Bayati S, Seckel BR. Inframammary crease ligament. Plast Reconstr Surg . 1995;95(3):501-508.
16 Breuing KH, Colwell AS. Inferolateral AlloDerm hammock for implant coverage in breast reconstruction. Ann Plast Surg . 2007;59(3):250-255.
17 Adams WP, 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.
18 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.
19 Evans GR, Schusterman MA, Kroll SS. Reconstruction and the radiated breast: is there a role for implants. Plast Reconstr Surg . 1995;96:1111.
20 Physician product labeling for Mentor™ saline and silicone implants. http://www.fda.gov/cdrh/breastimplants/labeling.html . (updated November 17, 2006, accessed May 23, 2008)
21 Cunningham B. The mentor study on contour profile gel silicone memorygel breast implants. Plast Reconstr Surg . December 2007;120(7 Supplement 1):33S-39S.
22 McCarthy CM, Pusic AL, Kerrigan CL. Silicone breast implants and magnetic resonance imaging screening for rupture: do US Food and Drug Administration Recommendations reflect an evidence-based practice approach to patient care? Plast Reconstr Surg . April 2008;121(4):1127-1134.
23 Handel N, Jensen JA, Black Q, Waisman JR, Silverstein MJ. The fate of breast implants: a critical analysis of complications and outcomes. Plast Reconstr Surg . 1995;96(7):1521-1533.
24 Spear SL, Howard MA, Boehmler JH, Ducic I, Low M, Abbruzzesse MR. The infected or exposed breast implant: management and treatment strategies. Plast Reconstr Surg . 2004;113(6):1634-1644.
25 Yii NW, Khoo CT. Salvage of infected expander prostheses in breast reconstruction. Plast Reconstr Surg . 2003;111(3):1087-1095.
26 Chun JK, Schulman MR. The infected breast prosthesis after mastectomy reconstruction: successful salvage of nine implants in eight consecutive patients. Plast Reconstr Surg . 2007;120(3):581-589.
CHAPTER 5 Latissimus Dorsi Flap Breast Reconstruction

James H. Boehmler, Charles E. Butler

Key Points
Latissimus dorsi (LD) myocutaneous flaps, first described by Tassini, 1 have been used in various reconstructive procedures for decades. In the setting of immediate or delayed breast reconstruction 2 LD flaps have several characteristics that can make them excellent options.
1. In part because of their vascular supply from the thoracodorsal vessels, LD flaps have reliable survival.
2. When used as pedicled flaps, LD flaps eliminate the need for microsurgery.
3. LD flaps can be customized, with variations that include full-muscle myocutaneous, split-muscle myocutaneous, muscle-only, and skin-and-fat-only flaps.
4. LD flaps are viable options for patients who have undergone radiotherapy.
5. LD flaps are good options for patients who are not candidates for abdominal flap-based reconstruction.
6. LD flaps can be used for chest wall coverage or as salvage therapy after a previous breast reconstruction has failed.

Patient Selection
Patients who have undergone radiotherapy can also benefit from the use of an LD flap in breast reconstruction. In these patients, the skin island of an LD flap can replace the constricted, irradiated skin of the breast; and the muscle of an LD flap can cover an implant, thereby decreasing the risk of capsular contracture and implant infection. 3 - 5 Patients who are at an increased risk of mastectomy skin flap necrosis, such as tobacco smokers, may also benefit from an LD flap, which can provide additional muscle coverage of a tissue expander or implant and a robust skin paddle. Furthermore, focal skin and soft tissue defects caused by previous partial mastectomy and radiotherapy that cannot be corrected with implants alone often can be repaired with an LD flap. 6 , 7

Indications
Every patient who desires breast reconstruction must undergo a thorough history and examination to help determine which reconstruction technique should be used. Specific details should be obtained regarding previous surgery to the abdomen, chest and axilla, previous history of radiation, and the patient’s preference for reconstruction method and willingness to undergo major surgery. Many reconstructive surgeons prefer abdominal flaps such as transverse rectus abdominis myocutaneous, deep inferior epigastric, or superficial inferior epigastric artery flaps for autologous tissue-based breast reconstruction. However, patients may not desire or have adequate tissue for an abdominal flap harvest. Furthermore, previous abdominal surgeries such as abdominoplasty, laparotomy, or liposuction may reduce the reliability of an abdominal flap or preclude abdominal flap-based breast reconstruction. In such cases, an LD flap offers a reliable alternative to an abdominal flap. In addition, if an implant is going to be included in the reconstruction, using an LD flap over the implant can improve the contour of the reconstructed breast, 8 particularly in thin patients, in whom implant-based reconstructions tend to have less esthetic results ( Table 5.1 ).

Table 5.1 Advantages and disadvantages of latissimus dorsi flap-based breast reconstruction compared to expander/implant-based reconstruction, and abdominal flap-based reconstruction

Operative Technique

Preoperative evaluation and markings
While the patient is awake and standing or sitting upright, the reconstructive surgeon uses a provocative maneuver to evaluate the contractility of the LD muscle ( Fig. 5.1 ). The patient adducts her arm; as the LD muscle contracts, the reconstructive surgeon palpates and marks the muscle’s anterior border. The tip of the scapula, posterior iliac crest, and midline are also marked to further delineate the muscle’s topography ( Fig. 5.2 ). If the patient has a history of lymph node sampling and the LD muscle does not contract when the patient adducts her arm, the thoracodorsal nerve may be injured or transected, and the adjacent thoracodorsal vascular pedicle may also be injured.

Fig. 5.1 Forced adduction of the shoulder enables palpation and marking of the latissimus dorsi muscle’s anterior border.

Fig. 5.2 Topography of the latissimus dorsi muscle. Key landmarks include the tip of the scapula, the iliac crest, the posterior midline, and the muscle’s anterior border.
If the breast reconstruction requires a skin island, the reconstructive surgeon can design and transpose a template of the size, shape, orientation, and location of the anticipated skin island onto the skin that overlies the LD muscle. The location of the anticipated skin paddle is critical in determining the relative location of the muscle and skin island in the reconstructed breast during inset. The template should also reflect the 90–110° of rotation the flap will undergo from the patient’s back to her chest during the reconstruction ( Fig. 5.3 ). Attaching the template to a towel and using the axilla as a pivot point can help the surgeon confirm the flap will reach its intended final location. To ensure that the flap donor site can be closed primarily, the reconstructive surgeon should pinch together the anticipated incision lines. In most patients, primary closure without significant tension can be performed if the skin island is less than 10 cm wide. If a skin island is not required for breast reconstruction, the reconstructive surgeon can harvest the LD flap through a small incision in the posterior axilla and use endoscopy to limit the number of incisions made on the patient’s back.

Fig. 5.3 Preoperative markings for bilateral immediate breast reconstruction with latissimus dorsi myocutaneous flaps and tissue expanders after skin-sparing mastectomy. The skin paddle is designed to rotate easily into the mastectomy defect, taking into consideration that 90–110 degrees of rotation will occur.

Positioning
For unilateral breast reconstruction, an LD flap is commonly harvested and the donor site closed while the patient is in a lateral decubitus position. The patient who undergoes immediate breast reconstruction is usually in a supine position during mastectomy, and the reconstructive surgeon can confirm the integrity of the thoracodorsal vascular pedicle and start the anterior dissection of the LD flap from this approach; the patient can then be placed in the lateral decubitus position for flap harvest and donor site closure. Following donor site closure, the patient is then repositioned in the supine position for implant placement, flap inset, and breast symmetry and shape examination.
For bilateral breast reconstruction, LD flaps can be efficiently harvested while the patient is in the prone position; however, care must be taken to avoid direct pressure on the mastectomy skin flaps while the patient is prone. Judicious use of padding can prevent breast skin flap compression.

Flap elevation

Full-muscle myocutaneous flap elevation
If the patient has undergone axillary lymph node sampling, the reconstructive surgeon should identify the vascular pedicle anteriorly though the mastectomy defect while the patient is supine. Once the pedicle has been identified and preserved, the reconstructive surgeon should mobilize the flap as much as possible from the surrounding soft tissues ( Box 5.1 ).

Box 5.1 Surgical steps in latissimus dorsi (LD) flap harvest

• Create a breast pocket in the chest and a superior tunnel into the axilla
• Identify and confirm the patency of the thoracodorsal pedicle from an anterior approach
• Dissect the thoracodorsal pedicle from surrounding soft tissue using an anterior approach
• Confirm skin paddle markings and simulate transposition
• Incise skin and bevel away from incision line through subcutaneous fat
• If harvesting an extended LD flap, elevate the flap just deep to Scarpa’s fascia
• If harvesting a standard LD flap, elevate the flap at the level of the muscle fascia
• Complete the superficial dissection up to the borders of the LD muscle
• Identify the anterior border of the LD flap superiorly and separate the LD muscle from the serratus anterior and external oblique muscles
• Elevate the LD muscle off the chest wall from the muscle’s anterior edge posteriorly
• Ligate all lumbar perforating vessels
• Divide the distal muscle from its inferior border
• Divide the medial muscle from the paraspinal fascia, taking care not to injure the fascia
• Separate the LD muscle superiorly from the trapezius and teres major muscles
• Identify the thoracodorsal pedicle on the deep surface of the LD muscle
• If necessary, circumferentially free the LD muscle proximal to the thoracodorsal pedicle and divide the insertion
• Identify and divide the thoracodorsal nerve
• Transpose the LD flap to the chest and anchor a portion of muscle in the anterior axilla to prevent traction injury to the vascular pedicle
• Place drains and close the donor site with quilting sutures
• Place the patient in the supine position
• Orient the LD muscle and skin paddle on the chest wall
• Suture the superior and medial aspects of the LD muscle into the edges of the breast pocket
• Place the expander or implant under the LD muscle
• Suture the remaining LD muscle around the expander or implant to provide complete muscle coverage
• Place drains in the breast pocket and irrigate with antibiotic solution
• Suture the skin paddle in place
• Apply sterile dressings
Figure 5.4 shows the dissection planes for the standard myocutaneous and extended myocutaneous LD flaps. To facilitate a smooth transition between the mastectomy skin and the skin island inset, the reconstructive surgeon incises the skin island at a slight outward angle through the subcutaneous fat. Sufficient subcutaneous fat is preserved at the edge of the donor site to prevent a depressed scar and/or fasciodesis. When harvesting an extended LD flap, the reconstructive surgeon creates a plane just deep to Scarpa’s fascia; the flap’s volume is increased by including a rim of deep fat below Scarpa’s fascia. 9 , 10 In contrast, when harvesting a standard LD myocutaneous flap, the reconstructive surgeon dissects directly down to the investing muscle fascia. Dissection over the LD muscle is continued to its peripheral margins. The anterior margin of the LD muscle is identified and separated from the serratus anterior muscle. Because the serratus and external oblique muscles coalesce with the LD muscle inferiorly and posteriorly, it is easier to identify the anterior border of the LD muscle cephalad and dissect the muscle from the chest wall caudally. Once the LD muscle’s anterior border is freed, the plane deep to the LD muscle is developed caudally to avoid injuring the vascular pedicle. The large lumbar and intercostal perforating vessels entering the posterior surface of the LD muscle are isolated and ligated.

Fig. 5.4 Dissection planes for the standard myocutaneous and extended myocutaneous latissimus dorsi flaps. The standard flap dissection plane bevels slightly away from the skin incision toward the deep investing fascia of the latissimus dorsi muscle. The extended flap dissection proceeds until the Scarpa’s fascia is identified; the flap is raised just deep to this fascia, leaving deep fat attached to the muscle for added soft-tissue bulk.
Using electrocautery or electrosurgical bipolar scissors, the inferior border of the LD muscle is divided. In a cephalad direction, the muscle is released from its medial fascial attachments and elevated off the chest wall. The underlying paraspinous fascia is not violated while the muscle is being detached from the posterior midline. The inferior lateral border of the overlying trapezius muscle is identified and preserved as medial dissection of the LD muscle progresses cephalad. Once the medial aspect of the LD muscle is freed, the muscle’s superior edge is separated from the trapezius muscle medially and from the teres major muscle laterally. If a deep fat pad is to be included with the LD flap, the teres major muscle is not raised with the flap.
Dissection of the LD muscle proceeds cephalad toward the neurovascular bundle, which enters the deep surface of the LD muscle 8–10 cm inferior to the axillary line and 2–3 cm lateral to the muscle’s anterior border. The anterior branch of the bundle that supplies the serratus anterior muscle group is identified and preserved unless it prevents adequate flap rotation. The pedicle dissected is typically 8–10 cm long, but complete dissection of the pedicle often is not necessary to allow for an adequate arc of rotation; therefore, pedicle dissection should proceed only to a point that enables adequate flap rotation without tension on the vascular pedicle ( Fig. 5.5 ).

Fig. 5.5 Elevated bilateral myocutaneous latissimus dorsi flaps, prior to inset into the mastectomy defects.
The tendinous insertion into the humerus is exposed by dissecting cephalad and circumferentially near the LD insertion. The reconstructive surgeon can divide the insertion to increase the arc of rotation and reduce any axillary bulging that the rotated proximal muscle may cause. 11 If the insertion is completely divided, care must be taken to prevent traction injury to the vascular pedicle.
The thoracodorsal nerve is identified, isolated, and divided at the surgeon’s discretion. Dividing the thoracodorsal nerve helps prevent muscle contraction when the patient attempts arm adduction and extension. If the nerve remains undivided, muscle contraction may resolve as the muscle atrophies; however, continued muscle contraction may annoy the patient, and secondary division of the nerve is difficult.
Two large, closed-suction drains are placed in a dependent location in the donor site. Drains are typically left in place for 1–3 weeks and removed once the output decreases to fewer than 30 ml of drainage per 24 hours. Placing quilting or progressive tension sutures from the donor site skin flaps to the chest wall may decrease the amount of drainage and incidence of seroma formation by closing off the dead space left by flap dissection and preventing shear forces. 13 Primary skin closure can be performed without significant tension in almost all cases in which the skin paddle is less than 10 cm wide ( Fig. 5.6 ).

Fig. 5.6 Primary closure of the donor site usually can be achieved when the skin paddle is less than 10 cm wide. Pinching together the anticipated incision lines can help determine the amount of skin that can be removed.

Split LD flap elevation
A split (segmental) LD flap can be useful in reconstructions for partial mastectomy defects. The anatomical basis for splitting the LD muscle is well established. 14 , 15 The skin paddle is marked as in Figure 5.3 and incised, and the anterior border of the LD muscle is identified. The lateral descending branch of the thoracodorsal pedicle is identified on the undersurface of the muscle, and intramuscular dissection is performed medial to the lateral vascular pedicle. The remaining muscle’s vascular pedicle is sacrificed to allow for flap rotation; however, the muscle’s nerve branches are preserved to provide motor function.

Thoracodorsal artery perforator flap elevation
Like a split LD flap, a thoracodorsal artery perforator flap 15 - 18 can be used to repair partial breast defects without compromising function of the remaining LD muscle. Preoperative ultrasonography or computed tomography angiography is usually used to help identify perforators on which to base the flap. The LD flap can be based on a row of perforators approximately 2 cm from the anterior margin of the flap just caudal to its scapular tip. Once the perforators are identified, a skin paddle is designed around the selected perforator. The skin island should be incised on only one side of the flap, preferably its anterior portion. Once the perforator is identified, the remainder of the skin island is elevated, and intramuscular dissection proceeds to the point at which the perforator meets with the thoracodorsal vascular pedicle. The LD muscle’s nerve branches are dissected from the vascular pedicle and preserved. All other vascular branches are divided until adequate pedicle length is attained. Great care must be taken to prevent traction injury to the perforators and vascular pedicle.

Flap insetting
A subcutaneous tunnel between the LD muscle donor site and the mastectomy defect should be created if one is not already present ( Fig. 5.7 ). This tunnel is made as high in the axilla as possible while still allowing adequate flap insetting to help recreate the breast’s anterior axillary fold and prevent excessive tissue bulk in the axilla. When an implant is included, the reconstructive surgeon uses interrupted sutures to attach the edge of the LD muscle to the lateral chest wall and prevent migration of the implant into the axilla or donor site ( Fig. 5.8 ). Securing the muscle to the chest wall laterally also helps prevent traction on the vascular pedicle, particularly if the muscle insertion has been transected.

Fig. 5.7 The subcutaneous tunnel for latissimus dorsi flap rotation should be made high in the axilla to better define the lateral border of the breast pocket and prevent the flap and/or implant from migrating into the axilla.

Fig. 5.8 The latissimus dorsi flap is brought to the chest through a high subcutaneous tunnel in the axilla. The proximal muscle is anchored with stitches to the lateral breast pocket to prevent traction injury to the thoracodorsal vascular pedicle.

Immediate reconstruction
The pectoralis major muscle is often maintained on the chest wall following mastectomy, and an implant can be placed above or beneath it. We prefer to elevate the pectoralis major muscle and place the implant beneath it to provide superior implant coverage and improve the contour transition from the chest wall to the implant along the superior pole of the reconstructed breast. In this case, the LD muscle is sutured ventral to the elevated pectoralis major muscle in a ‘pants-over-vest’ fashion ( Fig. 5.9 ). The borders of the LD muscle are secured to the chest wall within the mastectomy pocket. Inserting the transected LD muscle into the pectoralis major tendon can improve the axillary contour of the reconstructed breast. As much of the flap inset as possible should be performed before placement of the expander or implant. Carefully insetting the LD muscle is important to correctly position the reconstructed breast and maximize symmetry between the reconstructed and contralateral breast. The LD flap inset must also allow the skin island to be appropriately located on the reconstructed breast to provide skin coverage within the mastectomy flap skin edges. If the LD flap is not large enough to fully cover the implant, the LD muscle can be sutured to the inferior border of the elevated pectoralis major muscle to create adequate submuscular space for the implant. Closed-suction drains are placed between the subcutaneous mastectomy skin flaps and LD muscle and within the submuscular pocket. The skin edges are trimmed to their final dimensions, and the skin island is fully inset ( Fig. 5.10 ). Nipple and areola reconstruction are performed at a later stage ( Figs 5.11 and 5.12 ).

Fig. 5.9 The latissimus muscle is inset to completely cover the implant.

Fig. 5.10 The skin edges of the flap are trimmed and inset only after the mastectomy flaps are trimmed back to viable tissue.

Fig. 5.11 A A preoperative photograph of a patient about to undergo bilateral skin-sparing mastectomies and immediate breast reconstruction. B The final postoperative appearance of the patient after reconstruction with latissimus dorsi flaps and implants and subsequent nipple and areola reconstruction and tattooing.

Fig. 5.12 A A preoperative photograph of a patient about to undergo immediate unilateral breast reconstruction with a latissimus dorsi flap and implant and contralateral breast augmentation. B Preoperative markings. C The patient after subsequent nipple reconstruction. She will eventually receive tattooing to color the areola.

Delayed reconstruction
When LD flap breast reconstruction is performed in a delayed setting, including after previous expander- or implant-based reconstruction, the pectoralis major muscle can either be left with the mastectomy flap or placed back on the chest wall depending on the amount of LD muscle available and the integrity of the mastectomy skin flaps. In patients with very thin mastectomy flaps or patients who have undergone radiotherapy or use tobacco, the pectoralis major muscle should remain attached to the mastectomy flap to help reduce mastectomy skin flap necrosis. In some patients, the subpectoral space is too tight for implant placement, and the mastectomy flap may need to be freed from the pectoralis major muscle. If the pectoralis major muscle remains attached to the mastectomy flap, the LD muscle is attached to the inferior edge of the pectoralis major muscle and then to the inframammary fold. The LD flap skin island is usually inset at the re-incised mastectomy scar. If there is lower pole skin deficiency or the inframammary fold is markedly elevated, the skin paddle can be inset into an inframammary incision. To ensure that the skin island and LD muscle are correctly oriented in the reconstructed breast, the reconstructive surgeon should plan the incision and skin paddle inset position and mark the patient prior to the start of the surgery.

Pitfalls and How to Correct

Seroma
The large potential space created during LD flap harvest can contribute to donor site seroma, the most common complication of LD flap-based breast reconstruction. 5, 8, 10, 13, 19 Multiple long-term drains and quilting sutures can be used to prevent seromas. 13 If a seroma develops after all surgical drains have been removed, serial aspirations are generally the initial treatment step, and frequently, the seroma will resolve quickly. If not, a new drain can be placed; often, this treatment can be supplemented with diluted fibrin sealant injections, 20 sclerotherapy, 21 or steroid injections. 22 Using compression garments or wrapping the donor site with elastic bandages is an important adjunct to all treatment options. If the seroma persists, surgical decortication of the seroma pseudocapsule 23 can be performed with the use of quilting sutures and closed-suction drains.

Axillary node dissection
Weak or absent LD muscle function in patients who have undergone axillary node sampling is suggestive of thoracodorsal nerve and/or vascular pedicle injury; however, a functional LD muscle does not always indicate an intact vascular pedicle. Therefore, in patients who have undergone axillary node sampling, the reconstructive surgeon should confirm the patency of the pedicle before elevating the LD flap. If the thoracodorsal vessels have been injured or transected proximal to the branch to the serratus anterior muscle, an LD flap can be elevated based on this serratus branch with retrograde arterial inflow. 24 On the other hand, if the thoracodorsal and serratus branch vessels have been injured or transected, the reconstructive surgeon may choose to microsurgically repair the vessels or use a reconstructive technique that does not involve the ipsilateral LD muscle.

Vascular pedicle injury
Despite preventative measures, vascular pedicle injury can occur in LD flap breast reconstruction. Common causes include injury caused by traction and inadvertently dividing the pedicle from the flap while attempting to divide the thoracodorsal nerve. Depending on the injury, microsurgically repairing the flap vessel to the remaining thoracodorsal vessels can often be performed. If too much pedicle is sacrificed, converting to a free flap with the internal mammary arteries used as donor vessels or with the use of vein grafts to the subscapular axis vessels can be performed. If the injury is proximal to the serratus branch, the LD flap may be transferred based on retrograde flow through the serratus branch 24 to provide flap vascularity.

Postoperative Care
Sterile dressings are placed at the end of surgery. Pressure in the axilla needs to be avoided to prevent vascular compromise of the flap. An abduction pillow can be used to keep the abducted arm away from the axilla during the early postoperative period. A window in the dressing over the skin paddle should be created to enable clinical assessment of the flap’s vascularity.
The flap’s vascularity should be evaluated frequently by assessing the paddle’s temperature, appearance, and capillary refill color. Twists in the vascular pedicle, position-related tension, and/or hematoma should be corrected immediately with surgical re-exploration.
To reduce the risk of bleeding and prevent undue tension on the flap inset or vascular pedicle, patients should limit movement of the arm on the side of the reconstruction for 1–2 weeks. Thereafter, progressive range of motion exercises are initiated to help prevent shoulder stiffness. Prolonged shoulder stiffness, if it occurs, can be effectively treated with physical therapy. Patients generally regain full shoulder function and are able to resume their normal daily activities after 3 or 4 weeks. 25 , 26

Summary
LD flaps have consistent vascular anatomy and do not require microsurgery for transfer; they also provide good soft tissue coverage over implants that potentially improves the cosmesis of the reconstructed breast while decreasing the infection and capsular contracture rates associated with implant-only breast reconstruction. The LD flap’s skin paddle can be used to replace missing or deficient breast skin and enables immediate breast mound creation without the need for serial expansion of a tissue expander and subsequent placement of a permanent implant. In addition, LD flap-based breast reconstruction is an excellent option for women who are not candidates for or who do not wish to undergo abdominal flap-based breast reconstruction (Fig 12A–C). Variations of the LD flap, including the split-muscle flap and the thoracodorsal artery perforator flap, can be used to repair partial mastectomy defects with little donor site morbidity.

References

1 Maxwell GP. Iginio Tansini and the origin of the latissimus dorsi musculocutaneous flap. Plast Reconstr Surg . 1980;65:686.
2 Bostwick J, Nahai F, Wallace JG, Vasconez LO. Sixty latissimus dorsi flaps. Plast Reconstr Surg . 1979;63:31.
3 Spear SL, Boehmler JH, Taylor NS, Prada C. The role of the latissimus dorsi flap in reconstruction of the radiated breast. Plast Reconstr Surg . 2007;119:1.
4 Chang DW, Barnea Y, Robb GL. Effects of an autologous flap combined with an implant for breast reconstruction: an evaluation of 1000 consecutive reconstructions of previously irradiated breasts. Plast Reconstr Surg . 2008;122:356.
5 Pinsolle V, Grinfeder C, Mathoulin-Pelissier S, Faucher A. Complications analysis of 266 immediate breast reconstruction. J Plast Reconstr. Aesth Surg . 2006;59:1017.
6 Clough KB, Kroll SS, Audretsch W. An approach to the repair of partial mastectomy defects. Plast Reconstr Surg . 1999;104:409.
7 Kronowitz SJ, Feledy JA, Hunt KK, et al. Determining the optimal approach to breast reconstruction after partial mastectomy. Plast Reconstr Surg . 2006;117:1.
8 Moore TS, Farrell LD. Latissimus dorsi myocutaneous flap for breast reconstruction: long-term results. Plast Reconstr Surg . 1992;89:666.
9 Hofkin JAB, Silfverskiold KL. Breast reconstruction without an implant: results and complications using an extended latissimus dorsi flap. Plast Reconstr Surg . 1987;79:58.
10 Chang DW, Youssef A, Cha S, Reece GP. Autologous breast reconstruction with the extended latissimus dorsi flap. Plast Reconstr Surg . 2002;110:751.
11 Gerber B, Krause A, Reimer T, Muller H, Friese K. Breast reconstruction with latissimus dorsi flap: improved aesthetic results after transection of its humeral insertion. Plast Reconstr Surg . 1999;103:1876.
12 Akhtar S. Our early experience in the use of tissue glue to reduce the incidence of seroma formation from the latissimus dorsi flap donor site. Plast Reconstr Surg . 2005;116:347.
13 Rios JL, Pollock T, Adams WP. Progressive tension sutures to prevent seroma formation after latissimus dorsi harvest. Plast Reconstr Surg . 2003;112:1779.
14 Tobin GT, Schusterman M, Peterson GH, Nichols G, Bland KI. The intramuscular neurovascular anatomy of the latissimus dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg . 1981;67:637.
15 Schaverien M, Saint-Cyr M, Arbique G, Brown SA, Rohrich RJ. Three- and four-dimensional arterial and venous anatomies of the thoracodorsal artery perforator flap. Plast Reconstr Surg . 2008;121:1578.
16 Heitmann C, Guerra A, Metzinger SW, Levin LS, Allen RJ. The thoracodorsal artery perforator flap: anatomic basis and clinical applications. Ann Plast Surg . 2003;51:23.
17 Levine JL, Soueid NE, Allen RJ. Algorithm for autologous breast reconstruction for partial mastectomy defects. Plast Reconstr Surg . 2005;116:762.
18 Hamdi M, Van Landuyt K, Monstrey S, Blondeel P. Pedicled perforator flaps in breast reconstruction: a new concept. Br J Plast Surg . 2004;57:531.
19 Tomita K, Yano K, Masuoka T, Matsuda K, Takada A, Hosokawa K. Postoperative seroma formation in breast reconstruction with latissimus dorsi flaps. Ann Plast Surg . 2007;59:149.
20 Butler CE. Treatment of refractory donor-site seromas with percutaneous instillation of fibrin sealant. Plast Reconstr Surg . 2006;117:976.
21 Shermak MA, Rotellini-Coltvet LA, Chang D. Seroma development following body contouring surgery for massive weight loss: patient risk factors and treatment strategies. Plast Reconstr Surg . 2008;122:280.
22 Taghizadeh R, Shoaib T, Hart AM, Weiler-Mithoff EM. Triamcinolone reduces seroma re-accumulation in the extended latissimus dorsi donor site. J Plast Reconstr Aesth Surg . 2008;61:636.
23 Roje Z, Roje Z, Karanovic N, Utrobicic I. Abdominoplasty complications: a comprehensive approach of chronic seroma with pseudobursa. Aesth Plast Surg . 2006;30:611.
24 Fisher J, Bostwick J, Powell RW. Latissimus dorsi blood supply after thoracodorsal vessel division: the serratus collateral. Plast Reconstr Surg . 1983;72:502.
25 Russel RC, Pribaz J, Zook EG, Leighton WD, Erikkson E, Smith CJ. Functional evaluation of latissimus dorsi donor site. Plast Reconstr Surg . 1986;78:336.
26 Spear SL, Hess CL. A review of the biomechanical and functional changes in the shoulder following transfer of the latissimus dorsi muscles. Plast Reconstr Surg . 2005;115:2070.
CHAPTER 6 TRAM Flap Breast Reconstruction

Paul R. Weiss


Introduction
Breast reconstruction after mastectomy had its primitive beginning with an implant placed subcutaneously in a delayed procedure. The concept of immediate reconstruction was rejected for numerous unsubstantiated reasons, notably that the patient should live with the deformity and that early cancer recurrence would be masked by the reconstruction. Goin and Goin 1 advocated immediate reconstruction and emphasized the added benefit of contralateral prophylactic mastectomy when appropriate. Many specialists who could potentially refer their patients for reconstruction did not because of these unfounded concerns. In the late 1970s, musculocutaneous flaps were introduced, offering first the latissimus dorsi. 2 Several years later, Hartrampf et al 3 presented the rectus abdominis procedure which offered completely autologous reconstruction. These new techniques, together with tissue expanders, now achieved superior aesthetic results with a high degree of reliability. Despite these facts, convincing the oncologic surgeons to offer their patients delayed or immediate reconstruction was very difficult. With slow acceptance of delayed procedures, it took much longer for the immediate procedure to be recognized. Today the surgical armamentarium of flaps and tissue expander/implants makes the prospects of mastectomy for patients much easier to accept. For surgeons recommending the option of breast conservation versus mastectomy, the prospect of a satisfactory aesthetic result makes mastectomy more acceptable, if indicated. This includes those patients with small breasts or tumors located in the upper quadrants where the aesthetic result after lumpectomy and radiation often produce less than ideal results.

Patient Selection
The consultation with the plastic surgeon for a patient recently diagnosed with breast cancer is an emotionally charged experience. The history may reveal contraindications for a pedicled transverse rectus abdominis myocutaneous (TRAM) flap and the focus will turn to an alternate and more appropriate choice. The physical examination may also reveal scars or a body habitus that is inappropriate. If the procedure is unilateral, the breast remaining after the mastectomy must be carefully evaluated. If it is of reasonable size and the degree of ptosis is such that it is appropriate to match the reconstruction to it, the assessment is more straightforward. If the breast is either too large or too small, or if significant ptosis is present, the surgeon and patient must collaborate to decide how the reconstruction can and may be fashioned to achieve the desired end result. Realistic expectations must also be addressed, in conjunction with the patient’s overall cancer management and resultant anxiety.

Indications
The decision for TRAM reconstruction depends upon the patient’s appropriate anatomy and medical condition. Significant obesity and/or an associated pannus of redundant skin may compromise the circulation to the abdominal wall or TRAM. Abdominal wall scars may compromise the circulation of the abdominal skin flap resulting in necrosis and delayed healing. 4 The subcostal scar resulting from an open cholecystectomy is associated with division of the rectus muscle precluding its use as a pedicle on that side. A modification of the skin incision on the right abdomen to include the subcostal scar with the skin island placed higher eliminates the problem of an ischemic area below the scar, a potential cause of abdominal flap necrosis. This modification does not interfere with developing a satisfactory left-sided pedicle. 5 Vertical midline scars do not allow use of tissue across the scar unless a bilateral pedicle is employed for unilateral reconstruction. Recently, Mustoe has demonstrated that a delay procedure allows survival of tissue across a vertical midline scar with a unilateral pedicle. 6 Suprapubic scars do not pose a problem to the blood supply of either donor site or the TRAM musculocutaneous unit. With a large percentage of patients having undergone prior gynecologic procedures, the major problem encountered has been a more technically difficult dissection due to scarring. In one case, bowel adherent to the rectus muscle in an unrecognized midline infraumbilical hernia required a segmental small bowel resection when the gut wall was injured during a difficult dissection. A right lower quadrant appendectomy scar limits the use of tissue lateral to the scar or favors the use of a left sided pedicle as an alternative. Subjects who are very thin are still viable candidates if they have adequate redundant skin to create a TRAM island and allow closure of the donor site. Here, a prosthesis may be added immediately or at the time of nipple–areola reconstruction, which is the author’s preference.
Those patients with significant lumbosacral disease, that is, spondylolisthesis, are thought to be further compromised if the rectus muscle is sacrificed. Severe asthma or chronic obstructive pulmonary disease may compromise the postoperative recovery, but do not contraindicate the procedure. Ischemic heart disease may preclude a long surgery and anesthesia. Cardiac decompensation is a pertinent consideration for patients who have received prior treatment with cardiotoxic chemotherapeutic agents. Insulin-dependent diabetics have an increased risk of complications in general, but of particular concern is the viability of the abdominal wall where ischemia of the flap may result in fat or skin necrosis and wound dehiscence. Similar potential problems apply to smokers 7 and obese patients. 8
The choice of a pedicled TRAM over other autologous methods of reconstruction or prosthesis-based techniques depends upon many objective factors as described above. The subjective reasons to choose a particular procedure often involves the patient, referring oncologic surgeon or other healthcare provider. Experience with other patients, those of friends or family also often play a role in decision making. Because autologous reconstruction arguably offers the best result, it is the author’s first choice on the reconstructive ladder. Likewise, immediate reconstruction should be considered unless postoperative radiation therapy to the chest wall is certain or there is a possibility that a contralateral mastectomy is considered but refused by the patient or is not practical at the time. A tissue expander may be placed as a temporary method of preserving the mastectomy flaps as a spacer and leave the option open for later autologous reconstruction. 9 Genetic testing has significantly increased the number of patients opting for a prophylactic mastectomy of the opposite breast when diagnosed with cancer. The importance of family history in BRCA negative patients has also made prophylactic uni- and bilateral mastectomy and reconstruction a common occurrence. 10 Likewise, those patients with strong family history, positive genetic markers or concerns about cancer detection are presenting for bilateral mastectomy without a cancer diagnosis. 11 - 13 Because the abdominal donor site can only be used once, risk of future disease in the opposite breast must be considered as part of the treatment options and informed consent.
Planning mastectomy incisions is a collaborative effort between the oncologic and reconstructive surgeon to consider the many options. The position of the tumor and its relation to the nipple–areola is most important as the skin incision will be determined by their location. Many surgeons will include the biopsy site in the skin incision leading to additional skin flap sacrifice. The concept of skin sparing mastectomy has many interpretations. Preservation of the breast skin usually facilitates better aesthetic outcomes. When there is enough skin to allow a completely de-epithelialized TRAM island, minimal scarring usually results and there is no mismatch of skin color or contour. A transversely oriented scar can later be disguised if the nipple reconstruction punctuates it. Similarly, when only the nipple–areola is sacrificed, the scar is minimal as reconstruction of the nipple–areola will completely obliterate most or all of it. If the breast is large enough and the tumor position allows preservation of the upper breast skin, a Wise pattern (keyhole) mastectomy may be employed. 14 This approach allows contouring to reduce lateral fullness and very acceptable incision placement. The secondarily reconstructed nipple can usually be placed at or near the apex of the vertical limb of the inverted ‘T.’ A vertical mammaplasty pattern may also be useful in a skin sparing mastectomy. 15 , 16
The concept of considering the breast as an anatomical unit with regard to scars calls for sacrifice of the native inferior breast skin flap to the inframammary fold. This sacrifices sensate skin and may contribute to an unnecessarily tight skin closure. Compromise of the reconstructed breast shape or incision healing and scarring may also occur. Salvage situations including a poor outcome resulting from implant reconstruction may necessitate the sacrifice of skin above or below the original mastectomy scar, particularly when the previously reconstructed nipple is malpositioned, or may become malpositioned with alteration of skin anatomy.

Operative Technique I: Planning

Vascular anatomy
The design of the cutaneous component of a pedicle flap must take advantage of the best blood supply while utilizing the most satisfactory tissue to create a breast mound. The internal mammary artery descends subcostally dividing into the musculophrenic and deep superior epigastric branches. The musculophrenic sends branches to the intercostal vessels. This costomarginal anastomotic circulation is an alternate one when the internal mammary is divided as a result of previous surgery. The deep superior epigastric artery emerges under the medial costal margin and enters the deep surface of the muscle with its accompanying veins. The vessels course within the body of the muscle. Above the level of the umbilicus, the vessels become a web of choke vessels, which anastamose with the vascular supply from the deep inferior epigastric system. 17 Since the deep inferior epigastric artery that branches from the internal iliac is the dominant pedicle, there is circulatory compromise when the artery and its two venae comitantes are divided to allow pedicle transfer. This is because the skin island is located over the angiosome of the deep inferior epigastric artery and veins. The venous valves prevent flow superiorly until dilatation secondary to venous congestion renders them incompetent ( Fig. 6.1 ). Understanding the flow dynamics within the muscle and subcutaneous components of the flap are best explained in Moon and Taylor’s diagrammatic representation of the ‘staircase effect’ ( Fig. 6.2 ) Venous return is compromised more often than arterial and is manifested as venous congestion. When flap circulation is compromised, a satisfactory solution is decompression of one of the veins. This maneuver is described later in this chapter. Moon and Taylor 18 studied the rectus circulation and describe three patterns of supply from the deep epigastric artery. The most common type branches into two vessels just below the arcuate line. The inferior epigastric pedicle most often enters the deep side of the muscle from the lateral side. Perforating vessels are found in two rows just medial and lateral to the edges of the rectus fascia. There are no perforators below the arcuate line. The skin overlying the rectus muscle is supplied by perforators which pierce the fascia and arborize within the subcutaneous fat. These perforating vessels are largest in number in the periumbilical region and are a prime consideration in designing the skin island to include this region. Slavin 19 designed a skin island, which is centered above and below the umbilicus. While this design may result in better arterial supply, it may not allow the advantage of utilizing the best subcutaneous tissue and may leave too short a pedicle to allow adequate rotation. This design results in a surgical scar higher on the abdominal wall, which is more noticeable, thus less desirable.

Fig. 6.1 Rectus muscle blood supply. The superiorly based rectus abdominis flap: predicting and enhancing its blood supply based on an anatomical and clinical study.
Redrawn from Miller et al. Plast Reconstr Surg 1988; 81 :713.

Fig. 6.2 TRAM blood flow. Effect of choke vessel on perfusion pressure of territories supplied by a deep superior epigastric artery-based flap. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superficial epigastric system.
Redrawn from Moon H, Taylor I. Plast Reconstr Surg 1988; 82 :815.
The available skin and fat are considered in four vascular zones ( Fig. 6.3 ). They are numbered in decreasing order of blood supply flow: I–IV. Zone I lies directly over the muscle and has the best circulation with zone II lateral to zone I on the ipsilateral side. Across the midline, zone III has decreased pressure and as a result, its viability is often questionable and must be carefully assessed intraoperatively. Zone IV should not be considered as its viability is always poor. Some authors have labeled zone II as the segment across the midline and zone III ipsilateral next to zone I, but that implies a misleading stepwise progression of blood supply and viability. When a bilateral procedure is performed, each flap is composed of zone I and II. The impact of a vertical infraumbilical scar is discussed earlier.

Fig. 6.3 TRAM zones.

Operative Technique II: Surgical

Unilateral procedure ( Figs 6.4 - 6.6 )
Preoperative markings are usually unnecessary. Marking the inframammary folds and the proposed abdominal skin incisions in a standing position prior to the patient entering the operating room may be helpful. If the procedure is an immediate reconstruction, the mastectomy will be performed prior to the reconstruction. In some instances, it may be possible to begin the abdominal dissection while the mastectomy is in progress. This will shorten the duration of general anesthesia. For delayed reconstructions, such as mastectomies performed at an earlier time, it is appropriate to place markings on the chest wall preoperatively to define the original position of the breast so that the placement of the reconstruction will better match the intact contralateral side.

Fig. 6.4 Unilateral TRAM final intraoperative view. A Skin island. B Unilateral TRAM markings for reconstruction. C Fascia repair (mesh over arcuate line region).

Fig. 6.5 Unilateral TRAM (de-epithelialized). A Unilateral TRAM before surgery. B Preoperative abdominal view. C, D Preoperative lateral abdominal view. E After mastectomy and immediate TRAM de-epithelialized. F–H Planning the second stage. I–K After nipple–areola reconstruction and tattoo, left breast reduction.

Fig. 6.6 Unilateral TRAM. A Preoperative view. B Abdominal donor site. C Lateral preoperative view. D Preoperative nipple reconstruction. E Following completion of reconstruction. F Postoperative abdominal scarring. G, H Postoperative lateral views.
It is important that the operating table can be flexed to facilitate abdominal wall closure and that it is padded appropriately for the length of the procedure to prevent undue pressure on bony prominences. Sequential compression devices, a catheter in the urinary bladder, and antibiotic prophylaxis are essential. Pharmacologic DVT prophylaxis must be considered for high risk patients. 20 , 21
A transverse incision approximately 1.5 cm above the umbilicus is made from hip to hip. The incision is beveled superiorly through the subcutaneous fat to reach the rectus and external oblique fascia. The abdominal wall is then elevated to the costal margins bilaterally. The rectus abdominis muscle is then dissected from costal margin to the upper edge of the flap by incising the anterior rectus sheath, leaving a cuff of approximately 1 cm medial and lateral to the muscle. This leaves the anterior rectus sheath attached to the muscle. The dissection of the rectus muscle is facilitated with electrocautery at a low setting. At the inscriptions, care must be taken to avoid damaging both the muscle and the fascia. Retaining the attachment of the anterior rectus sheath to the muscle reduces the difficulty of dissection here.
A tunnel is now made into the mastectomy wound, crossing the midline. A lighted retractor facilitates the dissection, which is accomplished from above and below (mastectomy wound and abdominal dissection). Care must be taken to stay above the rectus sheath and remain in the same plane approaching the surface of the pectoralis major muscle in the chest.
A transverse incision is made, crossing in a curvilinear manner from each end of the transverse incision across the suprapubic region curving inferiorly. This dissection is taken to the rectus and external oblique fascia. The side opposite the rectus muscle pedicle is then dissected from lateral to medial along the external oblique and rectus fascia. As the perforating vessels are encountered, the larger ones are cross-clamped and ligated. Next, the umbilicus is incised circumferentially and dissected to the fascia, preserving its pedicle. Attention is then turned to the upper edge of the flap. A clamp is placed on the cuff of rectus sheath medially and the skin/fat flap dissected to that point around the umbilicus. The rectus sheath is then incised medially along the entire vertical length of the flap. On the ipsilateral side, a traction suture is placed through the skin and subcutaneous fat. Using this to elevate the flap, the dissection proceeds medially to the lateral border of the rectus fascia. Here, a clamp is placed on the cuff of rectus sheath superiorly and the dissection carried through the rectus sheath dividing it from the upper edge of the flap to the lower border of the skin island. Because of the anatomy of the muscle, the incision curves medially as the dissection proceeds inferiorly. The anterior rectus sheath is then incised along the lower edge of the flap, connecting the medial and lateral incisions. Blunt finger dissection is then used to separate the deep surface of the muscle from the underlying preperitoneal fat. The anterior rectus sheath is separated from the muscle inferiorly to enlarge the space. An Army-Navy retractor is then placed under the muscle and insulated from the surrounding skin by placing laparotomy pads under both ends. The muscle is then divided with electrocautery. The deep inferior epigastric pedicle is usually identified at this time, entering the muscle’s deep surface from the lateral side or in the middle. The pedicle is dissected to the first branch inferiorly, and divided. Double ligatures are placed on the inferior end. If the pedicle is encountered while dividing the muscle, it is similarly ligated. It is advantageous to leave the pedicle long, so that if there is vascular compromise, adjunctive vascular procedures will be easier to accomplish. The cutaneous portion of the musculocutaneous unit is cumbersome because of its size. Thus, it may be helpful to resect through the middle of zone III at this time. The rectus muscle is now dissected from the posterior rectus sheath, taking care to avoid avulsing the perforating vessels. The intercostal neurovascular bundles are divided between clamps and ligated or cauterized. Ligatures are preferable on the flap to reduce thermal trauma from the electrocautery. Fig. 6.7 demonstrates the cross-sectional anatomy of the musculocutaneous unit.

Fig. 6.7 Cross-sectional anatomy of the musculocutaneous flap.
A check for hemostasis in the mastectomy wound and tunnel is now made. As the musculocutaneous unit is usually contralateral, a right flap is rotated counter-clockwise through the tunnel so that the tail of zone II lies laterally and the flap is transversely oriented in the mastectomy wound. A left flap is similarly rotated clockwise through the tunnel. Inspection of the muscle is important to ensure that there is no kinking associated with its transposition. Further incision of the rectus fascia on the lateral aspect of the muscle over the costal margin may be necessary to avoid kinking of the muscle and potential vascular compromise. Lateral muscle fibers may be safely divided above the costal margin. Staples are now placed between the mastectomy flaps and the skin of the TRAM to stabilize it in its proposed final position. Depending upon the mastectomy defect and flap geometry, alternate positioning may be preferable (e.g. positioning zone II superiorly and the flap oriented vertically). Additional resection of tissue is accomplished as necessary. In delayed reconstructions, scarring and contracture of the mastectomy flaps, particularly after radiation therapy, may require manipulation to avoid undue compression of the musculocutaneous unit.
Attention is returned to the abdominal wall. This important step in maintaining functional integrity is discussed by Kroll and Marchi 22 and critiques by Nahai. 23 The rectus fascia is repaired with permanent figure of eight sutures from the costal margin to the pubis. Care must be taken to include the internal and external oblique aponeuroses in the lateral half of fascia repair. A large enough opening must be left at the costal margin to avoid constricting the muscle, but at the same time tight enough to avoid a hernia. A centralizing suture is placed on the anterior rectus sheath of the intact contralateral muscle to centralize the umbilicus. This is designed as an ellipse, being widest at the umbilicus and tapering above and below. A supporting prosthetic mesh is now sutured from the umbilicus to the pubis across the rectus fascia repair on the ipsilateral side. 0 Prolene sutures are used to fix the prosthesis to the fascia. Prolene mesh was previously used with success but has been replaced by Ultrapro, which is a less rigid material composed of both absorbable and permanent material. This method of repair maintains abdominal wall contour and reliably prevents bulge/hernia. The patient is then placed in a Trendelenberg position, and the back flexed approximately 20 to 30°. Suction drains are placed and brought out through the lateralmost aspect of the incision. For convention, the left drain is placed inferiorly along the incision, and the right drain along the costal margin. Skin closure is accomplished with 00 PDS sutures for the superficial fascia and 3-0 and 4-0 Monocryl sutures for the subcutaneous and subcuticular repairs, respectively. Alternatively, Insorb staples may be used. The umbilicus is brought out through a frown incision and sutured. A ‘V’ is cut from the inferior aspect of the umbilicus and the frown flap from the abdominal wall is sutured into it. If the patient is moderately obese, or there is concern about the circulation to the abdominal flap, a vertically oriented elliptical incision is made in the abdominal flap to admit the umbilicus.
Attention is now focused on the chest. The circulation of the flap is assessed, and if no problem is noted, closure is begun. It is usually appropriate for the flap to be oriented as described above. It may be necessary to reorient the flap if it appears that a better match to the intact contralateral breast can be made in so doing. The tail of zone II is resected, as is a portion of zone III, making sure to preserve satisfactory volume in the remaining tissue. As the circulation in zone III is less reliable, it should be the first region to be resected for a flap that is too large. Care should be taken to fill the mastectomy wound, even if the flap is too large, as reducing its overall size may lead to deficiency, particularly in the infraclavicular region (liposuction can later be performed to reduce flap volume). It is better to leave a flap too large than to have an area of deficiency. Tacking staples are placed to determine how much of the skin from the abdomen is to be left, and where it is oriented. They can easily be revised in a tailor-tack manner to achieve the best contour and position. The desired skin island is marked, the staples removed and the flap brought out onto the chest. After de-epithelialization around the skin island, the flap is returned to the mastectomy wound and it is sutured to the underlying pectoralis major muscle with 2-0 PDS sutures. A suction drain is placed, and skin closure accomplished with 4-0 Monocryl subcutaneous sutures and running 5-0 nylon for skin. Placement of subcutaneous sutures should compensate for the relatively thick breast flap sutured to the thinner dermal edge of the de-epithelialized TRAM. If the flap has been de-epithelialized completely, conventional skin closure is employed. Judgment is important to avoid too tight a closure and resultant flattening of the breast mound.
Non-compressive dressings are applied and the patient is transferred to a hospital bed in a flexed position after extubation. Utilization of the hospital bed eliminates multiple transfers of the patient in the immediate postoperative period.

Summary

1. For a delayed procedure, mark the mastectomy defect in a standing position.
2. Abdominal markings in a supine position – transverse incision 1 to 2 cm above umbilicus.
3. Undermine abdominal wall to costal margin.
4. Make tunnel into mastectomy wound.
5. Dissect rectus muscle from costal margin to flap.
6. Inferior incision dissected to fascia.
7. Incise umbilicus.
8. Dissect musculocutaneous unit by incising rectus sheath medial and lateral.
9. Identify deep inferior epigastric pedicle.
10. Divide rectus muscle.
11. Dissect musculocutaneous unit to costal margin.
12. Rotate flap into mastectomy wound and position.
13. Repair fascial defect with sutures, prosthesis below umbilicus.
14. Deliver and suture umbilicus, close abdominal incision.
15. De-epithelialize buried portion of flap after marking in place.
16. Secure TRAM island to pectoralis muscle.
17. Close breast wound.

Bilateral procedure ( Figs 6.8 - 6.10 )
The techniques are similar to those described above. Each musculocutaneous unit is transferred through a common tunnel branching to right and left from the abdomen into the chest. The author prefers ipsilateral transfer of each flap. Here the orientation of the muscle pedicle must be carefully addressed to avoid kinking. Zone II may be positioned superiorly or laterally for best aesthetic appearance and/or to avoid compression of the vascular pedicle.

Fig. 6.8 Bilateral TRAM intraoperative view. A Skin islands. B Muscle dissection. C Muscle defect. D Fascia repair with mesh. E, F De-epithelialized skin island. G Abdominal wall repair.

Fig. 6.9 Bilateral TRAM. A Preoperative view: left breast cancer, right prophylactic mastectomy. B Abdominal donor site with vertical midline scar. C, D Lateral view of abdominal donor site. E Following completion of reconstruction, including nipple–areola and tattoo. F, G Lateral view of follow-up. H–J Abdominal donor site.

Fig. 6.10 Bilateral TRAM with implants. A, B S-P left mastectomy and radiation with new right breast cancer (preoperative view). C Lateral preoperative view. D Following bilateral TRAM with breast implants placed sub-pectoral and nipple–areola reconstruction. E, F Postoperative lateral view.
Abdominal wall closure, in a bilateral procedure, is significantly different from the unilateral flap harvest. Here, a Prolene mesh prosthesis is used to repair the fascial defect. Care must be taken to make the repair of the fascia similar in size to the defect created. Otherwise, laxity of the abdominal wall results. The mesh is sewn to the lateral rectus sheath beginning at the umbilicus, where the tension is set. 0 Prolene horizontal mattress sutures are placed from side to side, traveling superiorly and inferiorly to the costal margin and pubis, respectively. The width of the prosthesis narrows in both directions to recreate the normal anatomic shape of the abdominal wall. The prosthesis is now trimmed to the edges of the suture repair and a running suture placed on each side to bring the cut end of the prosthesis to the fascia for a smooth contour. An opening is made in the prosthesis to admit the umbilicus. Tacking sutures may be added in the midline, particularly in the epigastrium to fix the prosthesis to the underlying fascia.

Summary

1. For a delayed procedure, mark the mastectomy defect in a standing position.
2. Abdominal markings in a supine position – transverse incision 1 to 2 cm above umbilicus.
3. Undermine abdominal wall to costal margin.
4. Make tunnels into mastectomy wounds.
5. Dissect rectus muscles from costal margin to flap.
6. Inferior incision dissected to fascia.
7. Incise umbilicus.
8. Dissect musculocutaneous units by incising rectus sheath medial and lateral.
9. Identify deep inferior epigastric pedicles.
10. Divide rectus muscles.
11. Dissect musculocutaneous units to costal margin.
12. Rotate flaps into mastectomy wounds and position.
13. Repair fascial defects with sutures, prosthesis from costal margin to pubis.
14. Deliver and suture umbilicus, close abdominal incision.
15. De-epithelialize buried portion of flaps after marking in place.
16. Secure TRAM islands to pectoralis muscle.
17. Close breast wounds.

Postoperative care
Patients are encouraged to walk on the first postoperative day. Diet is advanced slowly to avoid postoperative nausea and vomiting. The Foley catheter is not removed until the patient is able to walk to the bathroom. Patients are discharged home when they are ambulatory, afebrile and exhibit no wound or medical problems. Antibiotics are continued until the drains are removed. Upon discharge from the hospital, the patient is given a chart to record drain volume. Daily telephone follow-up is utilized to monitor this activity. The suction drains are not removed until they drain 30 cc or less in a 24 hour period. This caveat eliminates seromas successfully.

Delay procedures
Numerous authors have described delay procedures. 24 - 26 For immediate reconstruction, where timely treatment of the malignancy is so critical, it is not reasonable to consider the additional period required for the delay procedure. The additional procedure and possible additional scars are undesirable. Numerous methods have been advocated, but it is difficult to compare their efficacy. In consideration of the above, this author has declined to use delay procedures.

The congested flap
Some degree of venous congestion occurs in every pedicle flap after division of the vessels but is not sufficient to compromise tissue viability. The discussion of flap circulation in Hartrampf’s text 27 states that the compensation of arterial circulation is more rapid than venous when flow reverses after deep inferior epigastric pedicle division.
Despite an otherwise ideal candidate and an uncomplicated dissection, the TRAM flap may appear congested. It is not possible to predict which subjects will develop this problem. Venous congestion can occur even before the inferior epigastric pedicle is divided. This early manifestation of congestion is characterized by brisk capillary refill and/or blue or purple mottled appearance of the skin surface. When the congestion occurs after pedicle division, the appearance of the skin is similar to that described above, most apparent in zones III and IV. Inspection of the cut inferior epigastric vessels exhibits engorgement and dark red color. If the congestion is mild, transfer of the flap into the recipient site may resolve or at least improve the condition. Venotomy either before or after flap transfer will usually result in immediate resolution of the congestion. If the problem recurs after bleeding stops, a straightforward solution is to intubate one of the veins with a long angiocath connected to a three-way stopcock 28 ( Fig. 6.11 ). If the bleeding is minimal, the stopcock is left open and the angiocath brought out through the mastectomy incision and drained into a bile collection bag. If the flow is great, the three-way stopcock can be used with a syringe and heparinized saline to control the blood loss by periodically opening the flow. In most cases, the flow slows or ceases within several hours. During this time, there is adjustment of flow to increase venous return through the superior epigastric circulation, as vein dilatation renders the valves incompetent. With the flap in place in the chest, abdominal wall closure proceeds. Periodic evaluation of flap circulation is advisable to assess congestion. When resecting the excess tissue, the color of the bleeding at the cut edge also evaluates flap congestion and the bleeding itself relieves congestion, as does bleeding from the de-epithelialized portion of the flap. In deeply pigmented skin, bleeding from the cut dermal or fat edge can also be used to assess congestion. In addition, well oxygenated fat has an iridescent appearance. While venous congestion self corrects over time, a significant degree and duration of congestion will likely contribute to both fat necrosis and an unsatisfactory result due to cell death during the period of hypoxia. This prompts consideration of this technique when significant venous congestion is present. The obvious risk is the associated blood loss and potential need for transfusion.

Fig. 6.11 A–C Catheter placement for venous congestion.

The secondary procedure
The secondary procedure may simply be nipple–areola reconstruction, but usually both the reconstructed and remaining breast require modification to achieve the desired shape, size and symmetry. In order to fill the mastectomy wound and avoid an infraclavicular hollow, more of the flap must be utilized at the primary surgery to achieve this, often resulting in excess volume. Liposuction is utilized to correct the excess volume or improve contour wherever excess volume is present without redundant skin. The redundant skin is best treated by direct excision. When fullness that is present lateral to the TRAM skin island is both skin and subcutaneous fat, excision and V-Y closure is indicated. The redundant skin is an excellent source of skin to reconstruct the areola. Inframammary fold (IMF) position may be disrupted by the mastectomy or the creation of the tunnel for the pedicle, even with medial placement of the tunnel. Secondary correction of a malpositioned IMF often involves mobilization of much of the flap from the underlying pectoralis muscle to allow repositioning. One should not rely on bolster sutures alone for IMF repositioning. Access to allow this dissection requires opening of the TRAM-breast scar and dissecting the flap inferiorly to the IMF. The repositioned fold is sutured bringing the subcutaneous tissue to the underlying fascia. Revision of the TRAM skin island or breast flap to correct skin redundancy resulting from the change in position may be required when the IMF is repositioned.
Necrosis of a portion of the TRAM or breast flaps may require an extensive revision and should not be planned until the operative site has healed well enough to allow dissection without undue tissue damage. The TRAM island may require partial or total mobilization to produce satisfactory position and shape if this revision or the initial placement was incorrect. For deficient volume, either a saline or silicone prosthesis may be employed at this time unless there is concern about tissue viability. When a prosthesis is employed without other major revision, it is most easily placed subpectorally. The plane between the pectoralis and transposed rectus muscles is difficult to dissect because of scarring and thus should be avoided.

The opposite breast
The contralateral intact breast is treated at the second stage reconstruction to achieve symmetry. Vertical mastopexy with or without augmentation with a prosthesis is very useful. Breast reduction with a superomedial pedicle vertical technique or Wise pattern inferior pedicle technique is utilized according to the surgeon’s preference and breast volume.

Nipple–areola reconstruction ( Fig. 6.12 )
This portion of the reconstruction is performed as a secondary procedure, usually in combination with necessary modification of the reconstruction and alteration of the intact breast for symmetry discussed above. Following the description of the skate flap by Little and Noone 29 , 30 , the procedure has been refined with minor changes. The site is chosen and marked, sometimes modifying the measured symmetric position to achieve a better appearance. This is performed in a standing position prior to entering the operating room. A 35 mm diameter circle is drawn around the central mark. A line across the equator of the circle is drawn horizontally, or is oriented to avoid a bisecting surgical scar. A 10–12 mm circle is then drawn below the equator centered medial to lateral. If the nipple circle is centered within the areola circle, it will be placed too high. The diameter of the areola is the surgeon’s choice or is measured to match the other breast. This size is ideal for reconstruction. The diameter of the areola can be enlarged with a tattoo if necessary. This is added later. Two lines are drawn, one from each side of the circle curving to meet at the edge of the outer circle. The two wings of the skate are then elevated at a deep dermal level. Centrally, a cut is made into the underlying fat to the equator leaving a ‘keel’ of fat to give bulk to the new nipple. The two wings are brought together and sutured with 5-0 chromic. A second suture is placed several millimeters above and tied. The center of the flap is brought down and sutured to this point with adjustment of the position to achieve the desired projection. If the flaps are sutured together to their apices, a long narrow tubular appearance will result. Next, the corners of the nipple mound are trimmed and closure is completed with the chromic sutures. Since significant shrinking is expected, as much bulk as possible should be incorporated into the flap. However, overzealous deep incisions will result in collapse of the nipple flap and an unacceptable appearance. The upper half of the circle is now de-epithelialized and a full thickness skin graft is supplied after thinning it by excising much of the dermis. The graft may be obtained from a surgical dogear on the breast or abdomen or from a contralateral mastopexy or reduction. If none of these sites are available, non-hairbearing suprapubic or groin skin may be employed. The graft is sutured with interrupted and running 5-0 chromic sutures, a hole cut in the center to admit the nipple and additional sutures placed between the skin graft and nipple flap for stabilization. The skin graft is piecrusted to allow drainage. A donut dressing of Xeroform gauze and plain gauze is fabricated to provide compression of the skin graft but none to the nipple. This dressing is held in place with Steristrips or half inch paper tape and kept in place for 5–7 days. Six months later, the nipple–areola is tattooed to achieve the desired color. Color matching requires artistic ability, patience and experience. The tattoo may also be applied by a professional artist. Reconstructions that avoid a skin graft for the area are simpler to complete but the more irregular surface contour of the piecrusted skin graft together with a tattoo achieve a more realistic result (photographs and diagrams).

Fig. 6.12 Skate flap. A Nipple reconstruction with skate flap (markings). B Wings of skate flap dissected at dermal level. C Flap elevated. D Flap sutured with areola graft in place. E Later tattoo of nipple–areola.

Summary

1. Choose site for symmetry.
2. 35 mm diameter areola is aesthetic for most patients.
3. Make nipple circle below the equator.
4. Lateral skate wings deep dermal thickness.
5. Contour nipple flap and suture.
6. Complete de-epithelialization of upper half of areola.
7. Full thickness skin graft for areola and piecrust.
8. Dressing to provide pressure on areola graft only (donut).

Pitfalls and How to Correct

Breast
Once the breast reconstruction is healed, it is unusual to encounter significant problems. Early mild fat necrosis softens over time and does not require treatment. Several patients have experienced significant weight change resulting in asymmetry. Increasing volume of the TRAM fat is best resolved by weight loss. Liposuction is the practical surgical solution. Minor volume or contour deficiencies which are present early or occur over time may be corrected with autologous fat transfer. Several procedures are often required to achieve the desired result. If the volume deficiency is significant, an implant should be considered. Recurrent ptosis or volume change in the contralateral breast is corrected utilizing conventional techniques.

Abdomen
Weakness of the abdominal fascia closure below the arcuate line has been successfully addressed in the technique described above for the unilateral procedure. A number of patients present months or years later with a bulge, pain, spasm or a combination of complaints. Physical examination usually reveals weakness of the fascia in the infraumbilical region. Radiologic evaluation with CT or MRI may show the defect or a contour deformity of the abdominal wall but no true hernia as is expected. Repair requires elevation of the abdominal flap to expose the deficiency and repair of the fascia with sutures and mesh. Interestingly, there have been no contour problems in the bilateral cases using the repair described above. Prolonged hypesthesias or dyesthesias are common and in almost all cases resolve spontaneously. The unilateral TRAM patients are able to resume normal activity over time. In the bilateral cases, the expected deficiency of not being able to sit straight up from a lying position is observed in all patients but does not otherwise impede their activity. In those patients who later experience significant weight-gain, the abdomen remains flat while other anatomic areas enlarge.

References

1 Goin MK, Goin JM. Psychological reaction to prophylactic mastectomy synchronous with contralateral breast reconstruction. Plast Reconstr Surg . 1982;70:355.
2 Olivari N. The latissimus flap. Br J Plast Surg . 1976;29:126.
3 Hartrampf CR, Schleflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg . 1982;69:216.
4 Takeishi M, Shaw W, Ahn C, et al. TRAM flaps in patients with previous abdominal scars. Plast Reconstr Surg . 1982;69:216.
5 Weiss P. TRAM flaps in patients with previous abdominal scars. Correspondence and brief communications. Plast Reconstr Surg . 1998;102:2276.
6 O’Shaugnessy K, Mustoe T. The surgical TRAM flap delay: reliability of zone III using a simplified technique under local anesthesia. Plast Reconstr Surg . 2008;122:1627.
7 Padubidri A, Yetman R, Browne E, et al. Complications of postmastectomy breast reconstructions in smokers, ex-smokers, and non-smokers. Plast Reconstr Surg . 2001;107(2):342.
8 Greco J, Castaldo E, Nanney LB, et al. Autologous breast reconstruction: the Vanderbilt experience (1998 to 2005) of independent predictors of displeasing outcomes. J Am Coll Surg . 2008;207:49.
9 Fine N, Hirsch E. Keeping options open for patients with anticipated postmastectomy chest wall irradiation: immediate tissue expansion followed by reconstruction of choice. Plast Reconstr Surg . 2009;123:25.
10 Briasoulis E, Ziogas D, Fatouros M. Prophylactic surgery in the complex decision-making management of BRCA mutation carriers. Ann Surg Oncol . 2008;15:1788.
11 Wainberg S, Husted J. Utilization of screening and surgery among unaffected carriers of a BRCA1 or BRCA2 gene mutation. Cancer Epidemiol Biomarkers Prev . 2004;13:1989.
12 Robson M, Svahn T, McCormick B, et al. Appropriateness of breast-conserving treatment of breast carcinoma in women with germline mutations in BRCA1 or BRCA2. Cancer . 2004;103:44.
13 Metcalfe K, Lubinski J, Ghadirian P, et al. Predictors of contralateral prophylactic mastectomy in women with a BRCA1 or BRCA2 mutation: the hereditary breast cancer study group. J Clin Oncol . 2008;26:1093.
14 Skoll P, Hudson D. Skin sparing mastectomy using a modified Wise pattern. Plast Reconstr Surg . 2002;110:214.
15 Young K, Satovsky N. The vertical pattern breast reconstruction for large or ptotic breasts. Plast Reconstr Surg . 2005;115:2052.
16 Scholz T, Kretsis V, Kobayashi M, et al. Long-term outcomes after primary breast reconstruction using a vertical skin pattern for skin-sparing mastectomy. Plast Reconstr Surg . 2008;122:1603.
17 Miller LB, Bostwick J3rd, Hartrampf CRJr, Hester TRJr, Nahai F. The superiorly based rectus abdominis flap: predicting and enhancing its blood supply based on an anatomical and clinical study. Plast Reconstr Surg . 1988;81:713.
18 Moon H, Taylor I. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superficial epigastric system. Plast Reconstr Surg . 1988;82:815.
19 Slavin S, Goldwyn R. The midabdominal rectus abdominis mycocutaneous flap: review of 236 flaps. Plast Recosntr Surg . 1988;81:189.
20 Seruya M, Venturi L, Iorio ML, Davison SP. Efficacy and safety of venous thromboembolism prophylaxis in highest risk plastic surgery patients. Plast Reconstr Surg . 2008;122:1709.
21 Kim E, Eom J, Ahn SH, Son BH, Lee TJ. The efficacy of prophylactic low-molecular-weight Heparin to prevent pulmonary thromboembolism in immediate breast reconstruction using the TRAM flap. Plast Reconstr Surg . 2009;123:9.
22 Kroll S, Marchi M. Comparison of strategies for preventing abdominal wall weakness after TRAM flap breast reconstruction. Plast Reconstr Surg . 1992;89:1045.
23 Nahai F. Discussion of comparison of strategies for preventing abdominal wall weakness after TRAM flap breast reconstruction. Plast Reconstr Surg . 1992;89:1052.
24 Hudson D. The surgically delayed unpedicled TRAM flap for breast reconstruction. Am Plast Surg . 1996;36:238.
25 Codner M, Bostwick J. TRAM flap vascular delay for high-risk breast reconstruction. Plast Reconstr Surg . 1995;96:1615.
26 Restifo R, Ward B, Scoutt LM, Brown JM, Taylor KJ. Timing, magnitude and utility of surgical delay in the TRAM flap: part II. Plast Reconstr Surg . 1997;99:1.
27 Hartrampf C. Hartrampf’s breast reconstruction with living tissue . Norfolk: Hampton Press; 1991.
28 Caplin D, Nathan C, Couper SG. Salvage of TRAM flaps with compromised venous outflow. Plast Reconstr Surg . 2000;106:400.
29 Noone B, Little W. Nipple reconstruction with a skate flap. ASPRS annual meeting instructional course.
30 Shestak K, Gabriel A, Landecker A, Peters S, Shestak A, Kim J. Assessment of long-term nipple projection: a comparison of three techniques. Plast Reconstr Surg . 2002;110:780.
CHAPTER 7 TRAM Flap Variations in Breast Reconstruction

Henry C. Vasconez

Summary/Key Points

1. The pedicled transverse rectus abdominis myocutaneous (TRAM) flap still remains a very useful and the most popular method of autogenous breast reconstruction throughout the world. 1
2. Like any operation, careful planning and preoperative preparation is necessary in order to assure a successful outcome. In the TRAM flap this should include careful mapping of the perforators that will supply the flap.
3. In cases of patients with significant metabolic risk factors, TRAM flap variations such as a double-pedicled TRAM flap, a mid or upper abdominal TRAM flap, or a vascular delay of the TRAM flap should be considered. A free or perforator flap should be strongly considered in these patients if the expertise and facilities are available.
4. The choice of breast reconstruction depends on the characteristics of the mastectomy defect, the size and shape of the contralateral breast, and the condition and desires of the patient. Equally important is the experience of the surgeon.
5. In choosing autogenous reconstruction of the breast, a single-pedicled TRAM flap still remains an excellent choice in a healthy patient.
6. The increasing use of adjuvant radiation therapy has changed the trend from immediate breast reconstruction to a delayed form of breast reconstruction.

Patient Selection
Patient selection as in other surgical procedures is of critical importance in the success of breast reconstruction and in particular in the area of autologous breast reconstruction. Carl R. Hartrampf who developed and popularized the TRAM flap (originally termed by him as the transverse abdominal island flap) developed a strict criteria for patient selection that included patient risk factors as well as surgeon experience. 2
Once it has been determined that the patient is a candidate for breast reconstruction and has the desire and realistic expectations of what this involves, a more thorough evaluation of the patient can proceed for surgical repair. 3 , 4 The risk factors that keep coming up in studies as most significant include obesity, a strong smoking history, significant metabolic or cardiovascular compromise and a history or intention of using radiation therapy to the breast cancer site. These risk factors need to be considered individually and in combination in order to make a final decision whether breast reconstruction should be performed and what type is most appropriate. This chapter will concentrate on variations of the traditional TRAM flap that can in certain situations improve the chance of a successful outcome.

Indications
TRAM flap reconstruction can give a very satisfying outcome to the patient who has recently experienced the shock and hardship of a diagnosis of breast cancer. It does however require a considerable investment of time and effort on the part of the patient and the surgeon in order to achieve optimal results. The TRAM flap can also be used for other forms of chest reconstruction resulting from tumor excision or congenital problems such as Poland’s syndrome. It has been used very effectively based on the more robust inferior epigastric pedicle for pelvic and perineal reconstruction due to tumors, trauma, and other causes requiring a large volume of well vascularized tissue. The algorithmic flow charts in Figures 7.1 , 7.2 , 7.3 and 7.4 show the indications for the TRAM flap and its variations based on morphologic and treatment characteristics.

Fig. 7.1 Single-pedicled TRAM flap algorithm.

Fig. 7.2 Bipedicled TRAM flap algorithm.

Fig. 7.3 Delayed TRAM flap indications.

Fig. 7.4 Midabdominal TRAM flap indications.
The most common indication for TRAM flap reconstruction is for a patient with breast cancer who will undergo or has undergone some form of mastectomy. This brings up the issues of immediate or delayed reconstruction which has again become a timely concern with the increasing use of adjuvant radiation therapy for breast cancer. Many studies over the years have shown that immediate reconstruction is a very good option. 5 It does not add to the oncologic risks to the patient whether a traditional mastectomy or the increasingly popular skin-sparing mastectomy is performed. 6 , 7 It also permits the surgeon to perform an excellent reconstruction knowing how much breast tissue and volume have been removed, working with native tissues unaffected by scar and contracture, and having a three-dimensional image of the needs for reconstruction. It also permits the patient to recover more quickly overall from the ablative and reconstructive procedures. A psychological benefit in not experiencing a loss of the breast has also been noted, although there are recent counter-arguments in this regard. 7 However if post-mastectomy radiation therapy is indicated this will adversely affect the aesthetic outcome of the reconstructive procedure. This has been shown in cases of immediate and even delayed reconstruction. 8 The major problem arises when the decision for radiation therapy is determined after the operation when the final pathology of the specimen is determined. This usually occurs about one week after the mastectomy procedure. Several centers will prescribe delayed reconstruction in the patients with a high risk or a high potential for post-mastectomy radiation therapy. At times, reconstruction is temporized by placing a tissue expander in the mastectomy pocket that will be removed after radiation therapy or at the time of the delayed TRAM flap reconstruction. 9
The size and extent of the mastectomy defect will also determine the type of breast reconstruction to be performed. The size and shape of the contralateral breast is also important in the decision making process. A single-pedicled TRAM flap is appropriate for a small to moderate size defect along with a small to moderate contralateral breast. Increased size and volume may require a double-pedicled TRAM flap or a delay procedure or even free tissue transfer. The anatomy of the patient is also important in deciding what procedure to perform. We do not see many subcostal (Kocher) incisions for cholecystectomy any more that would require a left-sided single-pedicled TRAM flap. An infraumbilical midline incision is not uncommon, however. In these situations we would consider a single-pedicled hemi-flap, or if more volume is required a double-pedicled TRAM flap in order to use all of the lower abdominal tissue.
The pedicled TRAM flap is not indicated in a woman who does not want to lose a significant amount of their rectus abdominis musculature. Although studies have gone back and forth as to the significance of abdominal wall continence and strength with the removal of one or two rectus muscles, some form of donor deformity is to be expected. Athletic patients that routinely use their abdominal muscles should be offered other options such as perforator flaps of the deep inferior epigastric (DIE) vessels or superficial inferior epigastric (SIE) flaps or other methods.
Other contraindications for TRAM flap reconstruction are significant systemic disease such as cardiovascular and respiratory problems as well as insulin-dependent diabetes. Hartrampf included insulin-dependent diabetes as one of his significant risk factors. Other groups have not placed as much importance with this. 10 I personally have experienced some significant infectious complications in patients with insulin-dependent diabetes and so I am particularly cautious in these patients.
Morbid obesity and smoking have been shown in several studies to be significant risk factors in all forms of breast reconstructions including the TRAM flap. 11 , 12 Variations of the TRAM flap need to be considered in these cases. In the morbidly obese, a midabdominal TRAM flap, a delayed or a double-pedicled TRAM flap may be indicated if it is decided to do any surgery at all. Similarly, in a chronic smoker or one that has recently quit, these TRAM flap variations may also be useful. All attempts, of course, should be made for weight reduction and cessation of smoking prior to performing autologous breast reconstruction.
The experience and comfort level of the surgeon and the surgical team is an important factor in the final indication and decision for a particular type of breast reconstruction. The relative ease and decreased time of performing a TRAM flap makes it a most desirable method of reconstruction. However the surgeon should discuss the various options available in an honest and humble manner with the patient prior to making the final decision. Our understanding of the vascular supply of the TRAM flap is based on a great number of anatomical studies. The more recent classification of Ninkovic et al has refined our understanding of the zones of perfusion. This classification places more importance on the ipsilateral perfusion than the older Hartrampf classification that assigned greater importance across the midline (see Fig. 7.5 ).

Fig. 7.5 Newer classification of blood perfusion of the pedicled TRAM and free TRAM flaps according to Ninkovic et al. 24

Operative Technique

Preoperative preparation
The preoperative preparation of the patient should be well structured and thorough. The amount of time and effort that goes into this preparation will reap benefits intraoperatively as well as in the postoperative period. Any imaging or non-invasive vascular studies, such as laser Doppler flow studies, or computerized tomography (CT) angiogram 13 can be conducted preoperatively in order to get a good assessment of the vasculature of the lower abdomen and chest. This is not a substitute for careful operative dissection but can be useful in patients with risk factors that may also include previous scars on the abdomen. Preoperative marking is very important and should be done with the patient in a standing position. Scars of the abdomen are noted; they may include an upper or lower midline scar, appendectomy scar, paramedian scar, or a Pfannenstiel incision. All of these will impact on the type of TRAM flap that will be proposed as well as the incision of the flap. For instance, a lower midline incision may dictate a double-pedicled TRAM flap if a large volume of tissue is needed for reconstruction. The size of the contralateral breast is also taken into consideration. If any modifications are going to be made during the procedure or in a subsequent operation, this also needs to be taken into account. If it is an immediate reconstruction, the size and weight of the mastectomy specimen will be readily available. If it is a delayed reconstruction, it is useful to ascertain the size and weight of the prior mastectomy specimen. This was a very important piece of information to Hartrampf in deciding and predicting the amount of tissue needed for reconstruction. The midline of the abdomen from the xiphoid to the pubis is drawn. A lenticular or transverse elliptical pattern is then drawn on the lower abdomen. An attempt to establish symmetry on both sides is made. The anterior–superior iliac spines are delineated and used in the markings. A pinching of the lower abdominal tissue in order to get an idea for closure is then performed. Adjustments are made according to the ability to be able to close the abdominal wound once the flap has been raised.
Attention is then directed to the chest. In cases of immediate reconstruction, the marks for the resection are drawn jointly with the surgical oncologist. If possible a skin-sparing mastectomy technique should be used since it gives a better result overall. In situations of delayed reconstruction, the outline of the breast for reconstruction on the mastectomy site is drawn. The width and height of the breast is taken from the contralateral breast, if this is being used as a reference. Projection of the breast will be obtained by appropriate positioning and infolding of the excess pedicle tissue.
The patient is placed in a supine position and general endotracheal anesthesia is induced. A Foley catheter is placed and checked to be in good working condition. Sequential compression devices are now applied to both lower extremities. If the patient is at high risk for DVT or pulmonary embolus, prophylaxis with low molecular weight heparin or other indicated prophylactic drugs are given. Guidelines that include a list of risk factors should be followed to help in preventing thromboembolic disease. 14 Blood is screened but not cross-matched for possible transfusion which has become rare in ablative and reconstructive breast procedures.
Prior to prepping and draping the patient, the surgeon is advised to perform a careful Doppler examination of the abdomen and chest to look for appropriate perforators. This will serve as a good road map to follow during the dissection and will also confirm the type of TRAM flap or variation to be performed. The perforators are marked in ink that should not be washed off.

Surgical technique

Variation I: double-pedicled TRAM flap
The operative technique for a single-pedicled and double-pedicled TRAM flap (DPTF) 15 reconstruction initially is similar. Since the DPTF is much better vascularized, a larger flap can be drawn on the abdomen as both rectus muscle pedicles will be used (see Fig. 7.6 ). The indications for a double-pedicled TRAM flap for single breast reconstruction may be similar to those for free tissue transfer. Often there is a need for a larger volume of well-vascularized tissue for reconstruction, due to a larger defect on the mastectomy side or a larger contralateral breast. Similarly, there may be causes of impaired blood supply such as a history of smoking, radiation to the chest, or scars that have impaired the circulation distal to their sites. Obese patients generally have unpredictable blood supply and are also at risk for decreased perfusion and flap ischemia; many times they have long torsos and a significant lower abdominal pannus. In these cases a midabdominal position to the TRAM flap may be preferred.

Fig. 7.6 The double-pedicled TRAM flap elevates both rectus muscles and care should be taken in rotating and folding the pedicles to avoid undue torsion and tension.

Creation of the flap
The first incision to be made is the superior incision, usually at the periumbilical level. This is a very important point since it is essential to capture as many periumbilical perforators as possible. The initial dissection is beveled superiorly and then carried up to the xiphoid process and to the costal margins. At this point the patient is placed in a flexed position and evaluation of the closure of the upper abdominal flap is made in the distal portion of the abdomen. The closure should not be under a great amount of tension. Too tight a closure of the abdominal wall will lead to ischemia, necrosis, and partial or complete dehiscence. Pfannenstiel incisions are included, if possible, in the lower incision but otherwise disregarded if they do not comply with minimal tension closure.
Flap elevation is now performed from either side since both pedicles will be harvested. The dissection is carried forth to the beginning of the lateral row perforators on each side. At this point a Doppler examination is again performed in order to locate the perforators in the upper and midabdominal regions. A strip of fascia 2–4 cm. wide is then cut in the upper abdominal area over each specific rectus muscle. This is preferably done with a knife in order to avoid significant muscle contracture. Medial and lateral dissection is then carried out in order to expose the underlying rectus muscle. A muscle-sparing technique may be done at this point but it has not been shown to be of much functional value. Hartrampf essentially performed a muscle-sparing technique where he preserved a strip of medial rectus muscle as well as a third of the lateral rectus muscle while he carefully observed the course of the inferior epigastric vessels. He performed this muscle-sparing technique mainly to preserve important musculofascial elements necessary for adequate abdominal wall closure. Studies have been done where the medial and lateral segments of the individual rectus muscle are compressed and a significant decrease in the overall flow through the muscle is evident. If there is any concern about vascularity or viability of the rectus muscle or overlying flap, the majority or all of the muscle should be harvested. The inferior portion of the rectus muscle and the vessels are now dissected and identified. The deep inferior epigastric vessels should be dissected as close to their take-off from the iliac vessels as possible. This is an important point in case there are problems later in the procedure in which these vessels may become useful, such as for supercharging or free tissue transfer of the flap. These pedicles are identified and ligated on both sides. The inferior rectus muscle is then divided preferably with electrocautery in order to assure hemostasis.
There are essentially two methods of elevating the double-pedicled flap at this point. The first consists of continuing the dissection on one side under the muscle to approximately 2 cm from the linea alba in the midline. The overlying fascia is then incised and the dissection is continued to the other side of the linea alba by again making a fascial incision approximately 2 cm from the midline. The contralateral rectus muscle is now elevated and dissected off of the posterior rectus fascia out to the lateral extent of the muscle. During this entire dissection, the rectus perforators to the skin flap need to be watched closely so that no traction or excess torsion is applied.
A second method that can be used in order to elevate the double-pedicled flap often works a bit easier and consists of dissecting a tunnel blindly underneath the midline of the flap at the level of the linea alba. If there is a lower midline scar, this may make this technique more difficult and time-consuming. Then going from caudal to cephalad, an incision on either side of the linea alba is made leaving a fascial strip of 2 or 3 cm in the midline. The muscles on either side of the midline are carefully dissected from their medial and deep insertions until the fascial incisions are met at the level of the umbilicus. Obviously, the umbilical stalk should be freely dissected at this point in order to avoid injuring or cutting it. A huge lower abdominal flap is now in the surgeon and assistant’s hands, and the dissection is carefully continued superiorly to the subcostal margin as well as the xiphoid region. At this point, care is taken to divide the eighth intercostal nerve at each costal margin in order to assure for the most amount of muscle atrophy in the postoperative period which will greatly avoid or reduce the presence of a bulge in the epigastric area.

Insertion of the flap
A large enough tunnel is then constructed by performing dissections on either side from the chest and from the abdomen. It is important to localize the tunnel more in the midline or on the contralateral side of the midline so as not to disturb the medial inframammary fold of the newly reconstructed breast. The dissection in the chest is carried out so as to provide for a normal healthy pocket that will properly house the lower abdominal flap. Usually the passage of a clenched fist in the tunnel is sufficient for passage of the lower abdominal TRAM flap. The rotation and position of the flap is now based on the needs of the patient and the preferences of the surgeon. The usual approach to rotation of the flap is to bring the umbilicus more towards the midline. This produces a 90° rotation in a clockwise direction for a right-sided defect and in a counter-clockwise direction for a left-sided defect. This usually provides an excellent amount of tissue for filling of the defect and to provide the necessary shape and projection required. The superior and, more importantly, the inferior tips of the flap can be folded underneath in order to provide necessary breast projection or they can be resected. In situations where an extensive transverse defect is present, the flap can be left unrotated or can be rotated 180° in order to fill this defect adequately and still provide a good aesthetic result.
The flap is now left in place with a few staples or stitches making sure that the pedicles are not under any abnormal tension or torsion. The color of the flap is also inspected at this point; it should be close to normal or a little bit pale. It should not be cyanotic. If this is the case, inspection of the pedicles should be done immediately.
We look for too much tension or abnormal rotation of the muscle pedicles. Adjustments are made until the flap looks better. If this is not possible, a decision to switch to a microvascular flap is considered at this time. Many times the flap will improve when brought up to the chest because of better venous drainage.

Closure of the donor site

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