Reoperative Plastic Surgery of The Breast (PDF)

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Reoperative
Plastic Surgery
of the Breast
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Reoperative
Plastic Surgery
of the Breast
KENNETH C. SHESTAK, MD
Professor of Plastic Surgery
Department of Surgery
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
Illustrations by William R. Filer

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Reoperative Plastic Surgery of the Breast
Copyright 2006 by Lippincott Williams & Wilkins, a Wolter Kluwer business

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Philadelphia, PA 19106
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All rights reserved. This book is protected by copyright. No part of this book may be reproduced
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embodied in critical articles and reviews.
Library of Congress Cataloging-in-Publication Data

ISBN: 0-7817-2237-3
Shestak, Kenneth C.
Reoperative plastic surgery of the breast/Kenneth C. Shestak; illustrations by William R. Filer.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-7817-2237-3
1. BreastSurgery. 2. Surgery, Plastic. 3. Reoperation. I. Title (DNLM: 1. Mammaplastyadverse
effects. 2. Mammaplastymethods. 3. Physician-Patient Relations. 4. Postoperative Complications
prevention & control. 5. Reoperationmethods. 6. Reoperationpsychology. WP 910 S554r 2006)
RD539.8.S342 2006 618.19059dc22
2005023903
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I dedicate this book to my wife Cindy

for her love and unwavering support of my career,
and to our sonsAdam, Nate, Chris, and Ryan
who are the joy and light of our lives
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P R E FAC E A N D AC K N OW L E D G M E N T S
T
I would like to sincerely thank my secretaries, Nina,
Michele, and Amy, for their valuable help and assistance
his book represents lessons learned during a career
with transcription and going the distance with this
focusing on plastic surgery procedures on the breast. I am
project. A special tribute is due to Ron Filer for his out-
particularly indebted to Dr. Scott L. Williams for his
standing skills as a medical illustrator and for his
friendship and for entrusting me with the care of so many
patience in working with me on this book, and finally to
of his patients at the outset of my career. I owe a special
my friend Eric Hinrichsen for his technical support and
debt of thanks to Dr. Bill Futrell for his support and belief
digital wizardry in the management of the photographs
in me during the early phases of my career. I also wish to
and drawings.
poignantly acknowledge Dr. John Bostwick for his inspira-
Most of all I wish to thank the many patients I have
tion, teaching, and friendship. Finally, I am compelled to
been privileged to take care of for the opportunity to
pay tribute to the plastic surgery residents and the fellows
develop my skills in this aspect of plastic surgery of the
at the Univeristy of Pittsburgh for their help and collegial-
breast. This experience has been the source of great joy
ity over the past 20 years.
and fulfillment throughout my career.
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CONTENTS
1 Introduction to Reoperative Plastic Surgery of the Breast, Including Patient Selection and
Informed Consent 1
2 Breast Aesthetics in the Nonoperated and Reoperative Breast 17
3 Revising the Unsatisfactory Breast Augmentation 64
4 Evaluating Implant Integrity and Explantation Options and Techniques 146
5 Revision Surgery Following Breast Reduction and Mastopexy 183
6 Revision of Implant Breast Reconstruction 237
7 Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction 302
8 Revision and Salvage of the Suboptimal TRAM Flap 340
9 Reoperative Surgery Following Lumpectomy and Radiation Therapy 420
10 Revision of Nipple Areola Reconstruction 455
Index 489
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C h a p t e r 1
Introduction to Reoperative Plastic

Surgery of the Breast, Including Patient
Selection and Informed Consent
The Patient and the Surgeon 1 The Scope of Medical Malpractice 5
Patient Expectations 3 Minimizing the Risk of Medical Malpractice 6
Patient Education 3 Obtaining Informed Consent 7
The Decision Not to Operate 4 Patient DocumentationConsultation and

Operating Room Notes 8
The Decision to Proceed with Surgery 4
Breast Surgery and Litigation 8
Timing 4 Specifics 8
Photographic Documentation 5 Conclusion 10

Informed Consent 5
References 10
This book is an effort to share with plastic surgeons experience with you and hope that you can glean
my 20 years of experience in treating patients with insights that will be helpful in your practice in the
breast problems and managing patients who have wonderful subspecialty of plastic surgery of the
had previous breast surgery with less than the antic- breast.
ipated outcome. In the following chapters I present
my concepts about different areas of breast sur-
gerynot as doctrine, but as a method that I have THE PATIENT AND THE SURGEON
used to understand problem situations regarding
breast surgery and how to approach them. Reoperative plastic surgery in every area of the body
The reader will note that many chapters contain a is fraught with more challenges and greater potential
good deal of commentary on my approach to primary for difficulties and disappointments than is primary
surgery of the breast. This is because I believe that surgery. This is definitely true for reoperative surgery
preoperative analysis and planning are the para- of the breast. Nevertheless, as surgeons, we are all
mount considerations in virtually all of plastic sur- aware that a great deal of satisfaction can be achieved
gery. I offer my concepts of how to envision and by an appropriately timed, well-planned, and accu-
conceptualize the primary operation in various areas rately performed revisional surgery procedure.
of breast surgery as a way of illustrating approaches For the best possible outcome to occur in the set-
that have worked in my hands from the standpoint of ting of reoperative surgery, it is paramount that both
minimizing the incidence of reoperation. the surgeon and the patient be prepared and ready
Most of the text is devoted to sharing my thoughts for surgery. For the surgeon, this means that he or
on a myriad of problems following previous plastic she has made a diagnosis, understands the impor-
surgery procedures on the breast that all plastic sur- tant anatomic details, has formulated a sound surgi-
geons who focus in the area of breast surgery will cal plan, and has explained that plan to the patient.
see in the course of their practice. I wish to share my The surgeon must be sure that the patient is physi-
1
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2 Reoperative Plastic Surgery of the Breast
cally and emotionally prepared to undergo another and type of implant are very important to know in
surgical procedure. all cases.
It is important for the surgeon to connect with the I find it helpful to have the patient request her
patient. Toward this end, it is essential for the sur- previous medical records so that I can review these
geon to demonstrate a true sense of caring and con- in detail. This is done in writing, and we have the
cern for every patient. In practical terms, the surgeon forms in our office to facilitate the process. If there
must convey a sense that he or she is genuinely inter- are issues in the patients previous care that I do not
ested in helping the patient with her problem. First understand, I will ask the patients permission to
and foremost, this entails having an understanding of directly contact her previous surgeon.
the patients concerns, disappointment(s) with previ- Along these lines, it is important for the surgeon
ous surgery, motivations, and goals. It is critical that to gain insight into a patients feelings about her pre-
the surgeon spend the time necessary to communi- vious surgeon. Many times it is apparent that the
cate with the patient in an honest and sensitive way previous procedure was well planned and executed
about her problem so as to establish a positive doc- and that only a minimal revision may be necessary.
torpatient relationship. This relationship will pro- In this setting, I will often encourage the patient to
vide the background for the best possible patient pursue further contact with the original surgeon,
outcome and be the primary means of supporting the especially if I personally know him or her to have a
patient if the revisional surgical procedure results in high level of competence and concern. Obviously
less of an improvement than expected, or in addi- the decision to return to the original surgeon must
tional problems or complications. be left up to the patient.
When seeing a patient with a difficult problem, If the patient appears especially critical of her
the surgeon should be upbeat, understanding, and previous surgeon(s), this may represent a red flag,
supportive. I have found that greeting the patient and extreme caution must be exercised when decid-
with sincerity and meaningful eye contact is always ing whether to accept her as a new patient. This is
helpful. The surgeon must be sensitive to the particularly true if the result obtained from the pre-
patients needs, and most of all he or she must be vious surgery was relatively good but the patient
honest with the patient. expresses multiple criticisms about her result. Such
Honest communication between the patient and patients are typically difficult to satisfy, and if you
the surgeon is the key. It is important for the sur- decide to reoperate, you may be the next surgeon
geon to explain to the patient his or her assessment she is critical of.
of the patients current condition and what the rea- The breast is a very important organ in every
sonable expectations from additional surgery are. womans life, and it contributes greatly to the
The surgeon must spend a significant amount of patients body image and sense of femininity.
time educating the patient and building her confi- Different patients have different levels of psychologic
dence. Investment of time in and honest communica- investment in their breasts. As part of the initial eval-
tion with the patient are always important, and they uation, it is critical for the surgeon to understand
can pay huge dividends throughout the healing how many surgical procedures a patient has had and
process and over the long term. which ones were elective. Multiple previous aesthetic
It is important for the surgeon to gather as much procedures can often indicate a patient whose own
information as possible about the previous proce- body image is poor and may identify a patient who
dure(s). This starts with gathering information has unobtainable expectations from surgery.
from the patient herself, but in many cases more A decision to proceed with revisional surgery can
specific and detailed information should be gar- be made following the initial visit, but it is more
nered from a review of operative records and previ- often established following a second consultation.
ous offices notes, or from direct communication In complicated cases, however, it is often helpful to
with the previous surgeon(s). Such information is see a patient several times before deciding to pro-
usually extremely helpful in formulating an opera- ceed with surgery. This allows the surgeon to clarify
tive plan. In this regard, it may be important for the the details of the operative plan (e.g., outline for the
surgeon to obtain permission from the patient to patient the proposed incisions and position of
contact the previous surgeon. For example, in the implants) and permits a careful review of operative
setting of a previous mastopexy or breast reduction, goals, anticipated recovery time, and potential risks
it is critically important to understand the orienta- and complications. Most important, it allows the
tion of the blood supply to the pedicle that was surgeon to make sure that the patient and surgeon
used. Or, in the case of reoperation in the setting of are on the same wavelength with regard to the goals,
a previous breast augmentation, the size, position, anticipated results, and limitations of additional
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Chapter 1 Introduction to Reoperative Plastic Surgery of the Breast 3
surgery. There is no charge for additional surgical not possible. For example, many patients request that
consultations in this setting. I eliminate scars from a previous procedure or eradi-
As previously alluded to, consistent success in cate the possibility of developing another capsular
every area of plastic surgery requires an understand- contracture following a complicated implant opera-
ing of the patients chief complaint and goals, a care- tion. Another example is that of a patient who has an
ful analysis of the problem and pertinent anatomy, a unsatisfactory breast shape produced by an implant
highly individualized operative plan, and consistent that is inappropriately large for her physique and
surgical technique. who wants to have still bigger breasts following an
In complicated cases, or those in which multiple additional breast procedure. Often patients do not
procedures have already been performed, a thorough understand the limitations of an operation imposed
understanding of the surgical problem and a well- by suboptimal or compromised tissue elasticity and
thought-out approach for its improvement is critical the presence of scar tissue, or they do not compre-
on the part of the surgeon. This is only possible after hend the undeniable reoccurrence of breast ptosis
a careful and compulsive history and systematic following every mastopexy procedure. Many times
physical examination are completed. The formulated their ideas result from having an inadequate under-
plan is discussed in detail with the patient and at least standing of the likely outcome and limitations of sur-
one support person (spouse, relative, or close friend), gery. A true awareness of realistic expectations
and during this discussion the potential risks of addi- results from having an increased understanding of
tional surgery must be spelled out as completely and the surgical procedure(s), and in my experience this
clearly as possible. I find that having a support per- must be derived from patient education on the part
son there is important for the patient. That person of the plastic surgeon and his or her trained staff.
helps to clarify details for the patient and is there in
the event that additional complications arise. Only
when I am satisfied that the patient understands the PATIENT EDUCATION
risks and is psychologically and physiologically pre-
pared for surgery do we proceed. Patient education is in a real sense one of the most
important aspects of a physicians job. Other than
the precise performance of a well-planned proce-
PATIENT EXPECTATIONS dure, it may be the most important part of the plas-
tic surgeons practice.
The patient herself is the best person to define her We live in an age of information availability, as evi-
expectations from a surgical procedure and to demon- denced by the plethora of information present in
strate the aspect(s) of her breast appearance that she many lay publications and on many Internet websites.
wants to change. I place the onus on her in this regard In general this is a good thing, but it has its negative
and ask her to precisely describe her goals in terms points as well. Material contained on various websites
that both she and I understand. I will often have her about cosmetic and reconstructive breast surgery can
stand in front of a full-length mirror and point out on provide the patient with much useful background
her breast(s) precisely her areas of concern. information for understanding some of the issues
It is important for the surgeon to have a good idea relating to breast surgery, but it is often incomplete
of what the patient thinks about her breast size, and nonspecific. Although todays patients in many
shape, and previous scars. The surgeon must also ways are more sophisticated than patients in the past
understand any concerns she has about placing addi- in their knowledge about some aspects of breast sur-
tional scars on her breast(s) from the standpoint of gery, there is very little material they can review about
length and position because often additional scars reoperative surgery and the details related to it.
will be required to achieve the changes that are In this regard the surgeon must be both a good
requested. The surgeon must carefully explore and communicator and an educator. It is essential for the
understand the patients feeling about her breast surgeon to review with the patient and make sure she
symmetry because asymmetry is a very common rea- understands the operative plan, why it was chosen,
son for requesting additional surgery. Is she willing the necessary placement of incisions, the likely dura-
to accept the placement of an implant or have addition of the recovery, and the potential risks and com-
tional scars placed outside the breast if it is deter- plications. I find it helpful to point out the placement
mined that the addition of a flap may be necessary to of incisions on the patients breasts or on a diagram of
optimize her breast appearance and symmetry? the breasts, or to show the patient photographs of dif-
The patient must have realistic expectations about ferent patients who have had similar procedures.
what is possible with additional surgery and what is When using photographs as a means of patient
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education, it is important for the surgeon to show a and breast parenchyma alone) can be performed
range of outcomes and illustrate average surgical under local anesthesia with intravenous sedation.
results. It is essential for the surgeon to be honest and This includes most scar revisions, minor modifica-
not paint an overly rosy picture of potential outcomes. tions of a previous mastopexy or breast reduction,
In addition, it may be helpful for prospective patients and revision of many types of breast reconstructions.
to speak with patients who have had one or more For more involved deep layer procedures with signifi-
reoperative surgical procedures in a similar setting. cant tissue shifts, implant changes with extensive
Not uncommonly the optimal correction of a problem work on the periprosthetic capsular tissue, or surgery
may require two operations (e.g., the placement of a on the muscle layer, I prefer general anesthesia and
tissue expander before an implant for reconstruction will suggest this to the patient. The intraoperative
of a severely constricted breast deformity with a "dou- management of the patients anesthetic needs by
ble bubble" that is present after the initial treatment). trained and experienced anesthesia personnel allows
The patient must be aware of the need for this type of me to focus all of my attention, concentration, and
plan and accept the physical and financial conse- creative energy on the patients surgical problem
quences of possibly having two procedures. without concern about the patients overall state of
Having an accurate sense of the patients under- comfort, level of sedation, and safety. In either case
standing of the proposed procedure and insight into I will often have the patient consult with the anesthe-
her situation is an absolutely critical component of sia service before the planned procedure.
patient selection and is the most important reality
test for the surgeon.
TIMING
THE DECISION NOT TO OPERATE Timing is a very critical element in reoperative sur-
gery and is integral to its success. As previously
Following a consultation and thorough evaluation of stated, both the patient and the surgeon must be
the patients problems, often the best course of action optimally prepared. For the patient, this relates to
is not to reoperate. In these situations the patient must psychologic, physiologic, and anatomic factors.
be told no, but I will do everything I can to explain my The patient must be emotionally ready for
decision by presenting it to her in a way that reflects another surgical procedure. This is especially
sensitivity about her problem. As a doctor your duty is important in the setting of elective surgery. This
always to advise the patient on what you believe to be means that sufficient time has elapsed to permit the
the best course of action. Therefore, do not be afraid patient to clearly focus on recuperating from addi-
to sensitively and diplomatically convey to the patient tional surgery. From a physiologic and anatomic
that you believe that it would be best not to perform perspective, this usually means that the patient
additional surgery if this is your conclusion. must be well into the chronic stage of wound heal-
Alternatively, if I believe that an operation might ing, and tissue equilibrium must have returned.
be possible but that I am not the surgeon with the Enough time must have elapsed to allow softening
experience or surgical skill to perform the surgery of the tissues such that all of the edema and indura-
successfully, I will refer her to a colleague who tion have resolved and the tissues have regained
might better meet her needs. their normal mobility over the underlying muscle
structures. This analysis requires surgical judgment
that is routine for the experienced plastic surgeon.
THE DECISION TO PROCEED WITH The patients health should be optimal from both a
SURGERY physical and psychologic standpoint. Factors that
affect wound healing must be optimized. This
If it is determined that a patient has realistic expecta- includes the nutritional status, and perhaps most
tions and presents with a problem that I can address importantly the smoking history. I strongly believe
with a good chance of improvement, she is most that cigarette smoking has a deleterious effect on
often a good candidate for surgery and the process of wound healing and scar formation everywhere in the
preparing her for a revisional operation then pro- body and must be eliminated before proceeding with
ceeds. The options for treatment of her particular surgery. Of course the patient must be in good health
problem are reviewed, and the procedure I believe and any significant medical conditions or problems
will work best is explained. Included in the explana- (e.g., hypertension) must be well managed.
tion of the surgical procedure is my choice for anes- The surgeon must be optimally prepared as well.
thesia. Many operations on surface tissues (the skin This includes having a detailed understanding of the
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specific facts about the previous surgical proce- cropped the same way when taking the original pho-
dures, most importantly including previous inci- tographs. I find that it is helpful to visualize the
sions and their consequences, implant types and shoulders, and minimal amount of lower neck
positions, mammographic findings, and pathology anatomy should be included along with a view of the
reports where pertinent. upper abdomen. There should be a small amount of
In almost every situation the best outcomes from space on either side of the arm. I find it very helpful
reoperative surgery occur when both the patient and to have the same background color and lighting con-
the surgeon are optimally prepared for the surgical ditions for each picture. Obviously anything that
reintervention. can identify the patient (such as parts of the face)
should not be included in photographs. Maintaining
patient confidentiality is important.
PHOTOGRAPHIC DOCUMENTATION When I see a patient in consultation who has been
operated on previously by a different surgeon, I will
Photographic documentation is very helpful in my often ask if she has, or can obtain, copies or her pre-
plastic surgery practice. It is the optimal way of allow- operative photographs. Such photographs often pro-
ing me to analyze and plan plastic surgery proce- vide a valuable reference in that they give me an
dures. At times there are subtleties that I will pick up understanding of her original breast appearance and
during my study of photographs (or sometimes even condition of her tissues, along with insight into the
while looking through the viewfinder in my camera) actual changes that have occurred in her breasts.
that have eluded me during the physical examination.
More important, the patient can learn a great deal Informed Consent
from seeing photographs of herself, especially if they
are displayed in a full-page (8- 10-inch) format. An informed patient is your best ally.
Photographs of the breasts should be taken in
standard positions with the patient standing in a An explanation about a complication before sur-
relaxed posture with the arms either at the side or gery is an explanation. An explanation of a compli-
cation after surgery is an excuse.
crossed gently behind the back. These positions
should always include anteroposterior (AP), lateral, We have all heard these statements in some form or
and oblique views. They should include both shoul- another over the course of our training or practice
ders and extend from the lower neck to the waist careers. The process of obtaining consent for a pro-
region. Occasionally a view from above with an cedure is an essential component of the art of surgi-
overhead camera or taken from the top of an exami- cal practice. It is an individualized process that for
nation table or bed with the patient lying supine me represents a great percentage of the time spent
may be helpful. Occasionally a view from the foot of in each of my plastic surgery consultations.
the bed can be enlightening, especially for problems The informed consent process is critical for all
relating to implant position or malposition (Chapter surgical procedures, both primary and reoperative.
3). The view from above sometimes provides insight It is particularly important in the area of reoperative
for the surgeon in that it is the way the patient per- breast surgery from both a patient education and
ceives her breast in a bra or a bathing suit. medicolegal perspective. We practice medicine in an
In the past I have used 35-mm transparencies increasingly litigious environment. The surgeon
(slide photographs) and Polaroid pictures. I cur- must have a well-refined and effective approach to
rently use digital imaging. This allows me to store all minimizing exposure to medical malpractice claims
of my photographs in one secured location that is in his or her practice. The following comments are
backed up to a second secured site on a larger net- my thoughts and insights gleaned from my own
work. Such imaging permits me to print a black and practice and from published articles on the medical
white 8- 10-inch photograph of each patient, liability landscape.14
which is kept in her chart. This is a ready reference
in that the patient can see what we started with in
cases involving a staged reconstruction. THE SCOPE OF MEDICAL
The format is not as important as is the use of MALPRACTICE
standard photography. As noted, the picture should
be taken with the patient in the upright position According to Dr. Mark Gorney, president of the
with her arms in normal posture and with the Doctors Company,1,2 data from most malpractice
patient in a relaxed state. Set distances from the insurance companies reflect that approximately
subjects are employed and images should be 85% of all claims against plastic surgeons involve
Ch01.qxd 11/28/05 2:38 AM Page 6
no more than eight to ten elective aesthetic proce- The patient has a realistic idea of what is possible
dures. Of that total, 36% are related to elective and the limitations of a proposed procedure.
breast operations. The surgeon believes that an improvement can be
Of these procedures, approximately 55% are the made based on the presenting problem in light of
result of unsatisfactory scarring or circulatory com- his or her experience, and that the patients expec-
plications in breast reduction. The other 45% are tations can be met by the procedure.
from breast augmentation or breast reconstruction The procedure has been explained to the patient,
done with a tissue expander and subsequent implant including additional incisions and the potential
placement.2 In his discussion regarding issues lead- risks and complications, and these are under-
ing to the filing of complaints in a breast augmenta- stood by the patient, including the risk for further
tion, Gorney states that implant encapsulation, unplanned additional reoperative surgery.
wrong size enlargement (too little or too much),
When all of the conditions outlined are met, the
infection, repetitive surgery with attendant costs,
decision to proceed is most often reasonable and
and sensory nerve damage are the leading issues. In
can be made on a sound basis. In contrast, it is risky
the area of breast reduction and mastopexy, unsatis-
and not worth reoperating on a patient who is seek-
factory scarring, skin loss, nipple areola loss, asym-
ing to obtain an unrealistic improvementor a
metry, and combinations of these resulting in
patient who does not understand or will not accept
disfigurement are common issues.
the inherent risks of a particular procedureno
As outlined earlier, the basic tenets of limiting lia-
matter how much remuneration can result from
bility in medical practice include careful patient
such intervention.
selection, full disclosure, accurate documentation,
and staying within the limits of ones competence.
These issues seem almost intuitive; however, it is MINIMIZING THE RISK OF MEDICAL
surprising to find that deviation from such a sound MALPRACTICE
approach is not uncommon.1
Although patient selection is critical for suc- Gorney et al.1,2,4 advise plastic surgeons and other
cess in any area of plastic surgery, in aesthetic sur- physicians to minimize liability by emphasizing the
gery competitive pressures and the economics of importance of careful patient selection, full disclo-
decreasing reimbursement have at times blurred the sure, accurate documentation, and staying within
criteria for patient selection. The decision about the limits of ones competence. Such practice seems
whether to operate is made after an assessment of almost intuitive; however, it is surprising to find that
the presenting problem and following a discussion deviation from such a sound approach is not
with the patient. The surgeons decision must be uncommon.
made honestly and with the patients best interests Reoperative surgery implies that a patient has
in mind. already undergone a procedure that has not met
In reoperative surgery it is important for the sur- either the patients goals or the surgeons goals or
geon to analyze the result of previous procedures both. The situation is therefore inherently different
from the standpoint of tissue conditions, previous than that of a primary operative procedure. The
scars, and the patients specific goals. The surgeon experienced and conscientious surgeon must care-
must understand the patients perception of her own fully evaluate the patients current psychologic state,
reality, and this must be taken into account before the physiologic and anatomic tissue recovery, and
deciding whether to proceed. her expectations for a revision procedure. Although
The likely improvement with and limitations of a in most situations the main driver in the decision to
given surgical procedure used with a patient must consider and undertake reoperation appears to be
be carefully discussed with her. Such improvement the patient, it should be remembered that it is the
depends on the presenting clinical problem, the sur- surgeon who must make the ultimate decision as to
geons experience and skill, and the patients under- whether to reoperate.
standing and sense of realism. I believe that In the reoperative setting the surgeon may or may
reoperative surgery is most often about improve- not have performed the previous operation. If I per-
mentrather than perfection. I almost always men- formed the previous operation, the patient will most
tion this to the patient, regardless of what area of often have retained confidence in me and request
the body I am evaluating. that I perform the additional surgery. In my practice
My experience with reoperative plastic surgery of the unplanned reoperation rate following elective
the breast has reinforced the following conditions breast surgical procedures is approximately 4%.
for me: This includes breast augmentation, breast reduc-
Ch01.qxd 11/28/05 2:38 AM Page 7
tion, mastopexy, and augmentation mastopexy. The that it is during this interchange that the doctor has
fees related to such revisions, including the sur- the ability to lay the groundwork for a strong doc-
geons fee and the facility and anesthesia charges, torpatient relationship, and it is precisely this rela-
are best outlined for the patient before the initial tionship that can sustain a patients confidence and
operation. trust when the result obtained falls short of expecta-
When evaluating a patient who has been operated tions. I believe that a strong doctorpatient relation-
on by a different surgeon, the second surgeon must ship can in some cases head off a potential lawsuit.
not be harshly judgmental about the previous proce- This consultation must occur in an unhurried
dure, make inappropriate comments about the out- way, and the surgeon must use language that is
come, or convey a critical overtone with his or her understood by the patient and her family, husband,
body language, especially without understanding the friend, or significant other. It is helpful for the sur-
conditions that have led to the patients current situ- geon to use diagrams to explain concepts and to out-
ation. I should also mention here that if I decide to line the position of incisions, as is discussed later in
help such a patient with a reoperative surgical proce- this chapter. The specific procedure, including its
dure, I make it clear to the patient that under no cir- anticipated benefits, its limitations, and its potential
cumstances will I act as an expert witness offering complications, must be outlined. In all preoperative
opinions about the previous surgeons treatment. consultations the options for treatmentincluding
the option of no treatmentshould be explained. In
addition, the surgeon should tell the patient why he
OBTAINING INFORMED CONSENT or she believes the chosen surgical treatment is the
best one for the patient. In my opinion, and from the
Contrary to common belief, obtaining informed analysis of experts writing about the informed con-
consent is not merely having a patient sign a paper. sent process,2,4 this is an essential part of obtaining
It is a process.2 Although a signed form provides evi- informed consent.
dence that some consent was obtained from the It is important for the surgeon to document in the
patient, in and of itself it does not validate that the patients office chart that this interchange of infor-
consent was informed. mation during consultation took place. I find it
Simply stated, informed consent means that an important to record the outlined plan in my dictated
adult patient who is capable of rational communica- consultation note, including placement of incisions,
tion is provided with sufficient information about especially if they are different, longer, or more exten-
risks, benefits, and treatment alternatives (including sive than the previous incisions; the expected peri-
no treatment), enabling that patient to make a operative routine; and the potential risks and
rational judgment about whether to go forth with a possible complications, enumerating those that
procedure. As outlined by Gorney,2 physicians have were specifically mentioned as complications. Such
an affirmative duty to disclose such information, documentation should be accurate and contain all
meaning that they must not wait for questions from of the information given to the patient (e.g., details
the patient but must volunteer information. This regarding the likelihood of certain complications,
information must be communicated in an under- such as saline implant deflation of 2% per year). Any
standable way to the patient (using language that brochures or office pamphlets given to the patient
the patient understands), who is then given the nec- should also be documented. If there are problems
essary time to make an intelligent decision. that are more likely to occur in a particular setting
Obtaining informed consent is an important part of of reoperative plastic surgery, I emphasize these to
every consultation. I believe that, in a real sense, this the patient and document that I have done so in my
process is an art, and as such is it handled by each sur- dictated note. If a witness is present, I dictate that
geon his or her own way. The interchange of informa- persons name into the note.
tion between the surgeon and the patient about a I use preprinted consent forms for both the pri-
prospective surgical procedure is time intensive, and mary and revision surgery procedures that I per-
it can be somewhat laborious for the surgeon and anx- form in my surgical practice. These are modeled
iety provoking for the patient. Nevertheless, this inter- after the consent forms assembled by the American
change is an essential part of every patients Society of Plastic Surgeons for its members. This
preoperative preparation, and it may be more impor- builds into the process a sense of uniformity and
tant and more difficult in the setting of reoperative consistency for my discussions with each patient.
surgery than in that of primary surgical procedures. Sample consent forms for revision of a breast reduc-
The art lies in the surgeons ability to communi- tion, breast augmentation, mastopexy, augmenta-
cate and connect with the patient. I firmly believe tion mastopexy, implant breast reconstruction, and
Ch01.qxd 11/28/05 2:38 AM Page 8
a transverse rectus abdominis musculocutaneous convey the details of the consultation in an honest
(TRAM) flap breast reconstruction are included at and sensitive manner, and by doing so the surgeon is
the end of this chapter (Appendices AF). Based on often able to lessen the patients considerable anxi-
the individual situation, I will occasionally insert ety by giving her a sense that she is participating
additional information in the procedure section or with the surgeon in the procedure. Furthermore, the
add to the list of potential complications. patient can come to see the physician not as
Patients must receive, process, and understand a omnipotent, but as a caring human being who is
lot of information. Therefore, I often encourage a sharing the uncertainty of the outcome with the
patient to take a copy of the consent form home so patient herself.
that she may read it in the comfort of her own home.
I invite her to ask additional questions related to the
procedure after she has had a chance to digest this PATIENT DOCUMENTATION
information, at which time I can answer any addi- CONSULTATION AND OPERATING
tional questions either by telephone or by schedul- ROOM NOTES
ing an additional consultation if necessary. I
document any additional communication with the Suffice it to say that documentation is critical, and
patient in her office chart. it must be accurate. Operating room notes should
Studies on the recall of information disclosed be dictated on the day of surgery whenever possi-
during patient consultation in various fields of sur- ble, when the details are vivid and fresh in the
gery reveal that only 30% of what is presented is mind of the surgeon. Notes dictated at a later time
retained.57 I like to say that patients often exhibit are invariably less accurate and precise as to spe-
"selective cerebration." For a variety of reasons, cific and often important details of the procedure.
patients tend to hear and retain mainly what they Similarly, I try to dictate consultation notes on the
want to hear during a consultation and to block out day of the patients visit, when the details are fresh
many of the important details discussed regarding in my mind. I also try to maintain uniformity in the
the risks associated with a procedure. Because of medical recordkeeping process by dictating all
this I often insist on a second consultation, and the notes.
patient is instructed to have with her a support per- It goes without saying that under no circum-
son (husband, relative, friend, or significant other), stances should medical records ever be altered or
who is present for another discussion of the proce- changed after the fact. If a case is brought against
dure, including its likely outcome, limitations, and the surgeon exhibiting this behavior, such conduct is
potential risks and complications. The support per- easily deciphered, and it undermines or even
son tends to hear much more of what is presented, destroys the credibility and character of the surgeon
and he or she can then review details with the in the eyes of any jury.
patient and be available to support the patient
through the difficult postoperative period if a com-
plication or less-than-intended surgical improve-
BREAST SURGERY AND LITIGATION
ment occurs.
Each physician must be comfortable with the
Specifics
process he or she uses to obtain informed consent
from a patient for a particular procedure. Whether Elective breast surgery is an area in which a signifi-
that involves sending the patient a copy of the con- cant number of lawsuits are filed. In his review of
sent form or the dictated consultation note; using a the Doctors Company data, Gorney2 reports that the
checklist for each procedure, whereby the patient main sources of dissatisfaction and complaint are
acknowledges that the procedure was explained breast augmentation and breast reduction. With
and that she understands the inherent risks or regard to breast augmentation, the most often cited
complications in a line item format; or employing a sources of patient dissatisfaction that result in liti-
method similar to what I have outlined, there gation are the following:
should be documentation that such a process did
indeed occur. Capsular contracture with or without distortion
I firmly believe that the time spent educating and Wrong sizeeither too large or too small
communicating with the patient during the process Asymmetry
of informed consent is important. This is the time Persistent pain
when the patients confidence in the surgeon can be Rippling, ridges, and folds
built and solidified. It is essential for the surgeon to Sensory damage with nipple and areolar numbness
Ch01.qxd 11/28/05 2:38 AM Page 9
Economic damage related to unexpected addi- are not covered by insurance and that the patient
tional surgeries will be responsible for these costs.
Infection requiring implant removal With regard to breast reduction, the most often
cited sources of patient dissatisfaction that result in
I believe that capsular contracture following breast litigation are the following:
augmentation is not a complication but instead is an
Unsatisfactory scarring
inherent risk of the procedure. There is a difference
Loss of the nipple and covering breast tissue
between the two. The formation of a capsule hap-
Asymmetry/disfigurement
pens every time an implantation device of any kind
is introduced into the body. The firmness in the Every surgical procedure entails the placement of
breast that is noted with advanced forms of capsular an incision(s), which will result in a permanent
contracture is an extension of the natural biologic scar. This must be clearly told to all patients under-
process of incorporation of the implant by the body. going surgery. In the setting of breast reduction, the
The patient must be prepared to accept this as scars are often extensive and different in their ori-
inherent risk of the procedure. entation on the breast (i.e, the combination of hori-
I am careful never to promise a bra size to any zontal and vertical scars). During the course of
patient before a breast augmentation, or for that almost every consultation I remind the patient that
matter after a reduction or mastopexy. Different scars are permanent marks that never completely
bras fit patients in different ways, and I have found go away. I explain to the patient that in essence the
that it is not possible to precisely predict what bra operation may be viewed as a tradeoff: "scars for
size a patients breast will be after a given surgical shape." I also explain why it is necessary to place
procedure. scars in specific locations on the breast and illus-
Although the breasts are viewed as a paired organ trate the position of scars on a diagram, which
with implied general symmetry, precise symmetry is becomes part of the patients chart. I mention that
the exception rather than the rule. In the setting of scars can be wide or irregular and that sometimes
breast augmentation, the presence of a pre-existing the wounds will not heal perfectly, with a resulting
breast asymmetry is highly predictive of postopera- open wound that may take weeks to completely
tive asymmetry (Chapter 3). I point this out to all heal. I also mention that after such wounds heal,
patients and tell them to expect some element of the cosmetic appearance of the scars is often less
asymmetry following virtually every breast surgery than desirable, with loss of skin pigmentation and
procedure. contour abnormalities (indentations or step-off
Persistent pain, although uncommon, is a potential deformities) being quite common. In addition, I
problem with every surgical procedure. Alteration in show patients photographs of patients with good,
nipple sensation and sensation of the breast skin can average, and undesirable scars.
occur with any incisional approach used for breast Nipple loss is a dreaded complication of breast
augmentation. Nipple sensation can be completely reduction and mastopexy. I believe that it should be
lost, and this must be mentioned to the patient. mentioned as part of the preoperative informed
Infection is a rare but dreaded risk of breast augmen- consent. Patients are told that it is a rare occur-
tation. If infection occurs, removal of the implant may rence (1% or less), but nevertheless it is a possibility
be necessary, and the patient must often wait 6 to 12 with breast reduction. I mention that if it does
months before insertion of a new implant. occur methods can be used to reconstruct a new
Reoperation after every elective aesthetic proce- nipple, which may appear remarkably like the
dure is a possibility. It may be necessary to treat a patients native nipple, with the addition of an areo-
complication in the acute postoperative setting fol- lar tattoo. However, the reconstructed nipple will
lowing a breast augmentation (e.g., drainage of a not have sensation.
hematoma around the implant; Chapter 3), or it Some degree of asymmetry, i.e., a difference in
may be requested by the patient months or years the appearance with regard to breast shape, position
later (e.g., to address implant malposition or folds). of the scars, size, or inclination of the nipple areolar
Reoperation following breast augmentation occurs complex, following breast reduction (and even
with a frequency of between 14% and 20% within mastopexy) is very common. Scars are necessary
3 years of the initial procedure (Chapter 3). This must and may exhibit a suboptimal aesthetic appearance,
be explained to all prospective breast augmentation but true disfigurement is rare. Significant asymme-
patients. Furthermore, I believe that it is helpful to try can result when multiple complications occur in
clearly define for the patient at the time of the pri- the same breast. Patients should be informed of this
mary procedure that the costs for such reoperations preoperatively. I point out what factors exist that
Ch01.qxd 11/28/05 2:38 AM Page 10
may predispose a patient to such problems and improve almost every situation following previous
explain that unplanned additional surgery following surgery. The surgeon performing revisional surgery
a breast reduction or a mastopexy is also something should be careful not to promise a perfect or unreal-
she must be aware of. istic result. In this setting, and even in the setting of
primary surgery, I believe that it is best to under-
promise and then to overdeliver.
CONCLUSION
The surgeon and the patient should understand that REFERENCES

reoperative surgery is almost always more difficult
1. Gorney M. The wheel of misfortune. Clin Plast Surg.
than primary surgery in every respectincluding 1999;26:15.
delivering the desired result. 2. Gorney M. Preventing litigation in breast augmentation. Clin
It is only after I am comfortable that the patient Plast Surg. 2001;28:607.
3. Martello J. Basic medical legal principle. Clin Plast Surg.
understands the goals, limitations, and potential 1999;26:9.
risks of a given procedure and has what I consider 4. Gorney M, Martello J. The genesis of plastic surgery claims
reasonable expectations from a revisional breast a review of recurring problems. Clin Plast Surg. 1999;26:123.
5. Turner P, Williams C. Informed consent: patients listen and
surgery procedure that we can make the appropriate read, but what information do they retain? N Z Med
decision as to whether to proceed with additional J. October 25, 2002;115(1164):U218.
surgery. Successful practice in this area depends on 6. Langdon IJ, Hardin R, Learmonth ID. Informed consent for
total hip arthroplasty: does a written information sheet
a broad knowledge of the anatomy and concepts improve recall by patients? Ann R Coll Surg Engl. November
relating to breast surgery and experience. 2002;84(6):404408.
The experienced surgeon should not be overconfi- 7. Godwin Y. Do they listen? A review of information retained
by patients following consent for reduction mammoplasty. Br
dent when performing a revisional breast surgery J Plast Surg. March 2000;53(2):121125.
procedure. It is often tempting to think that one can
Ch01.qxd 11/28/05 2:38 AM Page 11
A p p e n d i x A
Revision Breast Augmentation Consent

I, ________________________, authorize Dr. Kenneth C. Shestak and/or such assistants
[Name of Patient]
and other physician(s) as may be designated by him, to perform the following surgical procedure(s), which
I understand to be: Revision of breast augmentation.
[Description of Procedure(s)]
The above procedure(s) have been fully explained to me by Dr. Kenneth C. Shestak, and I understand the risk
of the procedure(s) to be as follows: Bleeding, hematoma, seroma, infection, wound separation, implant
exposure, loss of implant if exposure or infection occurs, capsular contracture (possibly advanced), altered
nipple sensation, contour asymmetry, ripples, ridges or folds in skin, pain, rupture or deflation, allergic reac-
tion to medications, unfavorable scar position or formation, need for unplanned additional surgery, and sub-
optimal cosmetic result.
I understand the consequences of the procedure(s) to be as follows: _____________________________________
1. I acknowledge that I have discussed alternative treatment and options of no treatment with my
physician.
2. I understand that during the course of the procedure, unforeseen or unexpected conditions may arise
that necessitate additional or different procedures immediately necessary to treat my medical condi-
tion and to preserve my life or health. I request and authorize my physician(s) to perform such proce-
dures that in the physicians professional judgment are deemed medically necessary.
3. For the purpose of advancing medical education, I consent to the admittance of observers and discus-
sion of my procedure with others who may not be directly responsible for my care.
4. I understand that my physician(s) or others under the direction of my physician may choose to record,
photograph, televise, or videotape all or any portion of my operation for medical, scientific, or educa-
tional purposes. I consent to the recording, photographing, televising, and videotaping of the opera-
tions or procedures to be performed, including appropriate portions of my body, provided my identity
is not revealed. I understand and agree that (a) any photographs, films, videotapes, or other audio or
visual recordings will be the sole property of Magee-Womens Hospital and will not become part of my
medical record; and (b) Magee-Womens Hospital or any appropriate staff member may edit, preserve,
destroy, or release to my physician all or any part of the photographs, films, videotapes, or other audio
or visual recordings.
Ch01.qxd 11/28/05 2:38 AM Page 12
A p p e n d i x B
Revision Breast Reconstruction with

Synthetic Implant Consent

[Name of Patient]
I understand to be: Revision of breast reconstruction with synthetic implant.
of the procedure(s) to be as follows: Bleeding, hematoma, infection, unfavorable scar, imperfect healing,
wound separation, implant exposure, loss of implant if exposure or infection occurs, increased capsular con-
tracture, implant malposition, persistent asymmetry(ies), contour abnormality, ripples, ridges, folds in skin,
pain, need for additional surgery, implant rupture or deflation, allergic reaction to medications, suboptimal
cosmetic result.
I understand the consequences of the procedure(s) to be as follows: Reconstruction of brest with placement
of synthetic implant(s), scars on breasts.
physician.
Ch01.qxd 11/28/05 2:38 AM Page 13
A p p e n d i x C
Revision of MastopexyUniversal or
BilateralConsent

[Name of Patient]
I understand to be: Revision of mastopexyunilateral or bilateral.
of the procedure(s) to be as follows: Bleeding, hematoma, seroma, infection; unfavorable scarring, open
wounds, contour abnormality or asymmetry of breast(s); loss of nipple sensation; asymmetry of size, shape,
nipple position, nipple location or location of scars; pain, nipple loss, recurrent ptosis (sagging or settling) of
breasts; allergic reaction to medications; need for additional unplanned surgery(ies); suboptimal cosmetic
result.
I understand the consequences of the procedure(s) to be as follows:_____________________________________
physician.
Ch01.qxd 11/28/05 2:38 AM Page 14
A p p e n d i x D
Revision of Augmentation Mastopexy

Consent
[Name of Patient]
I understand to be: Revision of augmentation mastopexy.
of the procedure(s) to be as follows: Bleeding, hematoma, seroma, infection; unfavorable scarring, wound
separation, implant exposure, loss of implant should exposure or infection occur; decreased nipple sensa-
tion, nipple loss, capsular contracture (possibly increased); persistent asymmetry(ies) related to size, shape,
nipple appearance, position of implants or breast; recurrent breast ptosis (settling or sagging), allergic reac-
tion to medications, need for additional unplanned surgery(ies), suboptimal cosmetic result._____
physician.
Ch01.qxd 11/28/05 2:38 AM Page 15
A p p e n d i x E
Revision of TRAM Flap Breast

Reconstruction Consent
[Name of Patient]
I understand to be: Revision of TRAM flap breast reconstruction.
of the procedure(s) to be as follows: Bleeding, hematoma, skin necrosis, imperfect wound healing, open
wound, persistent contour abnormality of breast, persistent asymmetry of breast, fat necrosis, partial or
complete flap loss, unplanned additional surgery, suboptimal cosmetic result, allergic reaction to medica-
tions.
I understand the consequences of the procedure(s) to be as follows: Reconstruction of breast, scars on breast
and on abdominal wall and around umbilicus. ________________________________________________________
physician.
Ch01.qxd 11/28/05 2:38 AM Page 16
A p p e n d i x F
Revision of Breast Reduction Consent

[Name of Patient]
I understand to be: Revision of breast reduction.
of the procedure(s) to be as follows: Bleeding, hematoma, seroma, infection; imperfect healing, open
wounds, decreased aesthetic appearance of scars if open wounds occur; persistent breast asymmetry as relat-
ing to size, shape, position of nipple, position of scar, contour abnormality; fat necrosis resulting in lumps in
the breast; unfavorable scar or painful scar, pain in breast; allergic reaction to medications, need for addi-
tional unplanned surgery(ies), suboptimal cosmetic result.
physician.
Ch02.qxd 11/27/05 8:35 PM Page 17
C h a p t e r 2
Breast Aesthetics in the Nonoperated

and Reoperative Breast
Breast Development and Anatomic Skin Envelope Asymmetry 39

Distribution 18 Skin Scars 41
Scar Hypertrophy 42
Determinants of Breast Aesthetics 20 Contour Abnormalities 44
Breast Volume and Skin Envelope 20 Previous Breast Implant Surgery 46
Nipple Areolar Complex 20 Periprosthetic Capsular Surgery 46
Applied Aesthetics 22 The Effect of Implant Placement on Breast

Parenchymal Vascularity and Nipple Areolar
Breast Supporting Structures 24 Blood Supply 47
Coopers Ligaments 24
Skin 24 Aesthetic Priorities in Revisional Breast
Inframammary Fold 26 Surgery 48
ContourProblems with Dimension and Shape 50
Body Habitus and Breast Aesthetics 32 Spreading of Scars Secondary to Skin Loss 53
Bony Anatomy of the Thorax and Spine 32 Volume 55
What the Eye Sees 32 Nipple Areolar Complex 57
Symmetry 36
Nipple Areolar Complex 37 Combined DeformitiesDiscrepancies of Volume
and Nipple Position 59
Summary of Visual Aesthetics 37 Discrepancies of Contour, Volume, and Nipple
Position 60
How What the Eye Sees Affects Revisional
Breast Surgery, or What Is Wrong with Combined DeformitiesInadequate Volume,
This Picture? 38 Projection, and Contour 61
Inadequate Contour, Shape, Position,
The Previously Operated BreastImportant and Volume 62
Clinical and Anatomic Differences 38
Decreased Skin Elasticity 38 References 63
Obtaining the optimal aesthetic outcome in breast sur- Breast aesthetics are determined by the shape,
gery is a goal that every breast surgeon strives to volume, and position of the breast mound relative to
achieve, but it is also a goal that often remains elusive. a patients anterior torso. To optimize the aesthetic
Although definitions of the ideal breast exist, each sur- outcome, the surgeon must be able to image what
geons attempts at such creation are an internalized alteration he or she is trying to create in a particular
artistic vision that is brought to the operating table patients breast with regard to these relationships. In
after careful preoperative assessment and planning. addition, the surgeon must take into account how
This can be a learned form of artistry. It requires expe- expected alterations will be affected by wound heal-
rience, surgical skill, and the ability to understand the ing, eventual softening, and gravitational settling of
particular patients concerns and anatomic challenges. the breasts tissues following surgery.
17
Ch02.qxd 11/27/05 8:36 PM Page 18
Breast aesthetics involves two senses: the visual Topographical Breast Anatomy
and the tactile. Visual characteristics that are most
important are symmetry, contour, flow, and propor-
tion. The main tactile features are softness, mobility
of the breast tissues on the chest wall, and the
patients individual breast sensitivity. As previously
noted, I believe that it is important for every surgeon
to preoperatively image what alteration he or she is
trying to create in a particular patients breast. This
is achieved by developing a concept of a normal
attractive breast with an understanding of how
breast landmarks and a particular patients anatomic
features and proportions contribute to it.
BREAST DEVELOPMENT AND

ANATOMIC DISTRIBUTION
Anatomically, the breast vertically overlies the sec-

ond through sixth ribs (Fig. 2-1). In the horizontal
dimension it most typically extends from the lateral
FIGURE 2-1. Topographical distribution of the breast
sternal border to the mid axillary line (Fig. 2-2). On parenchyma extending from the second to the sixth rib. Note
frontal view the breast extends beyond the lateral that the lower pole extends below the origin of the pectoralis
margin of the ribs as it flows toward the lateral edge major muscle.
of the latissimus dorsi muscle (Fig. 2-2). This hori-
zontal dimension at the widest point of the inferior-
most aspect of the breast on the frontal view
FIGURE 2-2. In AP view the breast extends from the parasternal area laterally beyond the lateral rib
margin.
Ch02.qxd 11/27/05 8:36 PM Page 19
Chapter 2 Breast Aesthetics in the Nonoperated and Reoperative Breast 19
Sternal
notch
MCP
IMF
Breast
width
anterior
axillary line
FIGURE 2-3. AP view with commonly used dimensions for

aesthetic analysis and planning.
represents the base width, which is an important

visual characteristic (Fig. 2-3). Differences in breast
base width are readily recognized as asymmetries, FIGURE 2-4. Depiction of mammary ridge, or milk line,
especially in the setting of reconstructive breast sur- extending from axilla to groinnoted in embryo.
gery. This dimension is critical for tissue expander
and implant selection, as well as serving as an
important benchmark for revision surgery planning.
These anatomic boundaries and surface relation-
ships are foreshadowed by events that take place
early after fertilization leads to the creation of the
embryo. The breast develops in utero along the
mammary ridge, which is a line that extends from
the axilla to the groin (Fig. 2-4). The breast bud
develops from an ectodermal precursor, which
invaginates at the sixth week of in utero develop-
ment such that this aggregate of ectoderm (which is
the breast in the developing embryo) comes to lie
beneath the skin. This embryologic breast then actu-
ally develops within the anterior and posterior lay-
ers of the superficial fascia of the chest wall.
Although there are foci of breast tissue precursors
along the entire mammary ridge (Fig. 2-4), in the
normal situation only the aggregate in the fourth
intercostal space persists after birth, and thus this
accounts for the normal topographic location of the
breast. Persistence of breast tissue elsewhere along
this line can be present as supranumerary nipples
(Fig. 2-5) or as ectopic breast tissue (Fig. 2-6).
Normal breast development begins at approxi-
mately 10 years of age at the time of puberty and is
usually complete by 16 to 18 years of age. Under the
influence of various hormones, most notably estro- FIGURE 2-5. Supernumerary nipple noted in the milk line.
gen, the gland assumes a rounded, hemispheric This is the most commonly encountered congenital breast
shape characteristic of puberty (Fig. 2-7A). The vol- abnormality.
Ch02.qxd 11/27/05 8:36 PM Page 20
tion and appearance of the nipple areolar complex

(NAC), the quality of the skin envelope, and the rela-
tionship of the resulting breast to the patients ante-
rior chest structures. Of paramount importance is
the visual relationship of one breast to its counter-
part on the opposite side of the midline. Simply
stated, these components produce the image of
breast shape and symmetry (Fig. 2-8).
Breast Volume and Skin Envelope

The ideal breast (Fig. 2-8) exhibits elasticity of the
skin and parenchyma, a majority of volume in the
lower pole, and an NAC that is at the highest point
of the breast mound. On frontal or anteroposterior
(AP) view the breast has less fullness in the upper
pole and more fullness below and lateral to the NAC
in the lower pole. On lateral view the breast
parenchyma is positioned above the inframammary
(IM) fold and exhibits roundness of the lower pole
and a subtle fullness above the NAC, a feature that is
especially noted in youth.
Nipple Areolar Complex

The NAC (Fig. 2-9) is central to breast aesthetics. It
is the visual focal point of the breast and the eye is
immediately drawn to it. All breast lines flow
FIGURE 2-6. Ectopic breast tissue with accompanying nipples
toward it. In the youthful breast it is usually
noted bilaterally in the axilla. Patients often request excision of located at the highest point of the breast mound
this degree of tissue. along the midbreast meridian, which is a perpendi-
cular line dropped from the midclavicular point
inferiorly (Fig. 2-10). It is located slightly above the
IM fold. It has approximately 4 to 6 mm of projec-
tion on the average and slight medial inclination.
ume, or parenchyma, is predominantly distributed In most patients, the areolar diameter varies
as a round lower pole, which in youth projects maxi- between 38 and 42 mm and exhibits a characteris-
mally at the nipple and tapers to fill the upper hemi- tic color that is notable. That is to say, the color in
sphere of the breast (Fig. 2-7B). the nipple and areola is often a strong contributing
After puberty, the parenchyma becomes less factor to breast aesthetics. The position of the NAC
firm as the patient ages and the ratio of adipose may differ between breasts in a particular patient.
tissue to breast tissue increases. The breast With aging the NAC assumes a more dependent
parenchyma, therefore, contributes to the feel of position on the breast mound (see Fig. 2-7E). The
the breast and to its elasticity. This elasticity relationship of the NAC to the IM fold and the breast
changes and decreases with alterations in weight, parenchyma is very important as it forms the basis
age, and hormonal milieumost notably preg- of the most commonly used classification of mam-
nancy (Fig. 2-7CE). mary ptosis (Fig. 2-11).1 It is the hallmark of defin-
ing the youthful, aesthetic appearance of the breast.
This relationship of the NAC to the breast mound
DETERMINANTS OF BREAST forms the basis of a system of applied aesthetics as
AESTHETICS described in the following section, wherein the IM
fold is used to help determine the new position of
Breast aesthetics are determined by the volume, the NAC when it is relocated during bilateral mam-
parenchymal distribution, tissue elasticity, the loca- moplasty.
Ch02.qxd 11/27/05 8:36 PM Page 21
A B C D E
11 18 28 58 71
FIGURE 2-7. AE, Changes in shape of breast gland as a function of age. Note progressive degree
of ptosis.
FIGURE 28. Parenchymal distribution and skin envelope appearance of the teenage (A, B) and
mature (C, D) female breast. (continued)
Ch02.qxd 11/27/05 8:36 PM Page 22
FIGURE 2-8. (CONTINUED)
APPLIED AESTHETICS
A simplification of breast aesthetic analysis may be

done using topographical measurements from fixed
points on the torso to points on the breast itself. It is
most common to use the suprasternal notch (SSN),
nipple location, breast base width, and distance
from the nipple to the IM fold (see Fig. 2-3). As pre-
viously mentioned, the NAC is the focal point of the
breast (see Fig. 2-9). For this reason, determining
new nipple position is a critical part of every proce-
dure on the breast. As noted earlier, this is often
done by using distances from a fixed reference point
such as the SSN, the midline of the sternum, and
midposition of the clavicle. The midmeridian of the
breast is defined by a line dropped in a perpendicu-
lar manner from the midpoint of the clavicle, which
is midway between the SSN and the acromioclavic-
ular joint. The nipple is most often situated on a line
19 to 25 cm from the SSN in the midmeridian of the
breast, depending on the patients height. In youth it
is best envisioned at or slightly above a transposi-
tion of the IM fold. The method for establishing the
optimal position of the nipple during mammoplasty
FIGURE 2-9. The NAC is the visual focal point of the breast. has been classically taught by placing ones middle
Ch02.qxd 11/27/05 8:36 PM Page 23
Topographical Breast Aesthetics
m
5c
m
2
c
to
25
19
to
19
9t
o
12
cm
7 to 10cm
FIGURE 2-10. Lateral view relative to NAC, IM fold, and SSN with average distances as noted.
finger behind the breast to project the position of Establishing New Nipple Position
the IM fold anteriorly (Fig. 2-11). If done incorrectly
(and it is commonly done incorrectly) this can result
in too high a placement of the nipple. For this rea-
son I believe that the most accurate way of establish-
ing nipple position based on the IM fold level is
by placing a tape measure directly in the fold
(Fig. 2-12). The utility and reliability of this maneu-
ver is illustrated in later chapters.
The distance from the midsternal line to the nipple
is usually between 9 and 12 cm, and the average dis-
tance between the nipple and the IM fold varies Incorrect
between 7 and 10 cm. The base width of the breast in A
the frontal view varies between 11 and 16 cm in most
patients, and the distance over the surface of the breast
skin from the lateral sternal border to the midaxillary
line at the level of the nipple is most often 17 to 23 cm.
I find it helpful to record these dimensions on a dia-
gram in the chart of every patient (see Fig. 3-2).
It is important for the plastic surgeon to recog-
nize that these distances are relative and that real aes-
thetic relationships vary according to a particular
patients height, weight, body build, heredity, and
age.
The fallibility of clinging to absolute measure- Correct
ments alone when planning a breast operation is
B
perhaps best illustrated by focusing on the distance
from the SSN to the nipple. An often-cited publica- FIGURE 2-11. AB, Use of the middle finger to indicate the
tion from the 1950s suggests that the position of the transposition of the IM fold to the anterior breast. It is important
nipple on the breast mound relative to the SSN not to displace the fold too superiorly (incorrect method).
Ch02.qxd 11/27/05 8:36 PM Page 24
the skin envelope (by adding or removing skin) in a

given revision procedure. These dimensions provide a
framework for planning specific maneuvers and for
selecting certain techniques rather than others. In
addition, referring to them after the procedure is com-
pleted allows the surgeon to verify the accuracy of
such planning and to develop a sense of predictability
relative to the outcome of such planning.
BREAST SUPPORTING STRUCTURES
Coopers Ligaments
The breast actually develops within the anterior and
posterior layers of the superficial fascia of the chest
wall. During the first three decades of life the shape
of the breast is largely determined by the support
conferred to the parenchyma via condensations of
connective tissue arising from the pectoralis muscle
fascia, which run through the interlobular planes of
the breast gland and insert on the dermis (Fig. 2-14).
These ligaments were first described by Sir Astley
Cooper and are thus called Coopers ligaments. They
FIGURE 2-12. A more accurate delineation of the IM fold level are the most important supporting structure of the
is obtained by placing a tape measure in the IM fold and drawing breast from an anatomic standpoint. These struc-
a line on the skin. tures are not visible during breast surgery and there-
fore they cannot be reconstructed. They are
forms an equilateral triangle with the SSN to nipple inelastic. Therefore, when they are stretched beyond
distance being 21 cm and the internipple distance a certain point they cannot recoil, and subsequently
also being 21 cm.2 A careful reading of the paper their ability to support the breast parenchyma is
reveals that the subjects who were studied were severely compromised. This stretching of Coopers
healthy young volunteers, namely thin women in ligaments is most commonly noted following preg-
the late teens or early twenties. I have not found that nancy or with large or repeated fluctuations in a
this article pertains to most of the patients I see in patients weight. These two conditions represent the
consultation for breast surgery, especially patients I most common clinical situations producing a
am evaluating for a revisional surgical procedure. marked change in the shape of a patients breast.
That is to say, the distance from the SSN to the nip-
ple is not 21 cm in the majority of patients I have
Skin
encountered in the reoperative setting. Therefore,
positioning the nipple at this distance may be The skin is an essential medium for breast appear-
unwise and inappropriate for many patients. Rather, ance, and it contributes strongly to overall breast
the specific anatomy, height, weight, and tissue elas- aesthetics. By its essential features of color and
ticity of each patient must be taken into account elasticity, the skin conveys a sense of beauty and
when planning a revision mammoplasty in which youthfulness to the breast. In addition, its elasticity
the NAC will be transposed. helps determine breast shape.
Nevertheless it is common, and I believe helpful, to In youth the skin is relatively taut (see Fig. 2-8),
use quantitative measurements in reoperative surgery but changes during aging produce thinning and loss
of the breast. Measurements of the breast base width of elasticity. In the absence of previous surgery,
and vertical height recorded in centimeters (see Fig. 2- changes in the skin that are typically encountered
3) are important aides in selecting the appropriate by the plastic surgeon during a consultation with a
implant or tissue expander, for establishing the skin patient requesting a breast procedure include
paddle dimensions on flaps that are transferred to the altered skin elasticity. These changes are seen in
breast in a patient undergoing a delayed or redo this nulliparous 35-year-old athletic patient with
breast reconstruction (Fig. 2-13), and for adjusting significant (grade III) breast ptosis (Fig. 2-15A).
Ch02.qxd 11/27/05 8:36 PM Page 25
FIGURE 2-13. Careful measurement of the quantitative skin deficiency in both the vertical and hori-
zontal dimension is part of the planning for every delayed breast reconstruction as illustrated.
Most often this is marked by the presence of striae

Suspensory ligaments (which are physical evidence of rupture of the
of Cooper elastin fibers within the breast skin), a prominent
superficial subcutaneous vessel pattern that is most
often a visible network of fine reticular blood ves-
sels, or skin that is simply stretched. These skin
changes are most commonly seen in the setting of
macromastia associated with obesity or breast pto-
sis due to postpartum involution, significant weight
loss (Fig. 2-15B), or repeated fluctuations in a
patients weight.
In most patients progressive thinning of the skin
occurs with aging, thus reducing the skins contri-
bution to breast support and maintaining shape
(see Fig. 2-7E). The presence of decreased skin
elasticity is important to note because it is a predic-
tor of recurrent ptosis or gravitational changes fol-
lowing many breast procedures in which skin
support is relied on to maintain a change in shape.
Despite these limitations imposed by aging and the
other factors noted, historically the skin has been
the medium of the breast that is most often altered
by plastic surgeons in procedures aimed at improv-
ing breast aesthetics. Newer breast reshaping oper-
ations such as vertical scar mammoplasty rely on
parenchymal reshaping with internal suturing to
more significantly maintain changes in breast
shape and improved aesthetics. These parenchy-
FIGURE 2-14. The anatomic position of Coopers ligaments mal reshaping and stabilizing techniques may
course through the parenchyma in the interlobular area of the improve the longevity of changes they produce in
breast. the breast.
Ch02.qxd 11/27/05 8:36 PM Page 26
The relative definition or tightness of the IM fold

Inframammary Fold
varies in different patients (see Fig. 2-17AC). I
The IM fold is the most important architectural ele- believe that the IM fold definition is related to the
ment for defining the shape and appearance of the density of connective tissue relative to the amount
female breast. In my opinion, the IM fold is perhaps of adipose tissue (the ratio of fibrous tissue to sub-
the key structure for determining breast aesthetics in cutaneous adipose tissue) in the fold. The greater
almost all operative and reoperative breast cases. It the amount of adipose tissue, the lesser the defini-
is the foundation on which the breast is configured, tion of the fold. Conversely, the lesser the amount of
and it contributes strongly to shape, projection, and subcutaneous adipose tissue and the greater the
upper pole fullness when the patient is standing concentration of fibrous tissue, the more developed
upright. Therefore a careful analysis of the fold for or tight the IM fold development (Fig. 2-18A,B). In
shape, degree of development or tightness, and sym- some patients with tight folds, these connective tis-
metry constitutes an important part of every aes- sue condensations may extend below the superficial
thetic analysis of the breast that is conducted before fascia toward the pectoralis muscle fascia in greater
surgery. An understanding of IM fold anatomy and concentration. That is to say there are more fibrous
its contribution to the breast shape or problems elements connecting the superficial fascial system
with breast shape in a particular patient is a critical (SFS) to the PMM fascia in patients with tight folds.
tool in the breast surgeons surgical repertoire. As previously outlined, most embryologists
Clinically the IM fold extends from the paraster- believe that the breast develops within a split of the
nal area to the anterior axillary line in the frontal SFS (i.e., between the anterior and posterior layers
view. This fold subtends a smooth convex downward of this fascia) on the anterior trunk.1 These layers of
curve, which is most often symmetric when the the superficial fascia form the corresponding ante-
breasts are examined in the AP view (Fig. 2-16). Very rior and posterior capsule layers of the breast. As
importantly, I have come to recognize that the IM illustrated in Figure 2-1, the breast proper extends
fold displays different degrees of development in dif- from the second to the sixth intercostal space.
ferent patients. That is to say, it displays various Therefore the lower aspect of the breast extends well
degrees of looseness or tightness in a given individ- below the origin of the PMM and its fascia in most
ual (Fig. 2-17AC). The curve or convexity of the fold patients. For this reason I do not believe that there is
is most often symmetric, but any areas of asymme- a ligament joining these fibrous tissue elements to
try must be noted. The most inferior or lowest point the pectoralis muscle fascia as has been suggested.6
of the IM fold lies on or close to the vertically ori- I believe that most of the vertically oriented fibrous
ented midbreast meridian, which is a vertical line connective tissue elements that are responsible for
drawn from the midclavicular point through the
most projecting point of the breast, which usually
corresponds to the nipple (see Fig. 2-10). The fold is
positioned 4 to 6 cm from the lower areolar margin
in small- to medium-size breasts and 7 to 9 cm in
larger breasts.
The architecture and histologic composition of
the IM fold has been studied for more than 150
years, beginning with Sir Astley Coopers descrip-
tion in 1845.3 However, there is still considerable
debate about its exact anatomic makeup. I have
reviewed many of the recently published anatomic
studies and have derived the following concepts
regarding the anatomy of the IM fold from these
studies and from 20 years of surgical experience.46
The IM fold is formed by the condensation of con-
nective tissue arising from the superficial fascia that
extend vertically, coursing superficially through the
subcutaneous tissue to insert into the dermis at the
IM fold, producing the characteristic appearance of
the fold. To a much lesser degree some of these verti-
cal fibrous bands extend deep to the superficial fas- FIGURE 2-15. A, Decreased skin elasticity in this nulliparous
cia toward the pectoralis major muscle (PMM). patient with major (grade III) ptosis. (continued)
Ch02.qxd 11/27/05 8:36 PM Page 27
FIGURE 2-16. IM fold seen on AP view as a convex downward

FIGURE 2-15. (CONTINUED) B, Massive weight loss patients arc extending from parasternal area to anterior axillary line.
have an extreme form of this condition.
FIGURE 2-17. Clinical variations in the tightness of the IM fold. A, Loose fold. B, Moderately tight
fold. C, Extremely tight fold.
Ch02.qxd 11/27/05 8:36 PM Page 28
I envision and classify the various degrees of tight-

ness of the IM fold in different patients as illustrated
Deep layer SFS in Figure 2-19.
Chest wall muscle fascia
The degree of tightness of the fold has a definite
effect not only on breast shape, but also on the selec-
tion of procedure for certain breast operations. This
is true for both cosmetic and reconstructive breast
surgical procedures.
For example, from a clinical standpoint I do not
believe it is routinely possible to completely eradi-
Fibrous cate and redefine or reset a tight IM fold in most
canal cases. This becomes important in breast augmenta-
Skin tion in a patient with an extremely tight fold where
B
lowering of the IM fold is planned as part of a breast
Superficial augmentation. If such a maneuver (attempting to
layers
lower a tight IM fold by placing an implant beneath
it) is carried out in a patient with a very tight fold, a
A not uncommon sequela is the appearance of a dou-
FIGURE 2-18. AB, The density of the fibrous connective tis- ble bubble (Fig. 2-20). On the other hand, in recon-
sue in the fold determines its degree of looseness or tightness. struction of the constricted breast deformity
(From Acland PRS Feb 2002, with permission.) (Fig. 2-21AC), releasing, remolding, and reshaping
the tight IM fold is essential. This is best accom-
creating the fold lie between the SFS layer and the plished with an operation that entails a complete
skin.4 disinsertion of the breast parenchyma from the skin
As noted earlier, clinically the fold outlines an arc above and the PMM fascia below, coupled with the
beginning near the midline in the parasternal area placement of an implant. In some cases with an
and continues laterally, where it extends to the lat- extremely tight fold, a two-staged approach with the
eral aspect of the breast at its juncture with the release described earlier, along with the placement
lateral chest wall at the anterior axillary line of a tissue expander to gradually mold a new IM fold
(see Fig. 2-16). Different patients exhibit different contour, followed by the placement of an implant,
degrees of development of the IM fold. These vary may be most effective in resetting and reconstruct-
from a loose fold, or no development of the IM fold, ing the fold from the perspective of optimizing sym-
to a moderately tight fold, or moderate development metry and avoiding a double bubble deformity.
of the IM fold, to a tight IM fold (see Fig. 2-17AC). I make additional comments on this in Chapter 3.
Loose Moderate developed Tight
FIGURE 2-19. Diagrammatic representation of the varying degrees of tightness of the IM fold.
Ch02.qxd 11/27/05 8:37 PM Page 29
Most often the IM fold is roughly symmetric

when comparing both breasts. However, the sur-
geon must carefully note any element of asymmetry
in the position and the architecture of the IM fold as
both breasts are analyzed. Be aware that abnormali-
ties in the IM fold architecture can have a profound
effect on virtually every breast surgical procedure
from the standpoint of affecting symmetry.
Asymmetry in the level of the IM fold is a very com-
monly noted abnormality following previous breast
surgery (Fig. 2-22A,B) and is one that often requires
correction with revisional breast surgery to achieve
a better aesthetic result (Fig. 2-22C).
FIGURE 2-20. The double bubble is created when a subpec-

toral implant is positioned below a tight IM fold.
FIGURE 2-21. A, The constricted breast anomaly. B, The treat-

ment requires release of fibrous bands and reconstruction of the
IM fold at a lower level and reconstruction of the lower pole of
the breast. C, Reconstruction of lower pole of breast with new
lower IM fold. This patient had a contralateral vertical breast
reduction and is shown 14 months postoperative.
Ch02.qxd 11/27/05 8:37 PM Page 30
Possible deformities produced by variations in the pole of the gland will drape itself over an implant in a
IM fold development include a spectrum of con- much better way and produce more of a natural con-
stricted breast deformities and a frank tuberous or tour of the lower breast pole.
tubular breast deformity (see Fig. 2-23AC). A classifi- It is important to note where the breast takes off
cation of this constriction is proposed by Grolleau relative to the lateral border of the sternum and also
et al.7 Diagrammatically it is illustrated in Figure 2-24. how this point on one breast relates to the same area
The constricted breast (see Fig. 2-21A,B) is character- on the opposite breast. If it originates somewhat lat-
ized by a narrow base width, reduced skin dimension eral to the parasternal area, then a medial breast
between the areola and the IM fold, and deficiency of constriction deformity is present, and this must be
lower breast pole development. Clinically there are addressed especially if there is a difference in this
increased fibrous bands or fibrous condensations in takeoff point between the two breasts. Preoperative
the breast parenchyma itself, extending beneath the recognition of this deformity (see Fig. 2-23A) is
deep surface of the gland to the PMM fascia. The essential, and it must be addressed with the surgical
fibrous connections between the breast parenchyma intervention. Otherwise a persistent asymmetry
and the pectoralis muscle fascia must be released of the breast in the location of the IM fold will be
to treat the condition. For this reason these patients maintained.
benefit from the dual plane technique for implant Suffice it to say that the IM fold is a vitally impor-
reconstruction.8 In the most severe form (Type III; tant landmark for the breast surgeon because it is crit-
Fig. 2-23C) there is also an increased density of ical in determining many aspects of breast aesthetics.
fibrous bands within the breast gland itself. The prob- Any asymmetry or other problems related to it must
lem is amenable to treatment by releasing these fibers be recognized preoperatively and be carefully consid-
with incisions made in the parenchyma by radially ered as a surgical plan is formulated. Difficulties
scoring the deep surface of the breast gland as classi- related to correction of IM fold constriction should be
cally described.9 After release of these fibers the lower discussed with the patient preoperatively.
FIGURE 2-22. Asymmetry of the IM fold levels (A) following breast augmentation with the fold being
too high on the left side and in definition and (B) following TRAM flap breast reconstruction with the
fold being ill defined and too low in the reconstructed left breast. C, Oblique view of left breast showing
no definition of the IM fold.
Ch02.qxd 11/27/05 8:37 PM Page 31
FIGURE 2-23. Clinical spectrum of IM fold constriction. A, Medial aspect of left IM fold. B, Mild
bilateral constriction. C, Marked constriction of the IM fold with frank tubular breast deformity.
Medial
constriction
A B Medial and
central IM fold
constriction
Normal
IM fold
contour
Total
constricted
IM fold
FIGURE 2-24. Diagrammatic representation of the location of IM fold constriction. A, Medial.

B, Entire IM fold. C, Entire breast.
Ch02.qxd 11/27/05 8:37 PM Page 32
BODY HABITUS AND BREAST breast appearance, i.e., that which will be in con-
AESTHETICS formity with their wide chest. Similarly, volume
requirements for such a patient will be greater than
The analysis of breast aesthetics in a given patient those for the patient with a narrower chest dimen-
begins with observations of the patients body type, sion. This is very important in the setting of both
size, and proportions of the torso, which give the reconstructive and cosmetic breast augmentation
surgeon the ability to determine the ideal breast surgery where implants are used. This is illustrated
appearance for a particular patient. Patients with a in the patient shown in Figure 2-25, who underwent
wide chest dimension (Fig. 2-25) require a breast an implant-based reconstruction. This resulted in a
with a substantial base width to have an appropriate breast with inadequate base dimension for her
husky build and wide torso (Fig. 2-26). An implant
with a wider base width (low profile or a shaped tex-
tured implant with a short vertical dimension) for
the given volume would have been a better choice.
In general, patients with a husky build are often sub-
optimal candidates for implant reconstruction, as is
discussed in Chapter 6.
It suffices to say that in both primary and reoper-
ative breast surgery the surgeon must carefully
survey the chest wall musculature for tone, develop-
ment, and symmetry. For optimal aesthetics to be
realized, breast volume and contour must conform
to the proportions of the patients chest, torso
(abdomen and chest), and buttocks.
Bony Anatomy of the Thorax and Spine

Thoracic cage shape and contour, along with curva-
ture and rotation of the spine, can have a strong
influence on breast symmetry. Patients with pectus
excavatum (Fig. 2-27) often have breasts that appear
FIGURE 2-25. AP view of patient with wide chest dimension.
inclined toward the midline and nipples that point
medially, whereas patients with scoliosis often illus-
trate breast asymmetry due to rotational deformities
of the chest wall structures that may be extremely
difficult to correct (Fig. 2-28AD).
What the Eye Sees

The breast is a paired structure, and the eye expects
to see symmetry in terms of size or fullness, distribu-
tion of breast parenchyma or shape, and the NAC.
Although perfect symmetry is rarely noted, relative
symmetry is an important aesthetic feature of the
breasts. Simply stated, the eye expects to see that one
breast will look like the other. Therefore the challenge
to every plastic surgeon performing either primary or
reoperative breast surgery is to produce the most
symmetric-appearing breasts possible. That is to say,
the surgeons handiwork should result in a postopera-
FIGURE 2-26. Preoperative AP view of patient who will tive result that most closely simulates what the eye
undergo left mastectomy. Note wide chest dimension and husky sees and what the brain recognizes as a normal
build. Postoperative result showing breast asymmetry. Note
inadequate breast base width of the left implant breast recon- breast appearance in a given patient. Perhaps more
struction. This was noted despite the fact that the implant was a than anything else this requires an appreciation for
14-cm base-width device with 650 cc of saline. the curves produced by normal breast shape.
Ch02.qxd 11/27/05 8:37 PM Page 33
FIGURE 2-27. AC, Preoperative AP view of chest in patient

desiring breast augmentation. Note pectus excavatum with
medial inclination of NACs. The cleavage is overdefined and the
NACs are inclined toward each other.
From a visual perspective the breasts are a pleasing For the plastic surgeon planning an aesthetic
mixture of gentle curves, flowing lines, and aestheti- breast procedure (either a primary operation or a
cally pleasing contours (see Fig. 2-16). In the frontal corrective secondary surgery), the important dimen-
plane or AP view, the lines of breast contour flow from sions of base width, vertical height of the breast, and
the lateral sternal region as the breast immediately nipple to SSN distance (along with the spatial rela-
takes off in the parasternal area tracing a convex tionship of the NAC to the IM fold, and the relation-
downward curve as it flows from medial to lateral. ship of the breast mound to chest wall structures
These curves are accented by normal visual highlights such as the sternum, clavicle, and chest wall muscu-
over the surface landmarks of the breast, including lature) are contained within these lines of contour
the lower pole fullness with the covering skin of the (see Fig. 2-3). They are often used by the plastic sur-
lower pole, of which the most prominent feature is the geon to help quantify the essential features of breast
NAC. The eye immediately focuses on the NAC and aesthetics (see Fig. 2-29).
notes more fullness below and lateral to the NAC than The surgeon must also be keenly aware of the
above it (see Fig. 2-8AD). When viewed in the frontal quality and color of the breast skin, along with the
plane, the normal silhouette of the breast conceals position, size, and color of the NAC and the contrast
the anterolateral aspect of the ribs, as well as the ser- that this structure produces with the breast skin in
ratus anterior and latissimus dorsi muscles (see defining breast aesthetics. The folds, recesses, and
Fig. 2-16). In addition the lateral curve of the breast shadows produced by these curves and anatomic
extends superiorly toward the axilla, blending into the structures give rise to important concepts for the
transversely oriented clavicular head of the PMM at planning of incisions and placement of scars and in
the level of the second rib (see Fig. 2-16), continuing all types of breast surgery (Fig. 2-30) as outlined in
toward the axilla as the tail of Spence. the diagram. In addition, these visual images of the
Ch02.qxd 11/27/05 8:37 PM Page 34
FIGURE 2-28. AB, Preoperative breast asymmetry in patient with scoliosis and rotational deformity
of chest wall with the right breast being smaller and laterally inclined. CD, Augmentation with a larger
dimension and volume implant on the right is necessary to produce optimal symmetry.
Ch02.qxd 11/27/05 8:37 PM Page 35
19-24cm
5-9cm
FIGURE 2-29. Quantification of topographical breast aesthetic appearance in the AP view relative to
NAC, IM fold, and SSN with average distances as noted.
breast have a strong effect on determining the most Ideal placement and
ideal location for skin paddle placement when flaps design of breast incisions
are used for breast reconstruction.
In breast reconstruction cases where the plan is
to add tissue in the form of a flap, the best orienta-
tion of the incisions produces only one continuous
scar. Optimally this is a round periareolar scar.
When a larger skin replacement is needed, again,
only the more superior incision, in either an oblique
or transverse orientation, should be visible. The sec-
ond incision is best placed in or near the IM fold,
where it is concealed by the flap. This produces the
most aesthetically pleasing appearance in terms of
contour restoration and scar position (Fig. 2-30B).
In general, scars (the superior-most scar from the
flap inset) should be kept as low as possible on the
reconstructed breast.
In summary, I believe that the best aesthetic out-
come following skin paddle inset during breast
reconstruction almost always results when the skin
paddle of the flap is positioned in the inferior aspect
of the reconstructed breast mound. This produces
an appearance that most closely resembles what the A
eye expects to see. This is an important concept for
the reconstructive breast surgeon in both primary FIGURE 2-30. A, Ideal placement of incisions and insertion of
and reoperative breast surgery.10 flaps for breast reconstruction.
Ch02.qxd 11/27/05 8:38 PM Page 36
Symmetry
It is often said that no womans breasts are perfectly
symmetric. For the most part this is a true state-
ment. In the setting of either primary or reoperative
surgery the surgeon should always strive to optimize
symmetry between the breasts, but I am careful to
never promise symmetry as something that I can
predictably deliver. In fact, I usually tell my patients
to expect some degree of asymmetryassuring
them that this will not be lopsidedness. I further
communicate to them that I will make every attempt
to make their breasts look as similar as possible.
The symmetric appearance of the breast shape
relates to breast volume from the standpoint of the
position and distribution of the breast parenchyma.
This characteristic of breast appearance is also best
appreciated in both the AP and oblique views with
the patient in the upright position.
In every consultation it is important for the plastic
surgeon to listen to the patient in terms of the volume
of breast tissue. More specifically, it is important for
the surgeon to understand the patients own feelings
about her breast volume and shape. If additional vol-
Most aesthetic
flap skin replacement ume is needed, this is most often best provided by the
use of an implant. Placing a breast implant allows the
greatest precision in increasing the volume of the
breast, and the implant can be more reliably placed
in a superior position, where it is most often needed.
When reshaping of the breast is needed, it is often
possible to redistribute the breast parenchyma by
performing surgical maneuvers to shift the volume,
usually in a superior direction. This is most com-
monly done in breast reduction and mastopexy pro-
cedures. Classically the volume redistribution and
shape change have been most often accomplished
by excision and tightening of the breast skin in the
vertical and horizontal planes or dimensions. I have
found that the use of tailor tracking, or temporary
skin suture placement, is the best guide as to exactly
how much skin must be excised to optimize breast
shape in a particular mammoplasty (Fig. 2-31).
Tailor tacking is an extremely helpful technique
in virtually all breast reshaping procedures, whether
these are aesthetic reconstructive in nature. It
behooves every breast surgeon to become familiar
with its use.
Breast reshaping today involves not only skin
tightening but also actual repositioning and suture
fixation of the breast parenchyma. When there is a
need for repositioning the breast tissue in a more
superior location, the vertical mammoplasty tech-
nique is a powerful breast reshaping tool whereby
C the parenchyma is redistributed superiorly and
FIGURE 2-30. (CONTINUED) B, Periareolar placement fol- sutured in position.1113 This technique is particu-
lowing the ultimate skin-sparing mastectomy. C, Lower outer larly suited to creating maximum superior fullness,
quadrant. which is discussed later in this chapter (Chapter 4).
Ch02.qxd 11/27/05 8:38 PM Page 37
fairly closely approximate each other on the breasts.

The outline of the areolar complex is also important
in that it should approximate a round shape. When
such a shape is produced bilaterally, overall breast
aesthetics are enhanced (Fig. 2-32).
SUMMARY OF VISUAL AESTHETICS
The breast shape in every photographic view or visual

vantage point is defined by lines, curves, convexities,
and concavities that produce visual highlights and
subtletiesall of which contribute to the creation of
the normal visual construct of the breast. When
FIGURE 2-31. Tailor-tacking technique used to estimate skin viewed from the front (the AP view), the IM fold
resection needed to drape over reshaped breast. should have a well-defined takeoff from the paraster-
nal region and flow in an uninterrupted convex man-
ner into the lateral contour. A smooth convergence of
Breast fullness and contour produce the shape of the this lateral breast silhouette into the axilla with a lat-
breast, but the NAC is also a key anatomic feature eral fullness that overlaps the lateral ribs and latis-
from the standpoint of aesthetic breast appearance simus muscle is what the eye expects to see. The NAC
and symmetry. The NAC should be in the correct is the visual focal point of the breast and greatly
position. That is to say, when looking at the breasts defines the aesthetic appearance of the breast in each
from the AP view, there should be approximate sym- patient (Fig. 2-32).
metry in the position and pigmentation of the NACs The folds, recesses, and shadows produced by
as they are compared. As previously noted, this usu- these curves and anatomic structures give rise to
ally means that the nipple is located at the highest important concepts for the planning of incisions
projection of the breast mound. Occasionally this will and placement of scars in all types of breast surgery
vary (as is discussed in Chapters 8 and 10), but for the as outlined in Figure 2-30A. In addition, these visual
most part the optimal position of the nipple is at the subunits of the breast have a strong effect on deter-
point of maximal projection of the breast mound. mining the most ideal location for skin paddle place-
Also important from an aesthetic perspective is ment when flaps are used for breast reconstruction
that the dimensions and color of the NAC should (see Fig. 2-30C).
FIGURE 2-32. Ideal postoperative appearance of the NAC in a postreduction mammoplasty patient.
Ch02.qxd 11/27/05 8:38 PM Page 38
These are recurring motifs that I apply in virtu- THE PREVIOUSLY OPERATED
ally every patient who is seeking reoperative sur- BREASTIMPORTANT CLINICAL AND
gery of the breast. I will re-emphasize these ANATOMIC DIFFERENCES
concepts throughout the book. The breast surgeon
must have in mind a framework regarding breast Decreased Skin Elasticity
aesthetics and use it along with his or her intrinsic
It is essential for the surgeon to recognize the pres-
artistic and aesthetic senses to create, recreate, and
ence of decreased skin elasticity in the setting of
restore optimal breast shape and symmetry in
either the primary or reoperative surgery of the
patients who present for revisional or reoperative
breast. The condition is perhaps most commonly
breast surgery.
encountered in the breast reduction patient popula-
tion, but it is also often noted in the young patient
who has accentuated mammary ptosis in the
absence of previous pregnancy or significant weight
HOW WHAT THE EYE SEES AFFECTS
fluctuation (Fig. 2-33). Recognition of this tissue
REVISIONAL BREAST SURGERY,
characteristic enables the surgeon to preoperatively
OR WHAT IS WRONG WITH THIS
point out to the patient the limitations of a particu-
PICTURE?
lar procedure related to decreased skin elasticity
and explain the likely untoward sequela related to
As just discussed, I believe it is very important for
the decreased elasticity. The most obvious example
the surgeon to obtain a visual gestalt of the
of this is the likelihood of recurrent ptosis following
breasts. By this I mean that it is critical to evaluate
a mastopexy in a patient with very loose skin and
the breast form and aesthetics from the standpoint
parenchymal tissues.
of what the eye sees and what the brain will regis-
Previous breast surgery can produce a decrease in
ter and recognize as either within the range of nor-
elasticity. This is perhaps most commonly noted fol-
mal or abnormal in a given patient. The eye will
lowing implant surgery, e.g., breast augmentation in
pick up curves, contours, skin tones, and the posi-
thin patients (Fig. 2-34A), especially when subglan-
tion of the NAC. The eye will also immediately
dular augmentation has been performed with large
detect scars and their position, quantitative and
(>400 cc) saline implants (Fig. 2-34B) or in cases of
qualitative differences in the skin (i.e., differences
implant-based breast reconstruction performed
in envelope size or color), volume discrepancies,
with a large volume implant(s).
and contour abnormalities.
The essence of reoperative plastic surgery of the
breast is to bring the form and appearance of
the previously operated breast as close as possible to
what the eye would scan and what the brain would
register as a normal appearing breast. In general,
breast form, defined as volume and shape, is more
important than scars in establishing the breasts as
aesthetically pleasing. This holds true unless the
skin scars are very suboptimal from the standpoint
of thickness, color, tightness, or topography. When
scars are combined with abnormalities of contour
and shape, the combinations can be especially
unaesthetic as the negative aesthetic effects are
often additive.
I have developed a process of analyzing every
patient with concern about or a problem with her
breastswhether previously unoperated or in a
postoperative circumstanceworking from the
framework of Whats wrong with this picture? I do
this in every case using the concepts of breast aes-
thetics that we have just reviewed. I find that it is
helpful to analyze each case in this way from the FIGURE 2-33. Markedly decreased elasticity of the skin and
perspective of enabling me to formulate the best breast parenchyma in a 36-year-old nulliparous patient with
plan for treatment. grade III mammary ptosis.
Ch02.qxd 11/27/05 8:38 PM Page 39
FIGURE 2-34. Markedly stretched breast tissues in a 32-year-old patient with a 510-cc smooth-walled
subglandular saline breast implant. A, AP view. B, Lateral view.
The skin is an important medium for helping to of the breasts, and they should be addressed as part
maintain a shape change in the breast. The surgeon of the revision procedure.
must make judgments about a particular patients I find it very helpful to systematically quantify
skin and select procedures accordingly. An analysis asymmetries by directly measuring the skin dimen-
of skin quality is an essential part of the evaluation sions in both a vertical and a horizontal orientation
of every patient seeking reoperative breast surgery. using a tape measure. These dimensions are noted
along the vertical midbreast meridian from the mid-
clavicular point to the IM fold and along the hori-
Skin Envelope Asymmetry
zontal meridian from the midaxillary line to the
Recognizing and appropriately treating skin defi- parasternal region through the level of the nipple.
ciency is a key concept in reoperative breast surgical These measurements (see Fig. 2-3) are then
procedures. Asymmetries in the skin envelope of the recorded in centimeters in the patients chart on a
breast are commonly encountered in the setting of standard breast worksheet. Such deficiency is also
breast reconstruction and are seen with varying assessed in the breast reconstruction patient as
degrees in virtually all cases of previous mastec- illustrated (Fig. 2-35) with appropriate quantitation
tomy. Skin deficiency is commonly noted with of the skin tissue deficiency.
developmental breast asymmetries, in cases where When planning breast reconstruction, small dif-
breast augmentation or reconstruction has been ferences in skin envelope dimension can be treated
carried out with different size implants, and follow- by stretching or expanding the skin with either a
ing a previous lumpectomy. Even subtle asymme- breast implant or tissue expander. However, as the
tries are generally apparent on careful examination discrepancy in skin envelopes increases to greater
Ch02.qxd 11/27/05 8:38 PM Page 40
than 4 cm the surgeon should begin to think about If on the other hand a reduction of the larger
adding tissue if symmetry between the breasts is the breast (which always entails some degree of a reduc-
goal and there is no plan to reduce the size of the tion in the skin envelope) is part of the plan, then
larger breast. Therefore in the setting of breast this contralateral breast modification can be com-
reconstruction, in my opinion a skin difference of bined with a tissue expander or an implant insertion
greater than 4 cm is an indication for adding tissue beneath the smaller breast skin envelope. This oppo-
by means of a flap. site breast modification allows the tissue expansion
FIGURE 2-35. Developmental breast asymmetry with right breast larger than the left. AP (A) and
oblique (B) views with outline of planned unilateral (right) breast reduction. C, D, Five years postoper-
ative result following unilateral breast reduction shows a correction of the skin envelope and volume
asymmetry and excellent breast symmetry.
Ch02.qxd 11/27/05 8:38 PM Page 41
process to achieve better symmetry between the

breast skin envelopes.
Breast skin asymmetry is seen in many settings.
The eventual symmetry of a procedure requires that
the skin envelopes be equalized. A common scenario
is seen in this patient, who presented with a develop-
mental breast asymmetry (Fig. 2-35A). She liked the
size of her smaller breast and requested a unilateral
breast reduction. The plan was for parenchymal
reduction with an inferior pedicle technique (Fig.
2-35B) with a corresponding resection of the excess
skin on that breast. The result at 5 years postopera-
tive is shown (Fig. 2-35C,D) with maintenance of the
skin envelope and overall symmetry established at
surgery.
Skin Scars
In the setting of reoperative breast surgery there is
almost always a skin scar indicating that a previous
procedure has been performed (the exceptions are
breast augmentations performed with a transaxil-
lary or transumbilical incision or an augmentation
done simultaneously with an abdominoplasty with
the implant placed through the abdominal incision).
Scars are permanent marks that never completely
go away. Most often they fade with time as the bio-
logic processes of wound healing and scar matura-
tion proceed.
Early in my career I remember one of my teachers
said that plastic surgeons make their living placing
scars in locations where they will be most concealed
and where they will heal in the most optimal way.
This is true for every region of the body. On the breast
elective incisions are best placed in the locations out-
lined previously (see Fig. 2-30A). Most scars on the
breast are best made as curved lines that should be
roughly parallel to the outer aspect of the areolar con-
tour. Experience has validated that incisions in these
locations heal in the most favorable way.
Scars in the IM fold area of the breast should be
kept in the shadow of the lower aspect of the breast
or in the fold itself whenever possible and not off the
breast. When such a scar comes to lie off the breast it
is possible to reposition it back onto the breast as
illustrated by the following case. This patient
requested a revision of a previous subglandular
saline implant breast augmentation to achieve better
upper pole fullness and improved shape (Fig. 2-36A).
The plan was for an augmentation mastopexy using
a vertical scar technique with pocket reassignment
of a larger implant placed into the subpectoral space.
The skin excision was estimated using the tailor- FIGURE 2-36. Redirecting a surgical scar. A, Patient is seen 5
years following a subglandular breast augmentation with breast
tacking technique (Fig. 2-36B). To manage the lower ptosis and loss of superior fullness in breasts. The plan is for an
breast pole skin excess it was necessary to extend the augmentation mastopexy. B, A tailor-tacking technique will be
scar in an oblique orientation laterally incorporating used.
Ch02.qxd 11/27/05 8:39 PM Page 42
FIGURE 2-36. (CONTINUED) C, The scar is seen to descend

below the IM fold. D, Redirection of the lateral limb of the IM
incision is accomplished by excising triangles to create unequal
incision lengths at the line of closure. E, The scar has been repo-
sitioned into the IM fold laterally.
her previous IM incisions (Fig. 2-36C). The lateral

extent of the scar initially was found to lie off the
breast (Fig. 2-36D). The scar was redirected by excis-
ing a triangle of skin superior to it to create a curved
line of incision in a more favorable location on the
inferior lateral breast (Fig. 2-36E).
Scar Hypertrophy
As previously noted, scars are permanent marks that
never completely go away. They may heal as fine,
almost indistinct lines as in the IM fold region fol-
lowing most breast augmentation performed
through this incisional approach. However, they can
appear thick and hypertrophic. Hypertrophy is most
commonly seen in the lateral aspect of the lower FIGURE 2-37. Scar hypertrophy noted in the lateral and
medial aspect of the IM incision in a patient who had a breast
breast and is often noted following breast reduc- reduction with an inverted T incisional pattern.
tions done using the Wise pattern of skin incisions
(Fig. 2-37). If hypertrophy in a scar occurs, the appli- maximum of 1 cc. It is important not to inject this
cation of pressure applied by a bra with or without a medicine into the subcutaneous tissue because it
silicone sheet may soften the scar. Alternatively, a may cause atrophy of the adipose tissue that often
small amount of a depot steroid can be injected into may result in an indented appearance of the scar. In
the scar. I prefer to use Kenalog 40 and will inject a addition, it is important for the surgeon to inform
Ch02.qxd 11/27/05 8:39 PM Page 43
the patient about the possibility of hypopigmenta- ating a vertical Z-plasty within the wound. A precise
tion or color change in the scar with such a steriod reapproximation of the skin finishes the closure.
injection. Colors that I have encountered following The return of tissue equilibrium, which occurs
steroid injections include a blue, purple, or violet approximately 1 year following the redo stacked
color that may be distinctly different from the color wound repair, often improves the invaginated
of the scar tissue and surrounding skin. If a scar appearance of the skin scar.
revision is pursued, I find that it is best to wait at As noted, the presence of a scar(s) can visually
least 1 year before performing such surgery to allow detract from the aesthetic appearance of the breast.
the maximum chance for maturation and softening In addition, scars can negatively affect the blood
of the scar. supply of the breast skin, and this must be borne in
Scars can extend from the skin surface to deep mind whenever skin flaps are raised on a breast with
within the breast parenchyma. It is possible to make a previous incision. This is especially common when
this diagnosis by palpation of the tissues. Most com- performing a breast reduction or mastopexy in the
monly all of the tissues in these wounds are setting of a previous breast surgical procedure.
indurated with the skin being adherent to the under- Therefore in such settings the surgeon should alter
lying breast parenchyma, which can be quite firm. It the design of incisions and pattern of skin flap devel-
is imperative that the surgeon allows the return of opment to avoid raising flaps with scars at their base
tissue equilibrium to the entire wound before con- as much as is possible. It is particularly important
templating a reoperative surgical procedure. This for the surgeon to analyze the relationship of previ-
process usually requires at least 6 months, but often ous scars to the NAC. Any reoperative procedure on
it is necessary for 9 months or 1 year to elapse the breast in this setting must be planned to main-
before the induration completely resolves and a sub- tain circulation to this critical structure. In every
stantial degree of softness returns to the tissues. previous breast operation in which the nipple has
Having the patient perform daily deep wound mas- been moved on a pedicle, such as a breast reduction
sage may help hasten the progress of the wound into or mastopexy, I believe that it is critical for the sur-
the latter phases of chronic wound healing and the geon to know exactly what pedicle design was used
tissues to a condition of softness. Suffice it to say so as to best maintain adequate nipple vascularity in
that only after such tissue equilibrium has been any subsequent procedure.
acquired within the wound can the most precise I believe that the incidence of skin necrosis is sig-
manipulations for tissue movement and breast nificantly increased in every breast operation where
reshaping be carried out. a previous breast incision has been placed. This is
Scars will occasionally cross the contour lines of especially true when raising random pattern breast
the breast. In such locations they will be highly visi- skin flaps with a large length-to-width ratio. An
ble because they alter the natural contours of the example of this is illustrated in Figure 2-38 in a
breast silhouette. In this situation it may be possible patient who requires a mastectomy after the previ-
to change and redirect the scars by tissue rearrange- ous excision of two fibroadenomas performed
ments, flap transfer, or Z-plasty technique. In gen- through a long incision on the superior aspect of the
eral I believe that it is best to avoid obvious left breast (Fig. 2-38A). This mastectomy was com-
geometric scar formations (Z-plasties and W-plas- plicated by ischemic necrosis of the skin at the mar-
ties) on the immediately visible portions of the gins of the mastectomy incision (Fig. 2-38B) that
breast. required an additional surgical debridement (see
Skin scars can also be invaginated. This most Fig. 8-5AF).
often occurs as a result of a discrepancy between the When a mastectomy is to be performed in the
heights of skin surfaces on either side of the wound presence of a previous incision, it is most often
or following wound separation and healing by sec- advisable to elevate skin flaps that are as short as
ondary intention. If this invaginated appearance is possible and not have a scar transgressing the base
exaggerated, it can be a definite problem for the of the skin flap. In some instances it is not possible
patient. In these situations, when there is an ade- to accomplish this, and in such settings there is an
quate subcutaneous adipose tissue layer, it is often increased chance for wound healing difficulties. In
possible to excise the original wound, elevate the these situations the surgeon must be very analytic in
skin immediately below the dermis, and create flaps assessing the vascularity of the remaining skin flaps.
of subcutaneous tissues at different levels. Wound I often use intravenous fluorescein injection and
reapproximation then includes advancing these examination with a Woods lamp to increase the
flaps of subcutaneous tissue past each other, thus accuracy in assessing the state of skin blood flow in
stacking this layer beneath the skin incision and cre- this setting (Chapter 8).
Ch02.qxd 11/27/05 8:39 PM Page 44
Contour Abnormalities procedureespecially if they are medially located.

The excision should be accomplished to allow the
Abnormalities in contour are often noted following
scar to lie in the breast contour or within the
previous breast surgery. Perhaps the most common
shadow of the breast contour. Secondary excision
are elevations of skin at the ends of the incisions
results in a longer scar, and this must be explained
often called dog ears. They are the result of a well-
to the patient preoperatively.
intentioned effort to minimize the length of an inci-
Dog ears are most often addressed by combined
sion and are most often noted following breast
skin and subcutaneous adipose tissue excision. In
reduction and mastopexy. They are also commonly
some cases of small dog ears, the excision of subcu-
seen in the setting of breast reconstruction. In gen-
taneous adipose tissue alone will allow the skin to lie
eral it is best to excise such dog ears at the initial
flat on the breast contour. I find that it is almost
always necessary to excise a significant amount of
adipose tissue to effectively treat a large dog ear.
Deficits of subcutaneous adipose tissue are also not
uncommon after all types of breast procedures. They
most often are noted at the periphery of the breast.
Such abnormalities produce indentations or depres-
sions in the surface contour of the breast, and they
can be very noticeable and bothersome to the patient.
Classically the treatment has involved filling in
such indentations or deficits of contour with either
adipose tissue flaps or dermis fat grafts. A technique
that I find helpful when there is excess skin and adi-
pose tissue adjacent to the contour deficit is the
advancement of a de-epithelialized flap of adipose
tissue. It is the leading edge of a skin flap that is
advanced, and when sutured the adipose flap is held
in the appropriate position. This technique is
diagrammatically illustrated in Figure 2-39 and is
extremely helpful for both lateral and medial areas
of the breast when both the skin and the sub-
cutaneous adipose layer contours require revision.
A de-epithelialized leading edge of a random pattern
skin flap can be a very helpful tool for reconstruct-
ing a contour deficit with an indentation of tissue
that is adjacent to an area of contour prominence. It
is most often used for reconstruction of indenta-
tions in the superior medial breast area or along the
lateral contour of the breast (see Fig. 8-22C).
Dermis fat grafts are also helpful to treat small
contour deficits. Their utility is limited by size, i.e.,
only small amounts (thickness) of adipose tissue can
be included with such grafts. The important aspects
of technique are precise pocket dissection at the site
of the defect, meticulous hemostasis, and orienting
the graft such that the de-epithelialized dermal side
of the graft is placed superiorly against the dermis.
The patient should be informed about the need for a
FIGURE 2-38. The impact of skin scars on the healing of subse-
quently elevated breast skin flaps. A, AP view of a patient who has donor site scar and that there is often a long period
undergone a previous fibroadenoma excision in the upper pole of of induration at the site of graft placement before
the left breast and who now requires a total mastectomy for dif- eventual graft softening. With these limitations in
fuse ductal carcinoma in situ of the breast. B, Appearance of the mind, successful results can be achieved when
breast 6 days after mastectomy and immediate breast reconstruc- small, nonradiated defects are reconstructed using
tion with a TRAM flap. Note the ischemic change at the margins
of the incision, which required operative excision. The previous dermis fat grafts.
upper breast incision most likely produced a decrease in skin cir- Currently autologous fat grafting done with the
culation that resulted in marginal skin flap necrosis. injection of freshly harvested adipose cells is gain-
Ch02.qxd 11/27/05 8:39 PM Page 45
in
sk
ar
sc
Dermis fat
flap
advanced
de-epitheliaze
Contour
Release scar deficit
tissue to reconstructed
"recreate
A defect" C
B D
FIGURE 2-39. AD, Diagrammatic illustration of contour deficit correction using a de-epithelialized
lead edge of an adjacent random pattern skin flap.
ing popularity for treating contour abnormalities of previously transferred flap. It is important not to
the breast. I have had much experience treating clump the fat. I perform only minimal overcorrec-
small peripherally located contour abnormalities in tion of the defect.
the breast and can attest to its efficacy. Such grafts It is not uncommon to note some resorption of the
may be harvested from a variety of donor sites autologous fat grafts. Such grafts can be redone,
using a 1-mm liposuction cannula (Fig. 2-40A) after usually 4 to 6 months following the previous fat
the infiltration of the area with an epinephrine-con- graft. Microcalcifications can accompany graft
taining solution. Alternatively, a blunt-tipped 14- resorption, but its appearance is usually easily differ-
gauge needle may be used for very small amounts of entiated from the microcalcifications that may be
fat harvest (Fig. 2-40B). The harvested fat tissue associated with malignancy. I have found that previ-
must then be separated from the fatty oils. This is ous radiation to the breasts significantly compro-
done either by gravitational settling or by centrifu- mises the success of this technique. With these
gation (Fig. 2-41A). The supranatant fat tissue layer limitations in mind, autologous fat grafting is a tech-
is then transferred to 1-cc syringes and is injected nique with an ever-expanding role for treating con-
into the defect through 14-gauge needles (Fig. 2- tour abnormalities in all areas of the body, including
41B). The fat is injected into the tissues at the site of the breast. Examples of these methods for correcting
the defect in strands. It can be injected into the contour deficits are illustrated later in this chapter
subcutaneous adipose tissue, muscle tissue, and a and in subsequent chapters throughout this book.
Ch02.qxd 11/27/05 8:39 PM Page 46
FIGURE 2-40. Harvesting autologous fat grafts by aspiration with a 1-mm cannula (A) and a
14-gauge blunt-tipped needle (B).
FIGURE 2-41. A, Appearance of harvested fat after centrifugation at 3,000 rpm for 5 minutes. B, Fat
graft material is then transferred to 1-cc syringes for injection.
Previous Breast Implant Surgery Periprosthetic Capsular Surgery

The previous placement of a breast implant always A periprosthetic collagen envelope or scar tissue
produces predictable changes in the local tissues. capsule of varying thickness forms around every
Most commonly seen are stretching of the skin and implant that has been placed. Reoperative surgery
PMM, along with compaction of the overlying sub- following a breast augmentation or previous
cutaneous adipose tissue and muscle layer (if the implant-based breast reconstruction is performed to
implant was placed in a submuscular position). The treat problems of asymmetries relating to implant
net result almost always is some element of tissue malposition, abnormal IM fold position, or contrac-
stretching, and in some cases frank tissue attenua- ture of the periprosthetic capsule. For virtually all of
tion and decreased tissue elasticity. these problems, alteration of the capsule by direct
Ch02.qxd 11/27/05 8:39 PM Page 47
incisional release, suture capsulorrhaphy, or cap- cially important when a change of the implant sur-
sulectomy represents the most common approach. face (most often substituting a textured surface
Suture capsulorrhaphy (see Fig. 3-36), strip cap- device for a smooth surface implant) is done in
sulectomy (Chapter 6), and capsular flap applica- hopes of decreasing the chance for development of a
tion (Chapter 3) are particularly powerful tools in recurrent capsular contracture.
achieving alteration on the periprosthetic capsular Caution must be exercised in performing a cap-
space and for substantially modifying the appear- sulectomy in patients with very thin or significantly
ance of a breast with a previously placed implant. attenuated overlying tissues. The most prominent
Suffice it to say that in many instances of reoper- examples of such situations are patients who have
ative surgery following previous implant placement undergone subglandular breast augmentation with
the periprosthetic capsule, in a paradoxical way, is large implants and those who have undergone implant
an asset for the surgeon reoperating after previous reconstruction of the breasts following a previous sub-
breast implant surgery. The ability to precisely alter cutaneous mastectomy. A total capsulectomy in these
this capsule has a powerful effect on implant posi- settings may compromise the circulation to the overly-
tion and therefore on both the shape and contour of ing skin, which can threaten a subsequent implant.
the implanted breast. Becoming proficient with Often it is safer to leave portions of the capsule either
these techniques pays significant dividends for the on the anterior or posterior surface, opting for a subto-
surgeon performing reoperative surgery in this set- tal periprosthetic capsulectomy.
ting from the standpoint of achieving satisfactory Issues involved in preoperative decision making
outcomes in many of these cases. with regard to the management of the periprosthetic
Often, reoperative surgery in a patient with a pre- capsule and technical details about its performance
vious breast implant involves a decision about are extensively reviewed in Chapter 4.
whether to perform a capsulectomy. In many clinical
situations this is a prudent or even necessary course
of action. This is especially true when addressing the THE EFFECT OF IMPLANT PLACEMENT
problem of rupture of a previously placed silicone ON BREAST PARENCHYMAL
gel implant or when the surgeon must deal with a VASCULARITY AND NIPPLE AREOLAR
severe, recalcitrant capsular contracture when the BLOOD SUPPLY
plan entails placement of a new implant. In such sit-
uations, performing a total or subtotal periprosthetic It must be borne in mind that placing an implant in
capsulectomy removes as much of the silicone gel as the subglandular position definitely decreases the
possible and produces a virginal pocket into which a blood supply of the breast tissue and overlying skin,
new implant can be introduced. I believe this is espe- including the NAC (Fig. 2-42). Dissection to develop
FIGURE 2-42. Reduction in blood supply to the NAC following subglandular placement of a breast
implant for breast augmentation.
Ch02.qxd 11/27/05 8:39 PM Page 48
this plane interrupts a substantial amount of the are most favorable. Such incisions should be placed
blood supply from the PMM (musculocutaneous exactly in the junction between the areola and breast
perforators from the thoracoacromial vascular pedi- skin because they tend to undergo hypopigmenta-
cle), and to a lesser extent it may decrease contribution and thus will be most concealed if placed in the
tions from the internal mammary and lateral breast skinareola junction. Alternatively, scars
thoracic vessels. This is especially important for the placed in the IM fold or in the natural curve of the
surgeon to realize when he or she is contemplating a breast in general also heal well. As illustrated in
combined redo breast augmentation and a concomi- Figure 2-36AE, at times it may be possible to redi-
tant mastopexy in the setting of a previous subglan- rect a scar or move it to a slightly different location
dular breast augmentation. Such combined surgery on the breast so it will be less obvious.
may entail a significant risk for wound breakdown Scars in the IM region also heal well and are con-
along the skin incision. More important, there is a cealed with the patient in the upright position. Scars
decrease in NAC blood supply, which may be signifi- from incisions made on the breast proper tend to
cant in the setting of such combined surgery when a heal best if they are curvilinear in shape and are par-
significant transposition of the NAC on a parenchy- allel with the margin of the areola (see Fig. 2-30A).
mal pedicle can have dire consequences in terms of Any scar can undergo hypertrophy and appear
NAC viability. In this setting it is often advisable to thick and offensive. Breast incisions placed medially
stage the procedures of redo augmentation and in the parasternal area most often tend to do this
mastopexy. This caution most strongly applies to (Fig. 2-43A). Often incisions placed laterally in the IM
patients who use nicotine products. fold will also hypertrophy. Patients are often both-
ered by and request treatment for a scar that exhibits
a hypertrophic appearance. Most often in this situa-
AESTHETIC PRIORITIES IN REVISIONAL tion, the best medicine for the patient and the sur-
BREAST SURGERY geon is the tincture of time; time must be allowed to
elapse so that such scars may have a chance to
Priorities in revision surgery are often patient mature. Many scars will soften and fade in color. In
driven. Patients often come in to the office with a some cases the hypertrophic appearance will persist.
specific complaint or requesting specific changes At times these hypertrophic scars can also be painful.
in breast appearance. These complaints are This makes them doubly bothersome to the patient.
related to many issues we have discussed and are Scar hypertrophy can be addressed by taping the
listed in decreasing order according to frequency scars (I have found that placing paper tape on fresh
in Table 2-1. scars seems to limit the tendency of hypertrophy),
The classic tradeoff that most plastic surgeons massaging the scars, injecting depot steroids into the
have been taught is that of scars for shape. Most scar itself, or applying silicone gel sheeting. My per-
patients will accept additional scars on their breasts sonal experience with the latter approach has been
for improved shape. The plastic surgeon must bear somewhat disappointing.
in mind that scars on the breasts can detract from Scars can invaginate. Such a problem is most
breast appearance. In general, patients should be often related to underlying tissue deficiency and/or to
informed about the exact or potential location of dense subcutaneous cicatrix, producing an adhesion
such scars preoperatively. As outlined earlier (see to the deeper tissues. In cases that are not responsive
Fig. 2-30A), incisions made in certain locations on to aggressive massage, release of the cicatrix done
the breast tend to heal with more aesthetically through a small incision with the placement of
acceptable scars than incisions in other locations. injected autologous fat or a dermis fat graft is often
Incisions at the junction of the areola and breast skin helpful as illustrated by the following patient.
This 55-year-old diabetic patient had previously
undergone a right mastectomy and implant-based
TABLE 2-1 Reasons for Revisional Breast Surgery
reconstruction for stage II breast cancer when she
Contour problems: change in shape developed breast cancer in her left breast. This oppo-
Volume: excess or deficiency site breast was treated by lumpectomy and radiation
Nipple areolar asymmetry: position, size, inclination therapy. The patient developed an invagination of her
Problems with base dimension: base width and height lateral breast incision, as well as a depression at the
IM fold abnormalities: asymmetry, constriction, "double bubble" site of a previously placed intravenous access catheter
Skin envelope problems: amount, color in the parasternal area of the upper medial aspect of
Scar deformities
her left breast (Fig. 2-44). The subcutaneous cicatrix at
IM, inframammary. both sites was released and she had the injection of
Ch02.qxd 11/27/05 8:39 PM Page 49
FIGURE 2-44. Appearance of scar hypertrophy and contour

abnormality in a 55-year-old patient who had a lumpectomy and
radiation therapy for a stage II cancer of the left breast. Note the
invagination of the horizontal scar on the lateral aspect of her
breast from where the tumor had been excised.
FIGURE 2-43. A, Severe contour abnormality of right breast

noted following lumpectomy and radiation therapy for right
breast cancer. Also note the hypertrophic scar in the parasternal
aspect of the left breast. B, Note contour deformity. Also note
hypertrophic scar parasternal aspect of left breast with contour
depression following placement of chemotherapy port.
30 cc of autologous fat in conjunction with a dermis

fat graft below the lateral breast incision and a dermis
fat graft placement to reconstruct the contour deficit
in the superior medial aspect of her breast (Fig. 2-45).
At 2 years she demonstrated a marked improvement in
the contours of both areas (Fig. 2-46A,B). She is one of FIGURE 2-45. Planned correction of contour deficits. Dermis
many patients with small contour defects following fat grafts were used at both sites with the addition of autologous
previous surgery that I have treated in this way. fat injection under the lateral breast incision.
Ch02.qxd 11/27/05 8:39 PM Page 50
FIGURE 2-46. Appearance of contour deformities corrected by dermis fat graft for parasternal inden-
tation and cicatrix release and autologous fat injection beneath horizontal scar seen at 2 years postop-
erative. A, AP view. B, Lateral view.
ContourProblems with Dimension

defect with an immediate insertion of a tissue
and Shape
expander (Fig. 2-49A). She elected to have a con-
Contour may be the most important characteristic tralateral breast augmentation. Her reconstruction
defining breast appearance. It is made up of the pro- revealed both medial malposition of the implant
jection, recesses, highlights, shadows, and lines that that also had an inadequate base width that resulted
produce the visual gestalt of the breast. The eye will in a lateral rib show (Fig. 2-49B). This was treated
immediately pick up abnormal contour. In my expe- by correction of the medial malposition using a dou-
rience the most common reason for revising a previ- ble capsular flap technique (Fig. 2-49C; see Chapters
ous breast surgical procedure is to address problems 3 and 6) and replacement of her implant with a
with shape or contour and their effect on symmetry. larger base-width device (Fig. 2-49D). The ultimate
These abnormalities can be subtle, such as the restoration of breast symmetry requires precisely
difference in the superior medial fullness of the accurate positioning of the NACs (Fig. 2-49E). The
breasts seen following bilateral breast reconstruc- result following nipple reconstruction (Fig. 2-49F)
tion with transverse rectus abdominis muscle and intradermal tattoo revealed an excellent aesthetic
(TRAM) flaps (Fig. 2-47), or not so subtle deformi- appearance of the breasts.
ties as illustrated in an abnormal contour of the This case illustrates several important concepts of
lower breast following lumpectomy and radiation aesthetic analysis and surgical correction of abnormal
therapy (Fig. 2-48). The eye notes both deviations breast aesthetics. Restoring the appropriate silhouette
from what it expects to see, and these abnormal con- of the breast from the standpoint of breast dimension
tours represent a very common reason for reopera- and the correct position of the breast mound on the
tive breast surgery. chest wall, along with the re-establishing the right
Adequate dimensional restoration of the breast shape and contour, was the first step. The finishing
silhouette, especially in terms of base width, is an touches of both nipple reconstruction and the addi-
important concept from the perspective of creating tion of the areolar pigmentation by the intradermal
symmetry of contour. This is illustrated by this tattoo have transformed the more symmetric breast
patient, who was treated for a left postmastectomy mounds into aesthetically pleasing breasts.
Ch02.qxd 11/27/05 8:40 PM Page 51
FIGURE 2-47. Somewhat subtle asymmetry of superior medial FIGURE 2-48. Significant breast asymmetry with marked con-
breast fullness seen in this patient who underwent bilateral tour deformity in patient who underwent a previous lumpec-
breast reconstruction with TRAM flaps. tomy with resection of tissue in the lower pole of the breast
centrally with subsequent radiation therapy.
FIGURE 2-49. This sequence illustrates the impact of revision surgery on breast aesthetics. A, This
41-year-old patient requires a left mastectomy and she elects to undergo a staged reconstruction of the
breast with a tissue expander followed by an implant with a plan for a contralateral breast augmenta-
tion with silicone gel implants. Note the medial malposition of the tissue expander. B, The second stage
produced a suboptimal breast reconstruction with medial malposition of the implant, which had too
narrow a base width for the patients chest dimension. (continued)
Ch02.qxd 11/27/05 8:40 PM Page 52
FIGURE 2-49. (CONTINUED) C, This required a revision to correct the medial malposition using a
double capsular flap technique; breast implant with greater base width and volume was chosen. D, This
improved the breast silhouette and shape. E, The plan for nipple reconstruction illustrates the symme-
try achieved by this reoperative procedure. F, The intradermal tattoo completes the aesthetic revision,
transforming the breast mound into a lifelike breast facsimile.
Ch02.qxd 11/27/05 8:40 PM Page 53
Skin loss is not at all uncommon following breast

Spreading of Scars Secondary to Skin
reduction (see Chapter 6), and the resulting lighter,
Loss
wider, somewhat depressed scars can detract from
Skin abnormalities include scar deformities and the overall appearance of an otherwise pleasing
qualitative deficits, as well as other qualitative breast reduction as illustrated by this patient (Fig.
abnormalities. A common denominator for many 2-50A), whose vertical scar breast reduction caused
of these problems is skin loss at the margin of a significant skin loss in its lower aspect, resulting in a
skin flap that may have been closed with excess wide, unattractive scar (Fig. 2-50B). The patient did
tension. This results in an open wound that most not pursue scar revision. In this case healing by con-
often heals by contraction and epithelialization, traction and epithelialization did not detract from the
often with a suboptimal cosmetic appearance of shape or appearance of the breasts (Fig. 2-50C,D).
the eventual scar. However, when such skin loss results in a more
FIGURE 2-50. A, Preoperative AP view of a patient who will undergo a vertical breast reduction.
B, Significant skin loss in the lower aspect of the vertical incision resulted from excessive tension on the
skin and a superimposed Staph infection, which prolonged the time to complete healing. C, Topical and
orally administered antibiotics produced tertiary wound healing. D, The widened scar is hidden on the
undersurface of the breast; it does not detract from the shape or appearance in the upright position and
the patient did not wish to pursue scar revision.
Ch02.qxd 11/27/05 8:40 PM Page 54
noticeable scar deformity or produces a contour period (Fig. 2-51A). Revision of the scar (Fig. 2-51C)
deficit such as in this patient (Fig. 2-51B), who had with excision and multiple layer closure produces a
prolapse of her breast tissue and an abnormal breast better appearance of the skin and a better contour in
shape of the lower pole following a breast reduction the breast. Here scar resection, re-elevation, and
that was complicated by skin loss of the medial aspect advancement of skin flaps produced an improvement
of the lateral flap in the immediate postoperative in contour and scar appearance (Fig. 2-51D).
FIGURE 2-51. A, Skin loss noted on the medial aspect of the lateral skin flap immediately following an
inferior pedicle breast reduction using a Wise pattern. B, Following epithelialization and contraction there
is an unstable scar and prolapse of the breast tissue through the wound producing an abnormal lower pole
breast shape. C, Revision is undertaken to excise the scar tissue and to close the resulting wound in layers.
D, Two-year follow-up demonstrates better scars and better contour of lower pole of both breasts.
Ch02.qxd 11/27/05 8:40 PM Page 55
TRAM flap breast reconstruction, where it is com-

Volume
mon to overbuild the breast. This patient (Fig. 2-52A)
Volume asymmetries are very common. These can underwent a combined delayed left breast recon-
relate to excess volume or volume deficiencies. struction with a TRAM flap and a contralateral right
Volume excess is encountered in a variety of reopera- breast reduction. Postoperatively she was seen to
tive settings in the prospective breast surgery patient. have a volume asymmetry between the breasts
Most commonly this is seen in the breast reconstruc- (Fig. 2-52B). This was treated by liposuction and a
tion patient population and most specifically after minimal reduction of the TRAM flap skin paddle by
FIGURE 2-52. A, The plan for an immediate right breast reconstruction with a unipedicle TRAM flap
following previous lumpectomy. B, The initial postoperative result shows a breast asymmetry with
excess volume in the reconstructed right breast and an aesthetically undesirable patch effect from the
skin paddle inset. C, The plan is for volume reduction of the TRAM with suction lipectomy. D, The post-
operative result is shown 2 years later.
Ch02.qxd 11/27/05 8:41 PM Page 56
direct excision. Comitant nipple areola reconstruc- ble volume asymmetry (Fig. 2-53B). She is sched-
tion produced volume symmetry and created a nice uled for a revision of this procedure during which
finishing touch for the reconstruction (Fig. 2-52C). liposuction of the right breast will be used to
Volume asymmetry can also be seen after breast address the excess fullness of the right breast.
augmentation or breast reduction. This 70-year-old Liposuction is a very effective way of reducing the
patient presented to my office with symptomatic adipose volume in the breast (Fig. 2-53C). It is find-
macromastia (Fig. 2-53A) and underwent a breast ing increasing application in primary breast reduc-
reduction. She had a resection of 680 g on the right tion procedures in patients with fat replacement of
and 640 g of tissue on the left that resulted in a visi- their breast tissue.
FIGURE 2-53. A, This is a 70-year-old patient who will

undergo a bilateral breast reduction for symptomatic macro-
mastia. B, The procedure resulted in a volume asymmetry with
the right breast substantially larger than the left. C, The plan is
to address this asymmetry with liposuction alone to reduce the
volume of the right breast. The estimated volume excess is
between 70 and 100 g of tissue.
Ch02.qxd 11/27/05 8:41 PM Page 57
sic inverted T incisional pattern. The outcome of

this 1800-g reduction is quite superior from an aes-
The NAC is the visual focal point of the breast. All thetic standpoint. This is due to the symmetry of
visual lines converge toward it, and the eye is imme- shape. Of note are the positions and dimensions of
diately drawn to it. It has a powerful impact on the NACs, which are appropriately positioned and
breast aesthetics. This is illustrated by the following very symmetric in size (see Fig. 2-32).
two patients. The first is a young woman who A similar situation is seen in this breast recon-
underwent an elective breast reduction using a clas- struction patient who underwent an immediate
FIGURE 2-54. A, AP view of a patient who underwent a left

modified radical mastectomy with an ultimate skin-sparing
approach. She underwent immediate TRAM flap reconstruction.
B, A modified star flap was used for nipple reconstruction and
appears to detract from the breast aesthetics. C, An intradermal
tattoo restores excellent breast aesthetics.
Ch02.qxd 11/27/05 8:41 PM Page 58
breast reconstruction with a TRAM flap following The first patient underwent a breast reduction for
an ultimate skin-sparing mastectomy (Fig. 2-54A). mild macromastia and ptosis (Fig. 2-55). She imme-
The subsequent nipple reconstruction appeared to diately noted a discrepancy in areolar size postoper-
decrease the visual aesthetics (Fig. 2-54B). This was atively that was very bothersome to her and
rescued by an intradermal tattoo that produced required a revision. The details of this revision are
color patch symmetry and a true dimension of real- outlined in Chapter 5. This was addressed by down-
ism (Fig. 2-54C). sizing the areolar diameter and controlling the sur-
Asymmetries or discrepancies of nipple areolar rounding skin with a purse string suture. This
position, projection, and pigmentation, as well as produced better symmetry between the NACs. This
overall size and shape, detract from the overall illustrates the concept of taking time to ensure the
visual appearance and therefore from breast aes- best possible symmetry between the NAC from the
thetics. This is illustrated by the following patients. standpoint of size, shape, and position.
FIGURE 2-55. A, This 36-year-old female is shown 6 months

after a bilateral breast reduction. There is an obvious asymmetry
of the NACs in terms of size, shape, and position, which bothers
the patient. B, The plan is to decrease the size and elevate the
position of the NAC on the breast. C, An early postoperative AP
view illustrates correction of the nipple asymmetry.
Ch02.qxd 11/27/05 8:41 PM Page 59
COMBINED DEFORMITIES The following patients illustrate a deviation from

DISCREPANCIES OF VOLUME AND ideal breast aesthetics after lumpectomy and previ-
NIPPLE POSITION ous radiation. This first patient (Fig. 2-56A) had a
lumpectomy to treat a left breast cancer performed
Most reoperations on the breast that I perform are through a lateral areolar incision. She presented
done to address derangements in more than one of with an asymmetry relating to greater breast vol-
the areas listed previously. That is to say, contour ume, larger base dimension, and lower nipple areo-
deformities are usually accompanied by scar prob- lar position on the right side. These issues were
lems, volume asymmetries, or NAC discrepancies. addressed by performing a right vertical mastopexy
A common example in my practice is the (Fig. 2-56B) with resection of 150 g of breast tissue.
postlumpectomy patient whose asymmetry relates This significantly enhanced the symmetry between
to volume, shape, contour, nipple areolar displace- her breasts. However, the patient had a lateral incli-
ment or dislocation, and a scar abnormality. These nation of her left NAC (Fig. 2-56C) that produced a
findings are superimposed on the setting of previous visible asymmetry in the AP position and slightly
radiation therapy. marred what otherwise was a very good result.
FIGURE 2-56. A, This is a 55-year-old patient who underwent

a left lumpectomy and radiation therapy for breast cancer. She
presented for correction of the resulting breast asymmetry
marked by a difference in volume, nipple position, nipple areolar
inclination, and degree of ptosis. B, The plan was to perform a
right vertical mastopexy. C, At a 1-year follow-up the patient
demonstrates markedly improved breast aesthetics despite the
persistent nipple areolar asymmetry.
Ch02.qxd 11/27/05 8:41 PM Page 60
deformities are principally related to excessive

Discrepancies of Contour, Volume, and
parenchymal resection, which is related to the rela-
Nipple Position
tively small breast volume (see Chapter 9). She was
This next patient presented with a marked contour managed by reconstruction of her volume deficit
deformity, volume asymmetry, and nipple disloca- following scar tissue resection using a TRAM flap
tion after a lumpectomy in which a large segment of (Fig. 2-57C,D). There was virtually no skin replace-
tissue was removed from the central portion of the ment needed. The overall outcome indicated
lower pole of her left breast (Fig. 2-57A,B). These restoration of normal breast aesthetics.
FIGURE 2-57. A, Preoperative AP view of patient with severe combined deformity of right breast
marked by a contour abnormality, nipple dislocation, and volume discrepancy. This occurred following
lumpectomy and radiation therapy for tumor in the central inferior aspect of the breast. B, Oblique
view. C, AP view following correction of these aesthetic problems with a TRAM flap reconstruction of
the postlumpectomy defect. D, Oblique view following revision of the previous lumpectomy defect.
Ch02.qxd 11/27/05 8:41 PM Page 61
COMBINED DEFORMITIES abnormal shape due to capsular contracture, inade-

INADEQUATE VOLUME, PROJECTION, quate volume, and local tissue atrophy (Fig. 2-58A).
AND CONTOUR The previous reconstruction was selected because of
inadequate autologous options. The right breast revi-
This 36-year-old female presented with a breast asym- sion was done in stages with skin deficit replacement
metry following a postmastectomy right breast recon- and soft tissue reconstruction with a TRAM flap
struction. This was performed for recurrent breast (Fig. 2-58B) and then subsequent implant placement
cancer after lumpectomy and radiation therapy. The beneath the flap (Fig. 2-58C). This produced much
implant-based breast reconstruction showed an improved symmetry as detailed in Chapter 8.
FIGURE 2-58. A, Breast asymmetry following staged implant-

based reconstruction of previously radiated breast. Note smaller
contracted breast implant. B, First stage reconstruction of
breast with replacement of skin and subcutaneous tissue using a
TRAM flap. C, Second stage involved placement of an implant
beneath the TRAM, which provided excellent symmetry with the
opposite breast.
Ch02.qxd 11/27/05 8:42 PM Page 62
superiorly, and the implant contained obvious

Inadequate Contour, Shape, Position,
folds.
and Volume
The plan was for autogenous conversion to a
This 52-year-old female presented with a marked TRAM flap. Tissue requirements dictated the use of
breast asymmetry due to a severely contracted a free TRAM (Fig. 2-59B; see Chapter 7). The proce-
saline implant reconstruction of the right dure addressed the breast malposition, restored ade-
breast. This breast reconstruction was superi- quate volume and shape, and replaced a small skin
orly malpositioned with inadequate volume and deficit (Fig. 2-59C). The nipple areolar reconstruc-
lower pole shape to match the opposite side (Fig. 2- tion produced good symmetry with the opposite
59A). In addition, there was a step-off deformity breast (Fig. 2-59D).
FIGURE 2-59. A, Malpositioned, severely contracted, saline implant right breast reconstruction. The
implant was placed beneath previously irradiated tissues. B, The plan included removal of the implant
and reconstruction of the breast with a free TRAM flap. (continued)
Ch02.qxd 11/27/05 8:42 PM Page 63
FIGURE 2-59. (CONTINUED) C, This produced an excellent revision of the breast reconstruction. D,
The nipple reconstruction provided an excellent finishing touch.
REFERENCES ties, and asymmetry. Plast Reconstr Surg. December

1999;104(7):20402048.
8. Tebbetts JB. Dual plane breast augmentation: optimizing
1. Bostwick J III. Plastic and Reconstructive Surgery of the
implant-soft-tissue relationships in a wide range of breast
Breast. 2nd ed. St. Louis: Quality Medical Publishers; 2000.
types. Plast Reconstr Surg. April 15, 2001;107(5):12551272.
2. Penn J. Breast reduction. Br J Plast Surg. 1954;7:357.
9. Rees TD, Aston SJ. The tuberous breast. Clin Plast Surg. April
3. Cooper, AP. On Anatomy of the Breast. London: Longmans;
1976;3(2):339347.
1845:10.
10. Millard PRS 1984, Maxwell 1980, Shestak Clinics.
4. Muntan CD, Sundine MJ, Rink RD, et al. Inframammary
11. Lejour M. Vertical mammaplasty: update and appraisal of
fold: a histologic reappraisal. Plast Reconstr Surg. February
late results. Plast Reconstr Surg. September 1999;104(3):
2000;105(2):549556; discussion 557.
771781; discussion 782784.
5. Boutros S, Kattash M, Wienfeld A, et al. The intradermal
12. Hall-Findlay EJ. A simplified vertical reduction
anatomy of the inframammary fold. Plast Reconstr Surg.
mammaplasty: shortening the learning curve. Plast Reconstr
September 1998;102(4):10301033.
Surg. September 1999;104(3):748759; discussion 760763.
6. Bayati S, Seckel BR. Inframammary crease ligament. Plast
13. Lassus C. A 30-year experience with vertical mammaplasty.
Reconstr Surg. March 1995;95(3):501508.
Plast Reconstr Surg. February 1996;97(2):373380.
7. Grolleau JL, Lanfrey E, Lavigne B, et al. Breast base anom-
alies: treatment strategy for tuberous breasts, minor deformi-
Ch03.qxd 11/27/05 9:52 PM Page 64
C h a p t e r 3
Revising the Unsatisfactory Breast

Augmentation
The Scope of Reoperative Surgery Following Superficial Thrombophlebitis of the Axillary

Breast Augmentation 66 Veins 94
An Approach to Primary Breast Augmentation Problems Related to Inadequate Preoperative

Patient Evaluation and Decision Making 66 Planning and Surgical Technique 94
Choosing an Implant 67 Implant Too SmallPatient Desires Larger Size

94
Implant Position 70
Minimizing Reoperations for Size Change 96
Selection of Incision 74
Reducing Breast Size Following Breast
Infra-areolar Incision 74 Augmentation 96
Axillary Incision 75 Breast Asymmetries 99
Surgical Planning and Technique 76 Asymmetry of Breast Volume 100
Pocket Dissection 78 Multifactorial Breast AsymmetryBreast

Volume, Orientation, and Nipple Areola Position
Subglandular Pocket Dissection 78 and Inclination 100
Subpectoral Pocket Dissection 78 Pre-Existing Breast Asymmetry due to Combined

Breast Volume and Rotational Deformity of the
Postoperative Management 81 Chest Wall 101
Follow-Up Care 82 Inframammary Fold Asymmetries 101
Revision of Breast AugmentationHistory and Implant Malposition 107

Physical Examination 82
Implant Too High 110
Complications of Breast Augmentation 84
Implant Too Low 115
Acute Complications 85
Hematoma Formation 85 Inadequate Upper Pole Fullness due to
Insufficient Implant Size and Inferior
Seroma 89 Malposition 115
Infection 89 Implant Too LowFrank Inferior Malposition

115
Wound Dehiscence 92
Marked Inferior Implant Malposition 120
Mondors Disease 93
64
Ch03.qxd 11/27/05 9:52 PM Page 65
Chapter 3 Revising the Unsatisfactory Breast Augmentation 65
Implant Too Lateral 121 Surgical Treatment of Ripples, Ridges, and

Folds 132
Medial Malposition 126
Capsular Contracture 134
The Double Bubble Deformity 128
Early Capsular Contracture 136
Treating the Double Bubble 128
Established Capsular Contracture 136
Ripples, Ridges, Folds, and Implant Edge
Palpability 128 Summary Statement on Capsular Contracture
140
Theories on the Etiology of the Problem 129
Implant FailureRupture or Deflation 140
Frequency of the Problem 132
References 142
Minimizing Skin Wrinkling 132
Breast augmentation is a very popular procedure with a larger implant); breast asymmetry; implant malposition;
high degree of patient satisfaction.1 Over the past 4 implant palpability; and wrinkles, ripples, or folds seen in
decades many types of implants have been used to the breast tissue and the skin overlying the implant. The
increase the fullness of the female breast, with the major- complications following breast augmentation are almost
ity of these procedures involving the placement of a sili- exclusively local, i.e., they are confined to the breast
cone gel implant.2 Concerns about safety issues regarding itself.7
the silicone gel breast implant led the U.S. Food and Drug Revision surgery following the previous placement of a
Administration (FDA) to impose restrictions of their use breast implant can be very challenging. This is due to the
for routine breast augmentation in the United States in effects of the previous surgery or the implant itself in the
1992.3 This prompted an immediate shift to saline-filled form of tissue atrophy, scars in the skin and periprosthetic
implants for breast augmentation in the United States. capsular region, and decreased blood supply to the breast
Subsequent scientific evaluations47 of the published liter- parenchyma and nipple areolar complex (NAC), especially
ature on the silicone gel breast implant exonerated this when the implant was placed in the subglandular space.
implant from any connection with disease production in For these reasons I believe that reoperative surgery fol-
humans. lowing a previous breast augmentation carries a higher
The most common inherent risk or unwanted side risk of complications and patient disappointment than
effect of all implants is that of capsular contracture,2,49 does the primary augmentation procedure.
which is an exaggerated form of the foreign body Because of this the plastic surgeon reoperating on a
reaction10 whenever a foreign substance is implanted in, patient following a previous breast augmentation must
gains access to, or is accidentally introduced into the spend the time necessary to communicate with the patient
human body. It is important to realize that this is an inher- regarding the goals, risks, and possible complications of the
ent risk (not a complication) of every breast implantation surgery (Chapter 1, Appendix A). As outlined in Chapter 1,
procedure (both breast augmentation and breast recon- I find it helpful to review the potential benefits and limita-
struction). The next most common inherent risk for tions of the likely problems with the procedure with both
patients who have undergone breast augmentation is the the patient and a significant othereither a friend, relative,
need to undergo additional surgery to treat a problem spouse, or significant other. This additional person is more
with an implant.7 likely to hear the scope of potential adverse outcomes fol-
Revisional surgery following breast augmentation lowing such surgery and be able to support the patient
occurs for a variety of reasons. These reasons relate to should a complication arise.
technical aspects of the previous surgery, the implant From the plastic surgeons perspective, careful analysis
itself, or the response of the body to the implant. In addi- and planning are essential for producing a good outcome
tion, some breast augmentation patients request revision with the greatest chance for longevity in the setting of
for cosmetic issues such as inadequate size (change to a reoperation following a previous breast augmentation.
Ch03.qxd 11/27/05 9:52 PM Page 66
THE SCOPE OF REOPERATIVE From the foregoing studies it is apparent that reopera-
SURGERY FOLLOWING BREAST tion following a previous breast augmentation is com-
AUGMENTATION mon. Furthermore, it is my opinion that the revision rate
is too high for an elective cosmetic surgery procedure.
The incidence of reoperative surgery following the place- A significant portion of these reoperations are attribut-
ment of an implant, for either breast reconstruction or able to implant-related factors and therefore they are
breast augmentation, is significant. This has been docu- probably not preventable with the implants that are cur-
mented by numerous published studies.1117 The reopera- rently available for use. However, problems leading to
tion rate at 5 years for breast augmentationdocumented early revisions (e.g., those due to size change and opera-
by Gabriel et al.7 in a study of 1,800 patients at the Mayo tions done to treat implant malposition and some asym-
Clinicwas 12% at a 5-year follow-up, while 34% of metries) are most likely due to inadequate preoperative
patients who underwent implant placement for breast communication with the patient, improper analysis of
reconstruction required reoperation during that same time patient anatomic features, and incomplete preoperative
period. Additional studies have found reoperation rates of planning and/or errors in surgical technique. I am firmly
15% to 20% following silicone gel breast augmentation.12,13 convinced that the rate of reoperation for the conditions
At the height of the concern about safety issues regarding just mentioned can be reduced by better preoperative
breast implants in the early 1990s (popularly termed the planning and more consistent technical performance of
breast implant crisis),3 this rate was even higher because of the operation. Said another way, it seems apparent to me
the number of women requesting removal of their implants. that such problems are best addressed by prevention. This
After April of 1992 plastic surgeons in the United States view is shared by other authors as well.19,20
were confined to the exclusive use of saline implants for Toward this goal, I have adopted a methodical
primary breast augmentation.3 Data relating to this expe- approach to the evaluation of the prospective patient seek-
rience were collected by various authors and the implant ing breast augmentation. This includes taking a careful
manufacturers.1317 Once again, when one surveys the history with an emphasis on size concerns and conducting
incidence of reoperation in this group of patients, the risk a thorough physical examination with an anatomic and
during the first 3 to 5 years is high. The Mentor aesthetic analysis, which results in an individualized sur-
Corporation,16 in a prospective premarket approval study, gical plan for implant selection and the surgical approach.
reported an incidence of reoperation in 13% during the The procedure is performed with an awareness of the
first 3 years following saline implant breast augmenta- patients particular anatomy using mainly the electro-
tion. Similarly the McGhan Corporation in its study cautery with minimal gentle blunt dissection of the lateral
(AR95)17 reflected a 21% risk of reoperation at 3 years. pocket as described. The goal is to achieve precise pocket
A benchmark prospective, longitudinal study of saline dissection that will fit the chosen implant. This approach
breast implants published14 and updated15 demonstrates a has been successful in my hands from the standpoint of
26% incidence of reoperative surgery within 5 years of decreasing the incidence of short-term problems related
saline implant placement for breast augmentation. to doctorpatient communication (implant selection),
Additional studies, including that of Young et al.,13 dis- inadequate planning, and technical errors. The details of
close a high rate of reoperation in the form of explanta- this approach are described in the following section.
tion (24%) within 7 years of breast augmentation surgery, Subsequently, my approach to revision of breast augmen-
with many patients requiring more than one explantation. tation is discussed.
The most common reasons cited for explantation in these
studies include capsular contracture, rupture or deflation,
asymmetry, inadequate size, and patient request for AN APPROACH TO PRIMARY BREAST
implant change.13 AUGMENTATIONPATIENT
A new source of data on the outcome of saline breast EVALUATION AND DECISION MAKING
implant placement is the Saline Breast Implant Registry
(NaBIR), which was begun in 2000,18 largely through the As in all of medicine, the interaction with the patient
efforts of Dr. V. Leroy Young in conjunction with the begins with a careful history and physical examination.
Plastic Surgery Educational Foundation. It is a confiden- This also applies when approaching the prospective breast
tial registry of data submitted by plastic surgeons on augmentation patient. Careful attention must be paid
saline implant placement for either breast augmentation to the patients chief complaint or desires regarding the
or reconstruction that allows prospective tracking and operation, her anatomic features, and her breast develop-
comparison of results in an identifiable cohort of patients. ment. The latter is investigated regarding whether the
The data compiled thus far again indicate that the reoper- breast development has been symmetric. The patients
ation rate for explantation is significant (15.4%) within personal history of breast problems, e.g., pain, menstrual-
the first 4 years following surgery. cyclerelated breast variations, and history of breast
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masses, with any family history of breast cancer, is thor- the torso. Most often I find it helpful to measure the dis-
oughly investigated. tance from the nipple to the suprasternal notch (SSN) on
It is important to inquire about any lumps or masses each side, followed by the distance of nipple to the infra-
that the patient may have had in either breast during the mammary (IM) fold in the midmeridian of the breast and
course of her lifetime and what the treatment of these also the distance from the inferior aspect of the NAC to
was. Specifically, it is important to determine exactly what the IM fold. I record all these measurements on a breast
the diagnosis was and how it was resolved. In patients diagram or a worksheet I use for breast augmentation in
who are older than 35 years of age the physician must the patients chart (Fig. 3-2).
inquire about whether the patient has had a mammo- After performing a complete and systematic examina-
gram, and if so the results of the study must be known. I tion, I discuss with the patient the potential incisional and
find it helpful to personally review these mammograms implant position options. The incisional approaches I use
often with the help of a radiologist. If the patient has not are the IM (60%), transaxillary (30%), and periareolar
had a mammogram by this age, one should be ordered. (10%) (Fig. 3-3). All of these incisional approaches can
It is very important for the physician to understand, in work well in the appropriate situation and usually leave
as much as is possible, the patients desires relating to inconspicuous scars. Patients often have a preference for
breast size. If a patient has been pregnant, I find it helpful which scar position they would like, and it is usually pos-
to ask how large the breasts became during pregnancy and sible to accommodate their wishes. Exceptions would be
whether the patient was comfortable with or enjoyed the grade II or greater ptosis in a patient who desires a
size of her breasts during her pregnancy. To help me better transaxillary breast augmentation.
understand the patients desire for size and appearance of
the breast following surgery, I prefer to have the patient
bring in pictures of normal patients (not models) with sim- CHOOSING AN IMPLANT
ilar body types who have an appearance that they find
attractive and desirable. This gives me an insight into the The choice of implant is patient specific. Most patients
look that the patient is after. Such photos are available on a who undergo breast augmentation in the United States
variety of websites (Fig. 3-1). seek a breast volume increase of two cup sizes.1 Concepts
Similarly, in the setting of a previous pregnancy, it is about breast attractiveness relative to size are different in
important to inquire about the changes in the breast fol- different cultures, with women in Europe21 and South
lowing such pregnancies. Many patients are bothered by America21 in general desiring less breast volume enhance-
the loss of volume and the change in shape that has ment from a breast augmentation. I try to listen very
occurred. Carefully noting the patients opinion regarding intently to every idea and intention a particular patient
breast settling or ptosis is important, and when appropri- has about her perceived postoperative size. I have come to
ate, suggestions regarding breast ptosis correction in con- understand that what patients want and find desirable is
junction with breast augmentation should be made. I am often very different than what the plastic surgeon consid-
increasingly performing a mastopexy in conjunction with ers to be an aesthetically desirable result. As previously
an augmentation in this population of patients, especially mentioned, reviewing photographs brought in by the
as part of a revision procedure. If the plan entails a patient can yield an important insight into a particular
mastopexy, I believe that it is critical to discuss the posi- patients desires and expectations for both volume and
tion of scars, the fact that they will be permanent, and the shape following breast augmentation.
fact that recurrent breast ptosis is part of the picture with Preoperative planning and implant selection depend to
every mastopexyincluding augmentation mastopexy. I a significant degree on patient anatomic factors including
find that this operation carries a higher risk of complica- breast dimensions, torso dimension, degree of ptosis, pre-
tions than either of these procedures performed sepa- existing asymmetry(ies), and tissue quality, including elas-
rately. ticity, thickness, and ability to stretch.20 In my practice
Systematic examination of the breast is carried out as implant selection is governed mostly by anatomic surface
described in Chapter 2. The surgeon should note the gen- relationships, and I key into breast and torso dimensions.
eral appearance of the breasts, scanning them for symme- The most important is the base width (Fig. 3-2) of the
try in terms of contour, fullness, nipple areola position, breast, or the distance from the area immediately lateral to
and the position of the breast relative to chest wall struc- the lateral edge of the sternum to the lateral silhouette of
tures. Both obvious and subtle asymmetries are noted. As the breast. This distance determines the largest base width
alluded to previously, I find it helpful to measure the of the implant that can be placed, especially if a round
dimensions of the breast, including the base width, height implant is selected. The center of a round implant should
(the extent of upper pole fullness when the breast is gently be positioned beneath the nipple. If the implant has too
compressed against the chest wall), and various distances great a diameter (is too large dimensionally), then the
of the breast architectural features from a fixed point on breast will elongate vertically or produce an abnormal
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FIGURE 3-1. Example of downloaded photographs from a

website illustrating, A, preoperative appearance of the breasts
in an augmentation patient. B, The smaller breast implant and,
C, larger breast implant in the same patient.
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FIGURE 3-2. Worksheet illustrating topographical relationships of the breast to the chest wall. Note
relationship of suprasternal notch (SSN) to nipple and nipple to IM fold. Also note distance from the
lower areola to the IM fold.
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lateral silhouette of the breast on anteroposterior (AP)

view is also variable due to the distensibility of those tis-
sues. Therefore, the horizontal distance from the nipple to
the parasternal region represents the greatest implant
radius that should be selected when a round implant is
used. I will generally choose an implant that is smaller in
dimension than this distance.
The distance from the midclavicular point to the nipple
and the distance from the SSN to the nipple are also
important dimensions, and they are recorded on the pre-
operative worksheet (see Fig. 3-2). After carefully record-
ing these dimensions, I consult various implant charts
provided by the manufacturers to select an implant that
will best satisfy the patients desires and fit her anatomy
(Fig. 3-5AB).
If there are other anatomic considerations, such as
petite or small stature or narrow torso, it is often desirable
to select an implant with more volume for a given base
dimension. In such a patient a high-profile implant (one
with greater projection and volume for a given base diam-
FIGURE 3-3. Incisional approaches I use for breast augmenta- eter) may be helpful (Fig. 3-6A,B). Such implants are very
tion. helpful in patients who place a premium on a large vol-
ume in the face of smaller breast and torso dimensions.
Alternatively, a shaped textured implant can be used.
These implants are designed with variable heights and
horizontal contour. A helpful rule of thumb is that when volumes for a given base width, and they give the illusion
using a round implant the largest radius that should be of greater projection and volume for a given base diameter
used is equal to the distance from the nipple to the ipsilat- dimension (Fig. 3-6C). I use a shaped implant with a rela-
eral parasternal take-off of the breast (Fig. 3-4). This is tively short vertical dimension in patients of small stature
because the tissues between the nipple and the parasternal who desire a very full breast.22 Conversely, I have found
area are fixed. The height of the implant is also important, that shaped implants that have a long vertical dimension
but because the IM fold is often lowered the accommoda- may be helpful in the very tall patient (greater than 6 feet
tive height can vary. The distance from the nipple to the in height) who require tapered upper pole fullness as part
of their augmentation.
Although most plastic surgeons acquire the majority of
their individual experience with a certain style or type
of implant (I prefer a smooth round implant for most
patients seeking breast augmentation), the surgeon must
have experience with and facility using various types of
implants. This permits using the most individualized
approach with each patient.
IMPLANT POSITION
The two alternatives for implant position are either the

subglandular or the submuscular space (Fig. 3-7AB).
The choice, again, depends on the patients anatomy, sur-
geon analysis, and a combination of patient and surgeon
preference. Placing the implant in the subglandular space
simplifies the procedure in terms of the dissection, is
associated with less postoperative discomfort, and gener-
ally results in a quicker recovery.23 This position for the
FIGURE 3-4. Measurement of nipple to parasternal area yields implant is especially good for patients who have glandular,
maximum possible radius if a round implant is selected. grade I, and some mild forms of grade II mammary ptosis.
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Chapter 3
Revising the Unsatisfactory Breast Augmentation
FIGURE 3-5. Charts for surface dimensions and volume of various implants manufactured by the
Mentor (A) and the McGhan Corporation (B).
71
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FIGURE 3-6. A, Standard profile and similar volume high-profile implant. There are important differ-
ences in volume and projection for a given base dimension. These dimensional and volume differences
often play a significant role in revision of a previous breast augmentation. B, Implants have either a smooth
or textured (right image) surface. C, Shaped textured implants available as saline or silicone devices.
For the surgeon to use this position, the patient must have selected because this type of implant has a definite
sufficient upper pole breast tissue to cover or camouflage predilection for visibility and palpability. The major disad-
the edges of the implant. I determine the adequacy of the vantages of the subglandular position of an implant are
tissue in the upper part of the breast by using the pinch test that there is an increased risk of capsular contracture24,25
as described by Tebbetts.22 I too believe that there should and that mammograms are less sensitive,26 i.e., more of the
be at least 2.5 cm of tissue in the upper pole of the breast to breast tissue is hidden. Finally, the dissection to place an
adequately conceal a subglandular implant (Fig. 3-8). If implant in the subglandular space results in greater
there is not, it is best to use the subpectoral position for decrease in the blood supply to the remaining breast
implant placementespecially if a saline implant is parenchyma with the division of many perforating vessels
from the pectoralis major muscle (PMM; Fig. 3-9A,B).
In this era of saline implants, by far the most common
position is the submuscular or, more precisely stated, a
partial retropectoral position for the implants (see Fig. 3-
7B). This is because such positioning will maximally cam-
ouflage any type of irregularity related to the implant edge
or changes in implant shape related to the distribution of
the sterile saline filler substance within the implant. In
addition, subpectoral placement is associated with a
decreased incidence of capsular contracture regardless of
implant type.24 Finally, the subpectoral position affords
the best possible breast surveillance in terms of postoper-
ative mammograms.26 This may be an important consid-
eration for many patients, and increasingly I find it to be a
particular advantage. The dissection is a little more tech-
nically demanding, and it most often involves the release
of the origin of the PMM from the fifth and sixth ribs
(Fig. 3-10). After the release of this portion of the muscle,
the inferior aspect of the breast implant sits beneath the
lower pole of the breast, or even beneath the subcutaneous
FIGURE 3-7. A-B, Breast implants can be positioned in the sub- tissue in those patients who have a lowering of their previ-
glandular or submuscular position. Implants in the submuscular ous IM fold. There is also more postoperative discomfort
space are covered by muscle in only their upper 70%. The lower associated with this approach than that seen following
30% sits behind the breast gland or in the subcutaneous position. subglandular placement of a breast implant.
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FIGURE 3-10. Release of part of the origin of the PMM from

the fifth and sixth ribs in the lower aspect of the breast.
FIGURE 3-8. Pinching upper pole of the breast parenchyma is

an accurate way of estimating the thickness of the breast tissue
in that region.
FIGURE 3-9. A, Blood supply to the breast parenchyma is derived from various sources. B,
Subglandular implant placement results in a substantial decrease in the blood supply to the breast
parenchyma and NAC.
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SELECTION OF INCISION
breast, whereby the surgeon can address asymmetries
In my current practice the incisions I offer to patients are or treat discrepancies or constriction of the IM fold. It
the inframammary (IM), infra-areolar, and axillary. I cur- can be incorporated into a periareolar incision, thereby
rently do not perform transumbilical breast augmentation. making it an excellent choice for cases that are likely to
The IM incision is the most commonly used and most ver- include an augmentation mastopexy. It is also very use-
satile of the incisions used for breast augmentation. This is ful for treating patients with a constricted breast defor-
reflected in my practice and by data recorded in NaBIR.18 It mity (Fig. 3-11) because it allows a setback of the
provides direct visualization of the subglandular and sub- pseudo-herniation of the NAC, which is a salient feature
pectoral planes and offers the most direct approach for man- of that deformity. The incision should be placed in the
aging any problems in the lower pole such as IM fold junction of the more darkly pigmented areolar skin and
asymmetries. This incision has a tendency to ride up on the adjacent breast skin. In this position it is less conspicu-
implanted breast as the implant settles, and therefore it ous. Placing it within the areola itself may result in visi-
should be positioned adequately low or approximately 1 to 2 bility due to potential hypopigmentation of the
mm below the intended level of the new IM fold. A careful resulting scar. Access to the subglandular or subpec-
three-layered closure of the wound, which includes the tis- toral space is attained by dissecting directly through the
sue adjacent to the implant, the deep dermis, and an intracu- breast parenchyma or by inferior elevation of a breast
ticular apposition of the skin wound, is routinely performed. skin flap above the breast fascia and entrance into
either of these planes from below (Fig. 3-12A,B). I pre-
fer to dissect through the breast parenchyma as this
INFRA-AREOLAR INCISION route provides a direct exposure to either plane. The
incision often yields excellent cosmetic results, but it
The infra-areolar incision is also commonly used. It may result in a slightly greater chance for decreased
also affords excellent access to the lower pole of the nipple sensibility.
FIGURE 3-12. A-B, Dissection using periareolar incision is

FIGURE 3-11. Constricted breast deformity (oblique view) is done either around the lower pole of the breast or directly
best approached through periareolar incision. through the breast parenchyma.
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AXILLARY INCISION Information about the options just discussed is pre-

sented to the patient in an interactive format to encourage
The transaxillary approach to breast augmentation active participation in the decision-making process on the
avoids a scar on the breast, and in my practice it is part of the patient. During this time instructions regard-
a popular approach for young unmarried women. ing postoperative care are also given to the patient.
I believe that the incision should be positioned trans- Finally, a detailed enumeration of the potential risks and
versely, and I generally tend to place it in or just above complications concerning breast augmentation is pre-
the highest skin crease in the axilla. It should be kept sented to the patient. During this discussion we empha-
posterior to the posterolateral edge of the PMM and size that a breast implant will in all likelihood not be a
anterior to the latissimus dorsi muscle (Fig. 3-13A,B). lifetime device and that the two most common inherent
The incision should be limited to between 3.0 and risks following this operation are those of capsular con-
3.5 cm. With this approach the skin should be under- tracture and the need for reoperative surgery on the
mined for a distance of 2 cm in both an anterior and breast(s) at some point in the future.7 A sample of the con-
inferior direction, and dissection through the clavipec- sent form I use for primary breast augmentation is shown
toral fascia gives access to the subpectoral space. The in Appendix A of this chapter Finally, we discuss cost
resulting scar is almost always inconspicuous by 1 year implications regarding unplanned reoperative surgery
following surgery. There is an incidence of numbness after breast augmentation (surgeons fees, facility charges,
and paresthesias involving the upper inner arms related and anesthesia fees), both in the rare circumstance of sur-
to retraction of or injury to the intercostal brachiocuta- gery done immediately following the procedure (e.g., to
neous nerves, but in my experience this is less than 5%. drain a hematoma) or surgery undertaken at a later date.
In every case of transaxillary breast augmentation I Once decisions about the type of implant, position of
inform the patient preoperatively that should she require the implant, and selection of incision have been made, the
re-exploration for bleeding or other problems, this will patient must decide whether to proceed with surgery. I
usually require another incision on the breast, either in find that there is a high patient sign-up rate (>80%) for
the IM fold or infra-areolar area. patients I see in consultation for breast augmentation.
FIGURE 3-13. A, The appropriate incision for a transaxillary augmentation is high in the axilla and
lies posterior to the posterior edge of the PMM and anterior to the latissimus muscle. B, The high axil-
lary scar heals well and is barely perceptible at 1 year following surgery.
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SURGICAL PLANNING AND (Fig. 3-16A). These lines denote the medial-most extent
TECHNIQUE of the dissection (Fig. 3-16A). I do not dissect medial to
them. I have found that this will minimize the possibility
There is no doubt in my mind that careful preoperative of creating medial implant malposition (symmastia if it
planning and precise, consistent pocket dissection are is seen bilaterally). The midaxillary line on the lateral
important in every breast augmentation. Furthermore, chest wall should be noted. This vertically oriented line
I strongly believe that the incidence of immediate postop-
erative and short-term problems (implant malposition
and palpability, breast asymmetry), and perhaps long-
term problems as well (implant rupture or deflation and
even capsular contracture), following breast augmenta-
tion can be reduced by individualized surgical planning
and consistent technique.
The patient is carefully marked before surgery in the
upright position to ensure precise pocket dissection and
placement of incisions. Outlines of the existing IM fold
and breast base width are inscribed on the skin. Next, the
precise position of implant placement is noted
(Fig. 3-14A). If the IM fold is to be lowered, the exact
extent of this lowering is noted (Fig. 3-14B). I do not dis-
sect the largest possible pocket because this may predis-
pose to implant malposition. To create a more precise
pocket I next outline the extent of superior pocket dissec-
tion. I find it helpful to have the patient compress her
breast gently against the chest wall, and in this way the
most superior aspect of the breast is apparent (Fig. 3-15).
To limit the possibility of excess medial dissection I next
draw a vertical line in the middle of the sternum. Then I
draw two additional lines, one on either side of this first FIGURE 3-15. The superior extent of the patients breast tissue
line 1.5 cm lateral to it over the lateral sternal area is noted by gently compressing the breast against the chest wall.
FIGURE 3-14. A, Outline on the patients skin of the IM fold and proposed position of the implant is
noted. B, Outline of proposed lowering of the IM fold is also marked on the skin. Note that the position
of the incision is off the patients breast.
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lies midway between the lateral border of the PMM and Planning the surgery in this way provides a guide to
the anterior edge of the latissimus dorsi muscle, which precise pocket development. In my hands the combina-
can be easily appreciated in most patients (Fig. 3-16B). I tion of planning and consistent surgical technique opti-
do not dissect lateral to this point. Limiting the extent of mized postoperative breast symmetry and has limited the
lateral pocket dissection is an important factor in limit- occurrence of breast asymmetry and implant malposition
ing the likelihood of lateral implant malposition. and early reoperations related to them.
FIGURE 3-16. A, Vertical midsternal line drawn from SSN to xyphoid. Lines are drawn 1.5 cm lateral
to this line on each side, and the medial dissection should not proceed medially to this line. B, The lat-
eral dissection should not go beyond the midaxillary line. This will minimize the frequency of lateral
implant malposition.
FIGURE 3-17. One-year postoperative AP (A) and oblique (B) views of the patient noted in Figure 3-14.
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The 1-year postoperative results of the patient noted in This maneuver is very helpful in minimizing asymmetries
Fig. 3-14 on AP and oblique views is illustrated in Fig. 3-17 of the IM-fold level of the augmented breasts.
A, B). When I am completely satisfied with the implant posi-
tion and breast appearance, I perform a three-layer clo-
sure of the wound as described earlier, applying a
POCKET DISSECTION circumferential dressing consisting of both a Kerlix (Tyco
Healthcare Group, Mansfield, Mass) roll application and
Dissection of the pocket for implant insertion should be Ace (Becton Dickinson, Franklin Lakes, NJ) wrap. The
done in a gentle manner with attainment of meticulous dressing remains in place for approximately 3 days, at
hemostasis. I perform almost all of the dissection under which time the patient is taken out of her dressing and
direct vision with the electrocautery with the exception of switched to a sports bra. Bra support of the breasts is
the lateral aspect of the pocket, which is performed last maintained for 1 month following surgery. When an IM
with gentle digital dissection (Fig. 3-18) after the sizer has incision is used, I request that patients refrain from using
been positioned. Minimal, blunt gentle digital dissection an underwire bra for 3 months to minimize any adverse
minimizes injury to the lateral sensory nerves and the pos- effect on the incision.
sibility of lateral implant subluxation (Fig. 3-18) while
allowing me to maximize the medial fullness or cleavage.
The lateral sensory nerves very often can be palpated SUBPECTORAL POCKET DISSECTION
and/or directly visualized. Most recently when I have visu-
alized the nerves through an IM incision, I have occasion- The subpectoral space can be developed using any of the
ally performed this lateral pocket dissection with the incisions described earlier. From the IM approach I iden-
electrocautery, dividing tissue adjacent to the nerves with tify the lower pole of the breast tissue and gently sweep it
minimal danger of injuring them. superiorly using the electrocautery set to the coagulation
When using a saline implant sizer I inflate this device mode. This allows identification of the lateral border of
with air in situ using a one-way valve. The maneuver is the PMM, and the plane beneath it is easily entered under
carried out with the patient placed in the sitting position direct visualization (Fig. 3-21A). This plane is developed
at 90 degrees on the operating table (Fig. 3-19). Most often with electrocautery dissection directed superior-medially
I use implant sizers to assess the adequacy of pocket dis- toward the NAC. A narrow Deaver retractor is then
section and breast contour rather than to establish which inserted and the remainder of the dissection is performed
size implant I will choose. This decision is usually estab- with the electrocautery. The origins of the PMM are
lished before the operation. released on its deep surface along the length of the lower
aspect of the breast proceeding from lateral to medial,
establishing the desired inferior position of the implant
SUBGLANDULAR POCKET DISSECTION pocket. The PMM is completely released in most cases to
the parasternal area (Fig. 3-21A). The exception to this is
The subglandular space is easily dissected through either the exceedingly thin patient in whom the muscle is
an IM or infra-areolar incision using a headlight or released but the pectoralis fascial layer is maintained
lighted retractor. I perform the dissection inferior to intact by gently stretching this layer with blunt dissection.
medial to superior according to the preoperative skin This provides an additional layer of tissue to pad the
markings. The lateral dissection is initially limited. I implant in the lower breast. More important, this layer
then place an OpSite dressing on the skin to eliminate may help to support the weight of the implant. Along the
contact of the implant with the patients skin and associ- lateral sternal area the PMM is not divided but rather it is
ated skin flora (Fig. 3-20A). The sample sizing implant or attenuated on its deep surface (Fig. 3-21B). Releasing the
the implant to be used for the procedure is inserted muscle here can produce an abnormal contour, often lead-
through an incision made in the OpSite (Fig. 3-20B). ing to a step-off along the lateral sternum that is difficult
Before inserting this device I analyze this implant sizer to correct.
for its base dimension by measuring it. In addition, both Instead the medial PMM is attenuated on its deep sur-
pockets are irrigated with a solution containing 50,000 face (Fig. 3-21B). This is accomplished by scoring the
IU of bacitracin, 500 mg cefazolin (Ancef), and 80 mg muscle on its deep surface with the electrocautery set to
gentamicin in 1,000 cc of sterile saline intravenous (IV) the coagulation mode. The deep muscle surface is gently
fluid.27 touched in a doting-type fashion. The depth of the dissec-
The symmetry of the breasts, including implant position within the deep surface of the muscle is usually 3 to 5
tion and inferior level of the implants, is checked with mm. This attenuation of the PMM allows a favorable
both implants in place while exerting gentle downward drape over the implant and produces the best possible
pressure on the upper poles of the breast (see Fig. 3-19). cleavage when the subpectoral position is chosen for
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FIGURE 3-18. Lateral dissection is performed with gentle digi- FIGURE 3-19. Following insertion of the implant, the lower
tal dissection to maximally preserve the sensory nerves to the poles of the breasts are inspected for symmetry by applying gen-
nipple. tle pressure over the upper poles of the breasts with the patient
sitting at 90 degrees on the operating table.
FIGURE 3-20. A, Sterile OpSite barrier drape is placed over the incision on patients skin before
implant insertion. B, The implant is inserted through an opening in the barrier drape.
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FIGURE 3-21. A, Release of inferior origin of the PMM from the

lateral edge of the muscle to the lateral sternal edge. B, The PMM
is attenuated on its deep surface with a superficial incision into
the deep surface of the muscle with the electrocautery device
along the sternal margin.
breast augmentation. I believe that detaching the medial parenchyma and splitting the medial PMM in the direc-
or parasternal PMM should be avoided, and this view is tion of its fibers. This provides immediate and excellent
shared by others.28 Next, the superior extent of the pocket access to the underside of the PMM, and release of its ori-
is established. The lateral dissection is initially limited. gin from the fifth and sixth ribs can be accomplished as
The dissected pocket is then irrigated with the antibiotic outlined in the preceding paragraph. The remainder of the
solution noted earlier. A sizer is placed as noted earlier, procedure is as outlined earlier.
and the final adjustments to the lateral implant pocket are When using an axillary incision, standard markings are
completed with the patient in the sitting position using used (Figs. 3-13A and 3-22A). I currently prefer using
gentle digital dissection (see Fig. 3-18). Very often the sur- endoscopic assistance to perform the PMM release from
geon will feel the lateral intercostal nerves as transverse its origin on the fifth and sixth ribs inferiorly as opposed
bands. These can be slightly stretched, but they must be to using blunt dissection. As noted earlier, after the inci-
preserved intact. Once again, the lateral dissection should sion is made the skin is undermined for a distance of 2
never be carried posterior to the midaxillary line. This line cm, and then the dissection is deepened through the
is also routinely drawn on the patients skin preopera- clavipectoral fascia and the lateral border of the PMM is
tively. The final breast appearance is checked with sizers noted. The muscle fibers themselves are not exposed. The
in both implant pockets, and if it is completely satisfac- interval between the PMM and pectoralis minor muscle is
tory, implants are inserted and then the incision is closed directly visualized, and the subpectoral plane is developed
in three layers. by gentle blunt dissection with an Agris-Dingman dissec-
The subpectoral space can be developed through the tor inferiorly toward the origin of the PMM. A special bal-
infra-areolar incision by dissecting through the breast loon dissector is inserted and inflated to create the optical
Ch03.qxd 11/27/05 9:54 PM Page 81
cavity. I have found that a sample sizing implant works (see Fig. 3-19). When the appearance of the breasts is
equally well for this maneuver. Next the endoscope is completely satisfactory, the implants are inserted and the
inserted, and operating through the same transaxillary axillary incision is closed in two layers, including the deep
incision the origin of the PMM is visualized (Fig. 3-22B). dermis and skin wound. I prefer to approximate the skin
This technique provides a controlled release of the muscle incision with 5-0 nylon sutures. A similar dressing to that
(Fig. 3-22C) and can also facilitate hemostasis. The final described earlier is placed.
inferior dissection to establish the inferior aspect of the
implant pocket is done with the Agris-Dingman dissector.
After completing the dissection of both pockets, the space POSTOPERATIVE MANAGEMENT
is irrigated with a solution containing 50,000 IU of baci-
tracin, 500 cc cefazolin (Ancef), and 80 cc gentamicin in Following the procedure, patients are generally managed
1,000 cc of sterile saline IV fluid27 and the sample sizing with a period of abstinence from heavy exercise of
implants are placed. Symmetry between the breasts is approximately 6 weeks. They are started on a program of
checked with the patient in the sitting position. I find that implant displacement exercises (Fig. 3-23AC) on postop-
it is helpful to gently compress the upper poles of the siz- erative day 1 or 2 when a smooth-walled implant is used
ers to ensure symmetry of the lower aspect of the breasts according to their comfort level. The purpose of this
FIGURE 3-22. A, Preoperative AP view of transaxillary endo-

scopic-assisted augmentation mammoplasty patient. B, PMM
origin revealed under endoscopic visualization. C, Postoperative
AP view at 6 months following surgery.
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treatment is to maximize the mobility of the implant and

the distensibility of the periprosthetic capsule. I person-
ally believe that this maneuver helps keep the implant as
soft as possible, and it may limit the occurrence or extent
of capsular contracture. This opinion is shared by many
plastic surgeons.29,30 More important, this maneuver is
something that the patient can do to help her recovery
and preserve the softness and natural feel of her result.
FOLLOW-UP CARE
In addition to the displacement exercise regimen, we

emphasize the importance of clinical breast examina-
tions31 (CBEs) to all patients. More important than this
is long-term physician follow-up examinations. I offer
patients yearly follow-up visits for the rest of their lives at
no charge to them. I do this so that I can be satisfied that
they are being examined by a physician who is experienced
in the examination of the breast that has undergone an
augmentation. Most important, we recommend postopera-
tive mammograms on the schedule as prescribed by the
American Cancer Society.32 Mammography remains the
most accurate way of making the diagnosis of breast can-
cer. In breast augmentation patient, special views that
involve displacing the implant are routinely employed.33
When this technique is employed, implant-related compli-
cations are rare.34 Although there is a decreased sensitivity
of mammograms following breast augmentation,26,35 there
is no evidence that the diagnosis of breast cancer is made
at a later stage in patients in patients who have undergone
breast augmentation when compared with patients who
have not undergone breast augmentation.3436
REVISION OF BREAST
AUGMENTATIONHISTORY AND
PHYSICAL EXAMINATION
See Table 3-1.

As previously noted, revision of a previous breast augmen-
tation is not an uncommon operation.7,1117 When patients
present for such surgery, they are almost always a number
of years removed from their previous procedure(s). In this
setting, the surgeon must be very clear about exactly what
is bothering the patient. Again, this understanding comes
from a very careful history of not only the previous sur-
gery(ies), but also any changes that have occurred since
the time of her last operation. A good deal of time must
be spent with each patient seeking a revision of a previ-
ous breast augmentation to understand her particular
problem and to formulate the best possible treatment
FIGURE 3-23. Implant displacement exercises following breast
plan. The surgeon must communicate with the patient, augmentation. A, Medial displacement. B, Lateral displacement.
emphasizing realistic goals, limitations, and potential C, Vigorous superior displacement may also be helpful.
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TABLE 3-1 Overview of Reoperative Breast Augmentation

1. Gather patient history i. Implant visibility: ridges, ripples, folds
a. Breast development j. Implant edge palpability
b. Changes in breast volume and appearance with menstrual cycle k. Ptosis: relationship of nipple to breast tissue
c. Breast cancer history i. Grade of ptosis
d. Family history of breast cancer ii. Relationship of breast tissue to underlying implant
e. Previous breast surgery(ies) l. IM fold development: any element of constriction
f. Breast pain m. Asymmetry
g. Nipple sensitivity i. Breast volume or volume distribution
h. Mammogram history ii. Contour
2. Identify specific patient desires iii. Nipple areola height, size, inclination
a. What exactly bothers the patient n. Chest wall deformity: pectus excavatum
b. Is she satisfied with size, fullness, shape i. Ribs
c. Is there capsular contracture ii. Pectoralis muscles
d. What is status of nipple areolar symmetry o. Scoliosis
3. Examine the patient 4. Diagram the breasts: breast worksheet
a. Amount of breast tissue 5. Create photographic documentation
b. Distribution of breast tissue a. AP/lateral/oblique
c. Scars on the breast b. Special views: lying down, bending forward
d. Breast skin appearance and elasticity; presence of striae 6. Collect implant data
e. Thickness of subcutaneous tissue and breast parenchyma a. Chronology of operations
(tissue padding) b. Incisional approaches
f. Dimensions of breast c. Size
i. Base width d. Type
ii. Breast height when chest is gently compressed e. Position
iii. Nipple to IM fold distance 7. Collect breast imaging data
iv. SSN to nipple distance a. Mammogram/sonogram
v. Midclavicle to nipple distance b. MRI
g. Position of breast on chest wall; cleavage: wide or tight 8. Make diagnosis and formulate plan
h. Capsular contracture 9. Propose surgical approach to patient
i. Presence and degree 10. Review informed consent
ii. Baker classification (IIV) 11. Proceed with surgery if appropriate
IM, Inframammary; SSN, suprasternal notch; AP, anteroposterior; MRI, magnetic resonance imaging.
complications. This will build the best possible some insight as to whether I will be able to achieve an
doctorpatient relationship that I find so helpful during improvement in her situation with which she will be
the recovery from additional surgeryespecially if there happy.
are additional complications. The patients chief complaint should be as focused as
I always ask the patient if she was happy after the possible. Is the patient bothered by the size, lack of supe-
original operation. Her response often not only gives me rior fullness, or any asymmetry (i.e., of the shape, con-
insight into her specific complaints or concerns about tour, IM fold level or definition of the fold, or position of
the augmentation procedure, but also reflects the the implants)? It is important to understand the patients
patients general sense of satisfaction and can be an indi- feelings about her nipple position, the degree of firmness
cation of whether she can be content with the results of of the implant, and the relationship of the breast
additional surgery. Comments such as they were never parenchyma to the implant. Is there evidence of signifi-
large enough, or they were always so hard, or they cant capsular contracture? Are there problems with
never felt natural can be very telling, especially if the implant edge palpability, obvious folds that show
physical inspection of the breast and the examination is through the skin, or implant malposition? When such
at variance with these comments. Occasionally the malpositions (e.g., lateral, superior, inferior, or medial
patient will make an unsolicited comment about her displacement of the implant) exist, they may be
previous surgeon or surgeons, and this too may provide increased in certain postures or positions. If there are
Ch03.qxd 11/27/05 9:54 PM Page 84
particular positions that bother the patient, specific COMPLICATIONS OF BREAST

descriptions of these circumstances should be eluci- AUGMENTATION
dated. Is there pain or discomfort in the breast(s)? The
etiology of such breast pain or mastodynia in the setting A simple and useful way to think about complications fol-
of a previous breast augmentation is often difficult to lowing breast augmentation is to divide them into those
establish and most of the time is multifactorial. I most that are related to the surgical procedure itself, and those
often tell the patient that there is no surgical solution or that are related to the implant or to the biologic integra-
surgical cure for breast pain. Has there been a change in tion of the implant by the body. Surgical complications
the appearance of the breast, and if so what is the time that are noted within the first 4 weeks following surgery
course of the change? Is there a history of previous are referred to as acute complications. These include
implant rupture or deflation of a breast implant, and if hematomas, seromas, infections, and problems with
so how was that problem treated? wound healing, including wound separation with implant
As I have suggested, it is important to have a complete exposure. A rare complication is that of superficial venous
understanding of all of the patients previous breast pro- thrombosis in the superficial veins on the inferior breast,
cedures. This includes the chronology of and time inter- known as Mondors disease. More commonly seen is a
val between the operations, as well as implant types, thrombosis of the small superficial veins in the axillary
sizes, and position of placement. It is important to region in patients who undergo breast augmentation
inquire about whether any of the procedures were asso- using a transaxillary approach (Fig. 3-24).
ciated with acute complications, and if so how these Complications seen within the next 2 months are
complications were managed. Any history of trauma to termed as subacute complications, and these mainly refer
the breast(s) must be noted. Not uncommonly the sur- to implant malposition. Most often this consists mainly of
geon will elicit a history of a closed capsulotomy that excessive fullness in the upper pole of the breast that is
was done after a silicone gel breast augmentation. In the noted in the early postoperative period. This is not
past many patients routinely would undergo such a uncommon when the implant has been placed in the sub-
manipulation if early firmness of the implant was pectoral position. In my experience this is the most
detected following breast augmentation.37 This practice
has been documented to be associated with an increased
incidence of breast implant rupture.38,39 Such treatment
of mechanically squeezing the previously augmented
breast is now discouraged and it should no longer be
done.
A systematic examination of the breasts is then carried
out as described in Chapter 2. The surgeon should note
the general appearance of the breasts, scanning them for
symmetry in terms of contour, fullness, nipple areola posi-
tion, and position of the breast relative to the chest wall
structures. Any obvious asymmetries are immediately
noted. Next, more subtle asymmetries are examined. The
relationship of the patients native breast tissue to the
implant must be noted. Has there been any settling of the
breast tissue away from the implant?
I find it helpful to measure dimensions of the breast,
including base width, height, and the extent of upper pole
fullness when the breast is gently compressed against the
chest wall. I then carefully measure the distance of the
nipple from the fixed point of the SSN on each side, fol-
lowed by measurements of the distance from the nipple to
the IM fold in the midmeridian of the breast, and also the
distance from the inferior aspect of the NAC to the IM
fold. I then record all of these measurements on a breast
diagram in the patients chart (see Fig. 3-2). I find that it is
very helpful to refer to this initial diagram of the breast
whenever I perform any breast surgical procedure. This
diagram is especially helpful when planning a revisional FIGURE 3-24. The typical appearance of superficial throm-
procedure. bophlebitis in the axillary veins. Note cord below skin.
Ch03.qxd 11/27/05 9:54 PM Page 85
commonly noted abnormality early on after breast

augmentation. From my perspective, in these situations
there is little concern that the implant will descend to the
appropriate level if the implant was noted to be in the
appropriate position at the completion of the operation.
Most often the implant will settle into a lower position as
the pectoralis major muscle stretches out during the first
4 months following surgery. However, if significant mal-
position of the implant in a medial, lateral, or inferior
location is present at 3 months following surgery, it can
lead to a permanent breast asymmetry or deformities that
very well might represent an indication for revisional sur-
gery on the breast(s) later in the postoperative course.
Additional surgical or technique-related complications
are decreased nipple sensibility; breast asymmetry;
implant edge palpability; and the presence of ripples,
ridges, or folds that can be seen through the skin. The lat-
ter three conditions are noted if the dimensions of pocket
dissection is inappropriateeither too large or too small.
Late complications following breast augmentation are
seen much more frequently. Most of these are implant
related. These would most notably include implant palpa- FIGURE 3-25. AP view 3 years after subpectoral augmentation
bility,18 ridges or rippling at the edges of the implant,40 with smooth-walled saline implants. Distortion of the breast
implant malposition either inferior or superior in location implant produced by voluntary contracture of the PMM follow-
and that result in either inadequate or excessive superior ing a subpectoral breast augmentation.
pole fullness respectively, lateral implant subluxation,
medial implant malposition, or symmastia if medial
implant malposition is bilateral. Implant malposition is of dissection is done to create a pocket for the implant in
noted with increased frequency due to the use of increas- either the subglandular plane or subpectoral space. As
ingly larger saline implants. Contour deformities may noted, my approach is to perform almost all of this dissec-
occur long after the placement of the implant and these tion gently and precisely with the electrocautery device
can be related to capsular contracture.9 under direct vision with a headlight or lighted retractor or
Inherent risks of breast implant placement are the using an endoscope. Meticulous hemostasis is checked for
result of the patients biologic incorporation of the and procured following the completion of such a dissec-
implant or problems related to this process. The most tion before the implant is placed.
commonly occurring of these is capsular contrac- I strongly believe that it is important for all patients to
ture. 810 Also seen are dynamic deformities of the refrain from the ingestion of aspirin and all products
implant related to contraction of the pectoralis muscles containing cyclooxygenase inhibitors for at least 1 week
in patients who have undergone retropectoral position- before surgery. I will cancel a breast augmentation proce-
ing of their implants (Fig. 3-25), which is a difficult dure if a patient has ingested any medicine containing
problem to address. Finally, implant failure marked by aspirin within a week before surgery.
rupture 41-45 with gel extrusion if silicone gel has been I do not feel that it is necessary to obtain a bleeding
used, or deflation if a saline implant has been time, prothrombin time, or platelet count before a routine
employed,14-17,46 is commonly seen following a previous breast augmentation in a patient without a history of pre-
breast augmentation. vious bleeding disorders. I do inquire about bleeding ten-
dencies marked by easy bruising, very heavy menstrual
flows, excessive bleeding after dental work, or explained
bleeding after previous surgery. If any of these conditions
ACUTE COMPLICATIONS
are present and are mentioned in the history, I then
request are bleeding time. If this bleeding time is abnor-
Hematoma Formation
mal, the patient should be informed about this and a con-
Excessive accumulation of blood in the periprosthetic cap- sultation with a hematologist initiated to investigate this
sular space is a relatively rare complication following situation. Any problems that the patient has had with
breast augmentation. It occurs in less than 2% of the cases episodic hypertension should also be sought and treated
as noted by various reports.42 Certainly a significant degree before surgery.
Ch03.qxd 11/27/05 9:54 PM Page 86
patients that if a hematoma occurs they may require addi-

tional surgery. I also tell them that I will provide this serv-
ice to them without an additional professional fee, but in
the hospital environment in which I currently operate,
patients are told that they would be responsible for
charges related to the use of the hospital operating room
and anesthesia services. (I give this information to all of
my cosmetic surgery patients.)
If the diagnosis of significant hematoma is made, the
exploration of the periprosthetic capsular space can be
done through the previous incision, except if it was placed
in the axilla. I find that reopening an axillary incision and
exploring the submuscular space, even using an endo-
scope, is a difficult operation and, in my opinion, it should
not be attempted. Therefore, I tell patients who select a
transaxillary approach that should they develop a
hematoma, another incision on the breast, usually in the
IM location, will be needed to allow the best possible
exploration to evaluate any potential sources of bleeding
and thus I will convert the patient to IM incision for an
inspection of any bleeding.
At the time of reoperative surgery to evaluate a
hematoma, most often no distinct bleeding point is found.
This is true in spite of careful evaluation of the previously
FIGURE 3-26. A hematoma in the right breast following a par- dissected space. Any blood in the space is evacuated, and
tial subpectoral breast augmentation seen on postoperative day
6. Note ecchymosis and size difference between the breasts. careful irrigation of the space is performed with sterile
saline and antibiotic irrigation. When the surgeon is satis-
fied that there is no active bleeding, the implant can be
replaced. Most often I insert a small suction drain, which
Despite careful surgical technique, hematomas occur is brought out laterally on the chest wall within the bra
in approximately 2% of patients.42,45 The clinical symp- line, locating it in the midaxillary line. The surgeon should
toms most often include localized discomfort in the inform the patient about potential drain placement before
breast. In more pronounced cases (Fig. 3-26) there may be surgery. These drains [most often a 10-mm Jackson-Pratt
associated swelling and ecchymosis of the breast. (Cardinal Health, McGaw Park, Ill)] are left in place until
Treatment of breast hematoma is directly related to the the drainage is less than 30 cc per 24 hours.
severity of the process. A patient who complains of pain in Such a case is illustrated by this 18-year-old patient
the breast that is increasing, and especially if it is localized with a developmental breast asymmetry related to a con-
to one side, should be seen as soon as possible to be exam- stricted breast deformity (Fig. 3-27AC). She requested
ined. After this examination, if it is deemed that the bilateral breast augmentation with silicone gel implants.
hematoma is small or of minor severity, i.e., there is no The approach consisted of an IM incision for the partial
sign of visible difference between one breast and the other, retropectoral placement of different sized implants. We
and no difference between breast appearance noted used a 260-cc smooth normal-profile silicone device on
immediately at the completion of surgery in the operating the left side and a 325-cc smooth low-profile silicone gel
room and what is now present, then observation with implant on the constricted right side to increase the
careful breast support in terms of a dressing or a well-fit- apparent base width of the breast. When we contacted the
ting bra is provided. Most of the time this breast immobi- patient the day following surgery, she reported signifi-
lization is all that is needed. Such patients can usually cantly more pain on the right side than on the left and she
begin displacement exercises within a week to 10 days was immediately seen in the office. There was no differ-
after surgery. ence in size at that point and the discomfort on palpation
On the other hand, if there has been significant accu- was not excessive. Her discomfort persisted, and when she
mulation of blood (see Fig. 3-26), it is best to advise the was seen on postoperative day 5 there was obvious
patient that re-exploration for drainage of the hematoma swelling of the right breast and signs of ecchymosis (see
is necessary. It is my practice to preoperatively discuss Fig. 3-26). She was advised that surgical re-exploration
with each patient the potential need for operative inter- was necessary and was returned to the operating room on
vention in the acute postoperative period. I specifically tell postoperative day 8 for an evacuation of a 60-cc
Ch03.qxd 11/27/05 9:55 PM Page 87
FIGURE 3-27. A, Preoperative AP view of a patient with breast hypoplasia superimposed on a

constricted breast deformity producing an asymmetry. B, Lateral view. C, Oblique view. D, Hematoma
right breast noted on post-operative day 6 following partial sub-pectoral breast augmentation requiring
operative re-exploration for drainage.
hematoma. A new implant was placed along with a My analysis of the breast implant literature reveals
Jackson-Pratt drain. The drain was removed within 1 that a patient who develops a hematoma following a
week and she was begun on displacement exercises. At breast augmentation is at increased risk for later develop-
2 months following the hematoma evacuation surgery, she ing capsular contracture.4245 For that reason I believe
demonstrated excellent symmetry between the breasts that it is important to treat significant postoperative
(Fig. 3-28A), soft breasts (Fig. 3-28D), and correction of hematomas aggressively by surgical exploration and
the constricted breast deformity (Fig. 3-28B,C). drainage.
Ch03.qxd 11/27/05 9:55 PM Page 88
FIGURE 3-28. A, Postoperative appearance of the breasts on AP view 6 months following surgical
drainage of the hematoma. Note excellent contour and symmetry with no evidence of capsular contrac-
ture (B) and correction of the tuberous breast deformity (CD). Breast implants are soft and have no
evidence of capsular contracture as demonstrated by patient squeezing the breast.
Ch03.qxd 11/27/05 9:55 PM Page 89
SEROMA process resolves and that each of these aspirations carries

with it a small but definite risk of damage to the implant or
Some degree of fluid accumulation occurs around all infection.
breast implants after they are placed as part of the reac-
tion of the body to surgical manipulation of the tissues, or
surgical injury. This problem is rarely of significance, INFECTION
however. The study found its incidence to be 1%. I believe
that this fluid accumulation might be increased from Infection is a dreaded complication of any procedure in
shear stresses between the implant and surrounding tis- which a breast implant is placed. Fortunately its occur-
sues. For this reason I have all of my patients refrain from rence is rare. The quoted incidence of infection is between
vigorous activities for at least 6 weeks following breast 1% and 4%42 but varies between 1% and 2% in most series
augmentation procedures. Additionally, I have them sup- published in the literature.4749 Infections following breast
port their breasts with elastic support for 24 hours a day augmentation appear either early (most common) or late.
during the first month following surgery by wearing a bra. Perioperative infections are defined as those that occur
I have never operated on a breast augmentation patient within 30 days of surgery, whereas late infections may
for a suspected postoperative seroma. occur at any time thereafter, often without any apparent
In my experience the development of seromas has been reason or associated infectious event.
more common with the use of textured surface implants. If infection occurs following breast augmentation, it is
This is true for both textured silicone gel implants and tex- usually apparent within 7 to 10 days of surgery. Infections
tured saline implants. When using a textured device, it is may be either superficial, i.e., involving the area of the
absolutely essential to precisely dissect the pocket before skin incision and superficial subcutaneous tissues only, or
placing these implants and, more important, to position they can present as a deep infection with involvement of
the implant in a very precise manner because a textured the implant as well. The most common clinical sign of
implant will not move from its original position. Seromas infection is erythema in the skin which, if there is implant
can result in the formation of a biofilm around an implant. involvement, is often accompanied by pain with any
Such a biofilm can lead to the increased possibility of movement of the breast implant. With implant involve-
implant shifting and subsequently to implant malposition. ment there may also be abnormal swelling or pain in the
In addition, the accumulation of seroma fluid may result breast that is present even without moving the implant.
in an increased tendency for swelling in the breast, or a The breast is also most often warm to the touch.
patients perceiving and hearing a sloshing sound when Occasionally there will be drainage from the incision. The
moving about. Because there is an increased tendency for ipsilateral axillary lymph nodes may be enlarged and ten-
seroma fluid elaboration with the use of textured implants, der. Rarely are there early systemic manifestations of
I routinely place suction drains when textured implants infection.
are used for breast reconstruction procedures. I have not Patients who present with superficial infections at any
adopted this practice when using textured implants for early stage (Fig. 3-29A,B) may show a picture of cellulitis
breast augmentation, but rather I rely on precise pocket with erythema involving a small or moderate area of the
dissection and accurate implant placement. skin overlying the implant. In this situation there is no
In all likelihood most seromas are small in volume and pain on movement of the implant. If such a process is
are of little consequence to the overall surgical result. minimal, then treatment can be initiated on an outpa-
However, if a seroma causes significant swelling, it may be tient basis with a broad-spectrum oral antibiotic or
difficult to distinguish from a hematoma. I make the diag- combination of antibiotics that are effective against
nosis of seroma based on a clinical examination and usu- Staphylococcus aureus and Streptococcus spp. I prefer to
ally an ultrasonographic examination of the breast (a use a combination of a cephalosporin [cephalexin (Keflex)
sonogram performed by a radiologist). If there is a signifi- 500 mg by mouth (PO) every 6 hours (q6h)] and a semi-
cant fluid accumulation, I feel that it is best to re-explore synthetic penicillin (dicloxacillin 500 mg PO q6h) or
the breast wound in the operating room to evacuate the Augmentin 825 mg PO 2 times daily (b.i.d.). If the celluli-
seroma and to place the drain. In my opinion this allows tis is more advanced or pronounced in its appearance,
optimal healing between the implant and the surrounding then intravenous antibiotic therapy is begun on either an
tissues. outpatient or inpatient basis. I usually use a second-gener-
An alternative treatment involves displacing the ation cephalosporin [cefazolin (Ancef) 1 g IV q8h] or a
implant medially and performing a sterile percutaneous broader spectrum drug [ampicillin (Unasyn) 3 g IV q6h]. I
aspiration of the seroma fluid using an 18-gauge intra- will usually see the patient every day to monitor her
catheter. This must be done using strict aseptic technique. progress and to evaluate her clinical response to the spe-
The patient must be informed that it is often necessary to cific antibiotic therapy. A response is indicated by a
perform such aspirations a number of times before the decrease in the erythema within 48 hours of initiating the
Ch03.qxd 11/27/05 9:55 PM Page 90
FIGURE 3-29. A, Cellulitis of right breast following total periprosthetic capsulectomy and implant
exchange for severe capsular contracture. B, Outline of erythema is made on the breast to monitor
resolution.
antibiotic therapy. It has been my experience that, if fluid should be obtained. If there is any evidence of signifi-
caught early, many such infections following breast cant Periprosthetic capsular fluid in the space that sur-
implant placement can be successfully treated in this way. rounds the implant, especially if this fluid is turbid, or
The patient shows resolution of infection at 1 week follow- there is frank purulence around or attached to the implant
ing surgery (Fig. 3-30). (Fig. 3-31), the situation is more ominous. If this Gram
On the other hand, infections involving the breast stain shows obvious bacteria or proliferation of white
implant itself are difficult to treat. To have any chance of blood cells, it may be difficult to salvage the implant.
reversing this process they must be treated early and If an attempt to save the implant is elected, the
aggressively. I tell every patient preoperatively that it is periprosthetic capsular space is copiously irrigated first
difficult to sterilize an implant that has become infected. with normal saline and then with an antibiotic irrigation
If the infection is diagnosed early, without evidence of solution. The wound is then closed and, most often, a suc-
pronounced cellulitis, it may be possible to reverse the tion drain is then used. In the past suction-irrigation sys-
process and salvage the implant. This would be in a case tems have been used to continuously afford lavage of the
where there was no infected fluid in the periprosthetic periprosthetic capsular space with an antibiotic solution.
space around the implant. As previously stated, immediate I have not tried this form of therapy.
treatment with intravenous antibiotics is initiated. If there Most implant infections are caused by gram-positive
is no response within 48 to 72 hours, the patient should be organisms, with S. aureus being the most common. In a
advised that an imminent return to the operating room for study of implant infections following both breast aug-
the purposes of opening the incision and evaluating the mentation and breast reconstruction, Courtiss et al.50
implant is important. At that time, the surgeon can make a found S. aureus in 76% of the augmentation specimens
judgment as to the degree of local tissue involvement with and in 100% of the breast reconstruction patients.
the infection. The implant can be removed from the Additionally, the gram-positive organisms Staphylococcus
periprosthetic capsular space and a Gram stain of any epidermis and streptococcus (type A and type B) are most
Ch03.qxd 11/27/05 9:55 PM Page 91
FIGURE 3-30. Resolution of this infection was noted after a FIGURE 3-31. Purulent biofilm noted around infected pros-
10-day course of PO antibiotics (cephalexin 500 mg and thesis, which required removal to treat this implant infection.
dicloxacillin 500 mg q.i.d.). Appearance at 1 year postoperative.
commonly isolated as documented in other series.51 nated sponge the morning of surgery to decrease the bacte-
Other bacteria found less often in implant capsules rial count of the skin. Prosthetic infections seem to be
include Corynebacterium, Pseudomonas aeruginosa, related to prolonged surgical times, multiple insertions and
Staphylococcus intermedius,51,52 and Mycobacterium sp. reinsertions of sample sizing implants, and breaks in sterile
Much less commonly, enteric or gram-negative bacteria technique. I attempt to keep the surgical time under 2
such as Propionibacterium acne, Escherichia coli, and hours, use a closed filling system for saline breast implants,
Klebsiella spp. are isolated. For this reason cultures for and employ the no-touch technique with clean gloves and a
aerobic, anaerobic, acid-fast bacillus (AFB), and fungal sterile adhesive drape or OpSite dressing placed around the
organisms are routinely sent at the time of surgery.53 incision (see Fig. 3-26A,B) during implant insertion. All
Approximately 50% of breasts studied by bacteriologic implants used for the procedure should remain in their
analysis test positive for the presence of endogenous flora. sterile package until just before insertion rather than sit
These bacteria are presumably carried through the ductal open on the instrument table for prolonged periods. If
system.54 opened they should be immersed in antibiotic fluid until
In his review of infections associated with various inserted. As previously noted, I use triple-agent antibiotic
implantation devices Dougherty51 points out that gram- irrigation27 and give the patient prophylactic antibiotics,
positive organisms are found most often. However, infec- which are continued perioperatively for 5 days. I adminis-
tions caused by gram-negative organisms and fungi tend to ter a second generation cephalosporin [cefazolin (Ancef)
be more serious and unlikely to resolve without implant 1 g IV preoperatively and at least 1 g IV postoperatively).
removal. Therefore, it is extremely important for the sur- Alternatively, ciprofloxacin (750 mg twice daily) may be
geon and the operating team to take every precaution to substituted for this. I routinely use perioperative antibiotics
prevent an implant infection. Before I do my surgical mark- at the time of a breast augmentation. It is my custom to use
ing, I ask the patient about any symptoms that suggest an antibiotics in all breast surgeries, especially those in which
ongoing infection involving the pharynx, throat, sinus, or prosthetic materials (implants) are used. This has been
urinary tract. I then examine these systems for infection debated over the years in the literature. However, it is my
and appropriate lab tests are obtained. If present, these feeling that the cost-benefit ratio favors the administration
infections must be treated, and the patient should not of intravenous antibiotics, which I believe should be
undergo an elective breast augmentation at this time. I administered before making the surgical incision when a
have all patients shower with a hexachlorophene-impreg- breast implant (or implant of any kind) is to be inserted.
Ch03.qxd 11/27/05 9:55 PM Page 92
Before breast augmentation, part of the informed con- minutes before the procedure, with an additional 500 cc
sent must include the possibility of infection. I routinely to be taken 30 minutes after the procedure. For patients
tell patients that should infection occur, it will most likely who are penicillin allergic, I prescribe ciprofloxacin 750
be necessary to remove the implant and allow time for res- cc before and after the procedure on the same dosage
olution for the infection and for the attainment of normal schedule. This practice is not universal among plastic
tissue equilibrium. As noted earlier, this time frame is surgeons.
most often at least 6 months. I tell patients that if implant As outlined in the foregoing paragraphs, infections fol-
removal is necessary, they will be asymmetric if they elect lowing breast implant placement are rare. They tend to
to maintain implant on the breast that is not involved with occur more often after breast reconstruction than after
infection. Infections in my practice have been rare (less breast augmentation. The association between breast
than 1%). In the single instance, the patient had a unilat- implant infections and implant variables is examined by
eral infection that required implant removal. She asked Handel et al.,42 who found that infection was more than
me to remove the implant on the contralateral side as well twice as common after reconstruction (4.5%) than after
so as not to be unbalanced during her recovery. either primary breast augmentation (1.9%) or implant
To summarize this overview, as previously indicated, replacement (1.5%). No associations were detected
when addressing an established infection, if the implant between infections and implant filler material, surface
pocket shows signs of fluid accumulation it may be type (smooth versus textured vs. polyurethane), or
impossible to save the implant. Attempts to do this are implant position (subglandular vs. subpectoral).42
usually unsuccessful. They are often costly, extremely
inconvenient, and disappointing for the patient. In such
situations I have found it most advisable to remove the WOUND DEHISCENCE
implant, treat the local tissue infection, await resolution
of the process, and allow 4 to 6 months for tissue equilib- Wound separation following breast augmentation is an
rium to occur. It is at this point that it might be reasonable uncommon problem, with an incidence of 1% to 2%.
to consider reinserting the implant. I believe that waiting When it does occur, it is virtually always seen in the setting
at least 6 months is important to allow the immunologic of an IM incision.56 As previously stated, I believe that a
processes in the local tissues to eliminate bacteria from multiple-layer closure of the wound is essential. Such
any residual scar tissue. wound dehiscences are related to inadequate closure of
This clinical scenario is illustrated by the young the wound, or inadequate pocket dissection, which can
woman shown in Figure 3-32 who underwent a bilateral cause increased pressure from the implant on the inci-
submuscular silicone gel implant breast augmentation sion. In addition, a hematoma, seroma, and infection in
through an IM incision. She developed an infection the wound can also lead to wound dehiscence.
involving the right breast implant that failed to respond If the wound separation occurs within the first 2 to 3
to antibiotic therapy (Fig. 3-32A) and was removed days following surgery, the implant may perhaps be sal-
(Fig. 3-32B). Approximately 1 year later she underwent a vaged by immediately returning the patient to the operat-
redo of her breast augmentation (Fig. 3-32C). This was ing room for exploration and reclosure of the wound. If
complicated by an inferior implant malposition that the separation occurs much later than this (beyond 5
required revision with capsular suture plication of the days), I believe that it is almost never possible to salvage
lower aspect of her periprosthetic capsule to achieve satis- the implant. This is because at this phase of wound heal-
factory symmetry of her IM fold levels (Fig. 3-32D). ing the tissues of the wound have a limited ability to hold
After allowing suitable time for tissue equilibrium sutures. Such a situation is illustrated as follows.
(most often at least 6 months), it is possible to re-explore The 39-year-old patient shown in Figure 3-33 presented
the breast and replace the implant. It may be advisable to to the office self-referred after she noted a problem with
avoid operating through the same incision if at all possible. the right IM incision 3 weeks after a breast augmentation
I usually select a different incision and very often place the (Fig. 3-33A). There was evidence of exposure of her tex-
implant in a different space to minimize any chance of tured surface saline implant in the depths of the wound. It
contamination when replacing a breast implant. appeared that implant was exerting significant tension on
In an attempt to protect the previous breast augmenta- the wound closure. It was not possible to salvage the
tion patient against the possibility of infections long after implant, and she elected to have both implants removed
the original procedure, I administer prophylactic antibi- (Fig. 3-33B). A culture of the periprosthetic capsular space
otics to such patients when they undergo dental proce- was taken and this returned as negative. We allowed
dures or urologic and proctoscopic instrumentation.55 approximately 8 months to elapse so that the scar would
I do this in a manner similar to that used for patients with soften before we returned to the operating room for bilat-
prosthetic heart valves and prosthetic joint replace- eral implant reinsertion (Fig. 3-33C). This resulted in a
ments.55 I prescribe 2 g of amoxicillin to be taken PO 30 very satisfactory appearance at 1 year following surgery.
Ch03.qxd 11/27/05 9:55 PM Page 93
FIGURE 3-32. A, Infection of right breast implant following breast augmentation done 7 days earlier.
B, Appearance of patient after removal of both implants. This was done to allow complete healing of the
incision, and 8 months was allowed to elapse before the revision surgery. C, One-year postoperative
appearance following bilateral implant reinsertion. D, The patient is shown 6 months following the
revision surgery to adjust her right IM fold contour.
In this case I used the patients previous incision because MONDORS DISEASE
of an asymmetry of the IM folds, which could best be
addressed with the exposure afforded by this IM approach. Superficial venous thrombosis in the subcutaneous veins
This accounted for the additional 2 months of waiting before of the breast is a very uncommon entity that occasionally
proceeding with the surgical revision. However, it is often occurs after any type of breast surgery. Usually this pres-
advisable to use a different incision to avoid potential prob- ents as an area of inflammation with cord formation. It
lems with operating through a previous scar. Had there not most commonly occurs at the level of the IM fold. This
been a significant asymmetry of the IM fold, I might have superficial thrombophlebitis poses no risk to the patient
elected to perform this redo breast augmentation through a in terms of embolization. The patient is instructed to
transaxillary or infra-areolar surgical approach. apply moist heat to the area. This condition is self-limited
Ch03.qxd 11/27/05 9:56 PM Page 94
FIGURE 3-33. A, Patient seen in consultation 3 weeks after undergoing a bilateral glandular breast
augmentation with dehiscence of right IM incision and exposed implant. B, AP view of breasts 4 weeks
following the removal of both implants. C, Appearance 1 year following surgery to reinsert her
implants. This reinsertion was performed 8 months following implant removal.
Ch03.qxd 11/27/05 9:56 PM Page 95
and usually resolves within 4 to 6 weeks. I most often also reverse changes brought on by pregnancy, weight loss, or
prescribe a nonsteroidal anti-inflammatory drug (NSAID) aging, all of which lead to volume loss and very often to
such as ibuprofen [600 mg PO four times daily (q.i.d.) for breast ptosis, with the resulting loss of shape. As previ-
10 to 14 days]. ously noted, in my practice the choice of implant size is
based on body habitus, torso dimension, and breast base
width. To appear as close to natural as possible, a
SUPERFICIAL THROMBOPHLEBITIS OF given implant must have the appropriate tissue cover.
THE AXILLARY VEINS Sometimes the thickness of the covering tissues affects the
choice of implant. For example, I believe that it is neces-
The transaxillary approach is a very commonly employed sary to select larger implants with greater projection in
route of implant introduction. It involves a dissection obese patients with smaller breasts and thicker subcuta-
beneath the skin and subcutaneous tissue of the axillary neous tissue layer to produce more optimal breast aesthet-
region. At this point in the dissection the surgeon often ics following breast augmentation.
encounters small veins, which are routinely electrocauter- It is interesting to note that patients have different ideas
ized and divided. Cauterization of such veins can cause local concerning what is most aesthetic, and many are interested
irritation and thrombosis. This may present postoperatively in obtaining a certain look. This is illustrated by the fact
as an area of discomfort with a palpable cord in the axilla that many patients bring in pictures preoperatively indicat-
(see Fig. 3-24). This cord extends from the axilla down the ing how they want their breasts to appear postoperatively.
medial aspect of the arm and often involves the median Currently there is a plethora of information available on
basilic vein. It may be uncomfortable for the patient to com- the Internet with multiple websites (e.g., www.implanti-
pletely abduct her shoulder and extend the elbow. nfo.com) containing information about breast augmenta-
Here, too, the treatment is local and systemic. It tion and implants.1 In addition, various other sources on
involves the use of moist, warm (not hot) heat and the Internet58 also have pre- and postoperative pictures of
NSAIDs such as ibuprofen (Motrin). I recommend that patients who have undergone the procedure. As noted pre-
patients take the ibuprofen in the dosage of at least 600 viously, reviewing and discussing this information with the
mg t.i.d. for approximately 1 month. This is usually suc- patient can be helpful to the surgeon. Input from the
cessful in reversing the process. Recanalization of these patient regarding desired postoperative size is essential, but
superficial veins occurs, and generally speaking there is it is the surgeon who must decide if the patients desire for
no permanent sequela. breast appearance following augmentation can or should
be realized and give appropriate advice. As noted earlier,
many patients in the United States seek an increase of one
PROBLEMS RELATED TO INADEQUATE to two cup sizes with a breast augmentation.1 I believe that
PREOPERATIVE PLANNING AND the surgeon should beware of patients who seek a greater
SURGICAL TECHNIQUE increase than this because their tissues will often not sup-
port an implant of this size, and the reoperation rate in
Problems that occur within 3 months of surgery fall into such patients is high.
two categories: inadequate preoperative planning or errors Although I never promise a specific bra cup size to a
of surgical technique. Planning errors can result from patient before breast augmentation, it is very important
unclear communication between the surgeon and patient for me to understand the patients desires for postopera-
most commonly relating to implant size. Errors in surgical tive breast size in general terms when using a saline
technique can result in implant malposition and breast implant. I generally propose that we use either of two
asymmetries. Incomplete or inadequate evaluation of the implant sizes for a given breast augmentation, and the
patients breast anatomy, especially relating to existing patient will usually state her preference for going with the
asymmetries57 of volume, breast orientation on the chest bigger or the smaller size prior to the time of implant
wall, IM fold constriction, and skeletal asymmetries of the placement. I find that in most instances the patient will
chest wall, are often inadequately corrected or even magni- either make a comment about wanting to be natural in
fied by the placement of an implant. Both of these types of appearance or to be as full as possible, and this is helpful
errors often result in a suboptimal cosmetic result. to me.
Patients who desire an implant size change almost
always wish to be larger. This goal of increased breast size
IMPLANT TOO SMALLPATIENT is usually possible to achieve because the breast tissues
DESIRES LARGER SIZE have been expanded by the previously placed implant.
Generally the operation is done using the same access
All patients who undergo breast augmentation seek to incision. Most often patients seek superior fullness and a
have increased breast fullness. Some patients wish to fuller, more attractive cleavage.
Ch03.qxd 11/27/05 9:56 PM Page 96
A review of the data in NaBIR,18 which lists the reasons MINIMIZING REOPERATIONS FOR SIZE
for reoperation following a previous breast augmentation, CHANGE
reveals that the two most common reasons given for reop-
eration are patient desires a larger size and patient Although reoperating to increase the size of a breast
preference (which is also interpreted as patient desires implant is not a common occurrence in my practice
larger size) (Table 3-2). This substantiates my earlier (approximately 1% to 2% of my breast augmentation
statement that reoperation to increase the size of the patients undergo a change to larger implants), I have had
breast following previous breast augmentation is not at all patients voice the statement if I had it to do over again I
uncommon. would have gone larger to their friends or to my office
The typical scenario of a patient who is dissatisfied personnel. For this reason it is important for each surgeon
with her size following surgery is illustrated by this 5-feet, to spend a great deal of time listening to the patient to
1-inch, 110-lb patient of mine (Fig. 3-34A,B) who under- gain the best possible understanding of the patients
went breast augmentation with smooth round implants desires for postoperative breast size. I rely on my experi-
filled with 310 cc of saline. These were placed in the par- ence to determine how much fullness will be produced
tial subpectoral position through an IM incision. with a certain size of implant in a specific patient, recall-
Although they appeared to produce an excellent aesthetic ing patients with a similar body type, breast dimensions,
result (Fig. 3-35A,B), they did not meet the patients expec- and breast volume with whom I have used a similar
tations in terms of breast fullness. She could not adjust to implant. In addition, I make extensive use of implant size
what she perceived to be an inadequate breast volume, charts provided by the manufacturers. This usually leads
and her disappointment only increased with time. After 1 to the appropriate choice of breast implant from a
year and six office visits, these 310-cc implants were dimensional perspective. With the range of overfill avail-
removed and were replaced with round implants contain- able with saline implants (+10% to +30%) and the differ-
ing 450 cc of saline. The procedure entailed a medial and ent implant profile types available, there is potential for
superior capsulotomy (Fig. 3-36A,B) and was carried out increasing the fullness with a certain dimension of
using her previous incision without difficulty. This gave implant of greater than 100 cc depending on the particu-
significant superior fullness and overall breast size, which lar patient.
the patient had been seeking (Fig. 3-37A,B). I have never subscribed to the practice of having a
It is important whenever possible when using large patient fill a bra with implants preoperatively as a means
saline implants (>350 cc) for the surgeon to maintain of selecting a certain implant size. However, if the surgeon
some of the inferior periprosthetic capsule intact (i.e., to elects to use this method and subpectoral position is cho-
avoid a complete inferior capsulotomy) to minimize the sen, the choice of implant should be one size larger than
potential of subsequent inferior implant malposition. If that selected using the process of placing the implant in a
this is not possible, then I have found it helpful to place bra. This is to compensate for the compression of the soft
sutures between the edge of the divided capsule anteriorly tissues (breast and PMM) on the implant that occurs
and the deep edge of the capsule posteriorly (Fig. 3-38). To in situ.
date I have not interposed a synthetic substrate such as an Although more and more breast imaging programs
allogenic dermal graft59,60 [AlloDerm, LifeCell Corp., are being developed, currently there are no morphing
Branchburg, NJ] for this purpose. However, these grafts programs available that can accurately predict the
may hold promise in terms of preventing or treating degree of fullness after breast augmentation produced
implant malposition. I predict that such material will by an implant of specific surface and volume dimen-
become used more frequently as the increased prevalence sions.
of inferior implant malposition becomes more widely
recognized.
REDUCING BREAST SIZE FOLLOWING
BREAST AUGMENTATION
TABLE 3-2 Reasons for Reoperation after Saline When a change of implant to a smaller size is planned, it is
Implant Placement
important for the surgeon to anticipate changes in nipple
Patient requests size change position relative to the new breast mound size. This
Deflation maneuver often changes the relationship of the breast tis-
Patient preference sue envelope and also the position of the NAC relative to
Asymmetry the smaller breast implant. Because of this it may be nec-
Implant malposition essary to change the position of the NAC by modifying the
Capsular contracture
skin envelope with a periareolar, vertical, or inverted
Ripples, ridges, folds
T skin excision in the form of a mastopexy. In addition, it
Ch03.qxd 11/27/05 9:56 PM Page 97
FIGURE 3-34. Preoperative AP (A) and oblique (B) appearance of patient desiring a breast augmen-
tation from an A cup to a C cup.
FIGURE 3-35. Postoperative AP (A) and oblique (B) appearance following placement of 310-cc
smooth round implants in partial subpectoral position.
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FIGURE 3-36. Intraoperative views showing, A, superior-medial and inferior-lateral capsulectomy

and, B, insertion of implant sizer to stretch periprosthetic capsular space.
FIGURE 3-37. Appearance of breasts following implant removal and reinsertion of 450-cc smooth
round implants done in conjunction with a superior capsulectomy in AP view (A) and oblique view (B).
Ch03.qxd 11/27/05 9:57 PM Page 99
FIGURE 3-39. Diagram illustrating modification of peripros-

thetic capsular space by suture capsulorrhaphy to reduce the
volume of the space.
excavatum), and thoracic skeletal structures. These

asymmetries must be pointed out to the patient preopera-
tively. I very much feel that in many ways a breast aug-
FIGURE 3-38. Suture placement from the superficial fascial mentation is like exposing the breast to a magnifying
system to the divided edge of the posterior capsule inferiorly.
This maneuver can limit the recurrence of inferior implant glass. That is to say, that augmentation itself will not cor-
malposition. rect many asymmetries, and sometimes it can in fact
magnify them.
It is also important for the surgeon to note the relation-
may be necessary to change the position of the implant ship of the patients breast to the midline. Many patients
relative to the breast tissue with internal suturing of the have a wide-set cleavage before surgery, and these patients
capsule (Fig. 3-39) to modify the level of the inferior cap- will almost always have a wide-set cleavage after surgery.
sular space, which will alter the appearance of the breast It is important for the surgeon to inform patients with a
by changing the relationship of the implant volume to the wide-set cleavage that the placement of breast implants
overlying breast tissues. Altering the periprosthetic cap- will not provide a tight cleavage postoperatively. An exam-
sule in this way has a very powerful effect on breast shape ple of this is seen in this thin, athletic patient who pre-
and volume. Suffice it to say that altering the soft tissue sented with breast hypoplasia and a wide cleavage
envelope is often necessary when decreasing, or downsiz- (Fig. 3-40). These features of her anatomy were carefully
ing, the volume of a previously augmented breast. explained preoperatively and she was pleased with the
postoperative outcome of her breast augmentation (Fig. 3-
41), despite that she exhibited a somewhat wide separa-
BREAST ASYMMETRIES tion between the breasts.
Nevertheless, it is important to maximize the fullness
Asymmetries of the breast following augmentation are in the cleavage in virtually all patients. This is more diffi-
not uncommon. It is paramount for the surgeon to care- cult when performing a subpectoral breast augmentation.
fully evaluate the patient preoperatively to detect any pre- With this approach it is necessary to divide the inferior-
existing asymmetry in the breasts.57 This obviously most sternal origins of the PMM at the xyphoid. The
includes asymmetries of the IM fold level, nipple areola remainder of the PMM in the parasternal area is attenu-
height, and nipple areola inclination, as well as asymme- ated on its deep surface using the electrocautery device set
tries in terms of volume of breast tissue and distribution on the coagulation mode as illustrated in Figure 3-21B.
of the volume of breast tissue. Not as obvious but never- The amount of attenuation can be gauged by using the
theless important are orientation of the breast on the index finger to estimate the tightness of the PMM by exert-
chest wall and asymmetries of the PMM, sternum (pectus ing a gentle lifting maneuver in a superficial direction
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FIGURE 3-40. Preoperative appearance of the breasts in a FIGURE 3-41. Postoperative appearance in same patient who
patient with very wide set cleavage who desired a breast shows implants that are very far apart, reflecting the basic
augmentation. anatomic features of her breasts.
while visually observing the change that this maneuver MULTIFACTORIAL BREAST
produces on the medial contour. It is essential not to ASYMMETRYBREAST VOLUME,
divide the PMM along the sternum because this produces ORIENTATION, AND NIPPLE AREOLA
a contour deformity in the form of a step-off, or paraster- POSITION AND INCLINATION
nal hollow (Fig. 3-42). This deformity is difficult to treat
and every effort should be made to avoid it. The technique As previously noted, breasts can be asymmetric in many
of performing the medial, superior, and inferior dissection respects. This 40-year-old patient demonstrates an asym-
first and adjusting the extent of the lateral dissection last metry of volume, nipple inclination, and orientation of the
with a sample sizing implant in place as described earlier breast gland on the chest wall (Fig. 3-43A,B). The right
provides the best chance of maximizing medial fullness breast was smaller in volume, and the entire right breast
and thus breast cleavage postoperatively. gland and NAC was inclined in a lateral direction. This gave
the right breast the appearance of having a different lateral
contour than the left breast, with less skin show in its lat-
ASYMMETRY OF BREAST VOLUME eral lower pole. The preoperative analysis revealed that the
patient required an implant with a wider base dimension
As just alluded to, asymmetries of the breast in the that would accommodate more volume with slightly more
prospective breast augmentation patient are often multi- lateral pocket dissection on the right side than on the left.
dimensional. When multiple characteristics of the breast An IM incision was used, and the patient had the partial
and breast architecture are asymmetric, the placement of retropectoral placement of two smooth-walled saline
a breast implant alone will most often not produce sym- implants. The implant on the right side had a base width of
metry. This should be explained (and re-explained) to the 12.7 cm and was filled with 440 cc of saline. On the left side
patient preoperatively. I tell virtually every breast augmen- an 11.9-cm base width implant filled with 370 cc of saline
tation patient to expect some degree of asymmetry, imply- was inserted. This combination produced more lateral
ing that it will be subtle in nature. In the reoperative breast show on the right (see Fig. 3-44A,B), with an appar-
situation with significant asymmetry I often say, I cannot ent reorientation of the breast gland to a more forward fac-
make your right breast look exactly like your left breast. ing orientation and good overall symmetry.
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PREEXISTING BREAST ASYMMETRY

DUE TO COMBINED BREAST VOLUME
AND ROTATIONAL DEFORMITY OF THE
CHEST WALL
In addition to the breasts themselves, the entire area of the

chest must be carefully evaluated in every patient.
Thoracic scoliosis is not uncommon, and if significant
enough the curvature of the spine can result in a rotational
deformity of the chest wall structures such that the skeletal
platform of the ribs and costal cartilages are asymmetric.
This can contribute to an unsatisfactory outcome, requir-
ing reoperation as illustrated in the following case.
This 26-year-old patient who presented for a breast
augmentation was noted to have a pronounced breast
asymmetry, with her right breast being more than a full
cup size smaller than her left (Fig. 3-46AC). There was a
slight disparity in the nipple heights and size of the areo-
lar complexes and skin envelopes of the breasts. She was
also noted to have more prominent costal cartilages on
the left side due to a scoliosis [Fig. 3-46D]. She underwent
breast augmentation with different sized smooth-walled
saline implants. We used an 11.9-cm base width implant
filled with 340 cc of saline on the left and a 12.3-cm base
width implant filled it with 390 cc of saline on the right
(Fig. 3-47A,B). As the postoperative edema in the breasts
FIGURE 3-42. Step-off deformity in parasternal area of right subsided, she was noted to have progressive size discrep-
breast after release of PMM from the sternum.
ancy in the appearance of the breasts (Fig. 3-48A,B), with
the right again noted as smaller than the left. Eight months
following surgery she underwent removal of the right breast
implant and replacement with a 13-cm base width implant
Marked improvement is noted on preoperative filled with 460 cc of saline (Fig. 3-49A,B). This produced
oblique view (Fig. 3-45A) and postoperative oblique view improved symmetry and gave her the breast appearance
(Fig. 3-45B). that she was seeking (Fig. 3-50A,B).
A breast implant can produce the illusion of central- As illustrated by the previous case, in these situations of
izing a slight eccentricity of the nipple in some situa- preexisting breast asymmetry related to skeletal platform
tions. I find it necessary to study the implant charts (see deformities (e.g., produced by scoliosis with rotation of
Fig. 3-5A,B) to obtain the correct implants from the the chest wall structures), it is most often deceptive as to
standpoint of both dimension and volume. I make the how much additional implant volume is required to pro-
patient aware of the specific plan as part of the preoper- duce symmetry on the side with the smaller breast. Most
ative discussion. often, substantially more volume is needed than is initially
When attempting to produce the illusion of adjusting anticipated. This may be a situation where an adjustable
nipple position or breast fullness in a specific location the implant (a Becker or SpectrumMentor Corp.) has parti-
pocket dissection and implant position are precisely con- cular utility.
trolled and adjusted accordingly (see Figs. 3-64 and 3-65).
There is a limit to how much of a change can be produced
in the appearance of the breast when adjusting the dimen- INFRAMAMMARY FOLD ASYMMETRIES
sion, volume, and position of a breast implant. This is due
to the dynamics of implant surgery and the changes pro- As mentioned in Chapter 2, the IM fold is perhaps the key
duced in other contours when surgery is directed at architectural structure for virtually all plastic surgery pro-
changing a specific area. In this regard there is a parallel cedures on the breast. This is especially true for breast
to the dynamics of changing the structure in a nose during implant procedures. The IM fold most often defines the
rhinoplasty. The breast surgeon must be mindful of and shape of the lower pole, and it also has a profound effect
anticipate such changes when using an implant to change on upper breast shape and breast contour following the
the contour and visual illusion of the breast(s). placement of a breast implant.
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FIGURE 3-43. Preoperative appearance of patient with asymmetry of volume, lateral fullness, and
nipple inclination who desires breast augmentation. A, AP view; B, lateral view.
FIGURE 3-44. Postoperative appearance at 1 year following augmentation with different dimension
and volume implants with more base width (12.7 cm) and volume (440 cc) on the right than on the left
(11.9 cm and 370 cc). A, AP view; B, lateral view. The different size implants were necessary because of
dimensional (volume and base width) and positional asymmetry of the breasts.
Ch03.qxd 11/27/05 9:58 PM Page 103
(Fig. 3-51) and these must be noted preoperatively so that

appropriate adjustments can be made at surgery. My
understanding of the anatomy of the IM fold and classifi-
cation of the constricted breast deformity have been
reviewed (see Fig. 2-19), but some comments bear rein-
forcement.
The IM fold can be lowered by dissection inferior to it
in the plane deep to the superficial fascia in most cases,
and specifically in those cases where the fold is loose or
just moderately tight. Caution should be exercised when
approaching the patient with an extremely tight fold (see
Fig. 2-19). Dissecting inferior to such a fold with the
implant placed in the partial subpectoral position may not
eradicate the existing fold, and the so-called double bub-
ble deformity (discussed later in this chapter) may occur.
In such cases it may be best to accept the existing IM fold
and select an implant that will be accommodated by the
existing breast soft tissues. Furthermore, it may be aes-
thetically preferable to place the implant in the subglan-
dular positionespecially if a silicone gel implant is an
option.
The constricted breast anomaly is manifest by different
degrees of IM fold constriction as illustrated in Figure 2-19.
Subtle (type I) deformities (Fig. 3-52), especially if they are
medially positioned, may persist after implant placement.
The surgeon must recognize this and address this situation
with a biplanar or dual plane dissection, releasing the
fibrous attachments of the fold from the dermis in the area
of constriction. Even with assiduous dissection, remnants
of the partial fold constriction may persist following the
breast augmentation (Fig. 3-53). This possibility should be
pointed out to the patient preoperatively.
A very common problem following breast augmenta-
tion is IM fold asymmetry. It is perhaps more common
with subpectoral than with subglandular breast augmen-
tation. When performing a partial subpectoral breast aug-
mentation, it is important to release the PMM inferiorly to
best achieve a natural and symmetric position of the
implant. This will allow the best possible drape of the
breast tissues over the implant inferiorly, giving the most
natural contour and symmetry to the lower pole of the
breasts. Release of the PMM is straightforward when done
under direct vision. This is most facilitated by the use of
the IM incision. It is most difficult when using the
transaxillary approach for breast augmentation, espe-
cially if the endoscope is not used. However, IM fold asym-
metry can be noted with any of the approaches already
discussed for augmentation.
FIGURE 3-45. Comparison of oblique views. A, Preoperative
appearance. B, Postoperative appearance at 1 year.
An example of such asymmetry is illustrated by this 42-
year-old patient who underwent bilateral endoscopic
assisted transaxillary retropectoral pectoral breast aug-
At this point it is again important to emphasize that the mentation for postpartum involution of the breasts
surgeon must analyze the IM fold for its symmetry, degree (Fig. 3-54). She was noted to have an asymmetry of the IM
of tightness (see Fig. 2-19) and for any evidence of con- folds soon after surgery that detracted slightly from the
striction. Asymmetry of the IM folds in not uncommon overall result (Fig. 3-55).
Ch03.qxd 11/27/05 9:58 PM Page 104
FIGURE 3-46. Preoperative views of a young patient with a significant breast asymmetry including
volume, nipple areolar position, and skin envelope dimension. The right breast was smaller than the
left. A, AP view. B, Lateral view. C, Oblique view. D, Note prominent costal cartilagesternal junction
on left side (arrow), which was underappreciated before her breast augmentation.
Ch03.qxd 11/27/05 9:58 PM Page 105
FIGURE 3-47. Six-month postoperative appearance with mild asymmetry despite using 15% more
volume in right implant. A, AP view. B, Oblique view.
FIGURE 3-48. Fourteen-month postoperative breast asymmetry became accentuated with resolu-
tion of breast tissue edema. A, AP view. B, Oblique view. Patient requests change of right implant to
improve symmetry.
Ch03.qxd 11/27/05 9:59 PM Page 106
FIGURE 3-49. Plan for changing right implant to larger size with 20% increase in volume. A, AP view.
B, Oblique view with planned inferolateral and radial capsulotomies (outlined by the blue marks).
FIGURE 3-50. Appearance of breasts after reoperative surgery, at which time the volume of the right
implant was increased by 25%.
Ch03.qxd 11/27/05 9:59 PM Page 107
FIGURE 3-51. Preoperative AP view of patient who is inter-

ested in breast augmentation. Note significant asymmetry in
the levels of the IM fold. Asymmetry documented with tape FIGURE 3-52. Partial constriction of the medial aspect of the
measure. IM fold noted before planned breast augmentation.
FIGURE 3-53. The postoperative appearance of breasts on AP

view following biplanar breast augmentation. Note persistence FIGURE 3-54. Preoperative view of patient who underwent a
of IM fold asymmetry due to mild constriction in spite of con- transaxillary partial retropectoral endoscope-assisted breast
certed attempt to correct it. augmentation.
Ch03.qxd 11/27/05 9:59 PM Page 108
The surgeon must strive to achieve symmetry of the Anesthesiology Service on getting the operating room
level of the IM folds at the time of implant placement. At table). This affords the surgeon the best chance to analyze
surgery, it is important to place the patient in the the position of the implants. Gentle pressure is placed on
sitting position at 90 degrees (or as close to 90 degrees as the superior aspect of each implant, and they are carefully
possible, and I find it necessary to really push the assessed for symmetry of the lower pole (Fig. 3-56). If at
the time of this analysis the implant is noted to be too
high, dissection of the inferior tissues can allow incremen-
tal lowering. If the implant is positioned too low, and if the
problem is recognized at surgery, then superior position-
ing of the dissected pocket and new IM fold can be per-
formed with suture reapproximation of the lower thoracic
tissues to the chest wall fascia (Fig. 3-57). This can be
done using either PDS or Prolene sutures (Ethicon, Inc.,
Somerville, NJ). It is important to obtain a good purchase
on both the chest wall fascia (it is not necessary to attempt
suture placement in the periosteum of the ribs) with a
deep stitch and the overlying tissues, including the super-
ficial fascial system (SFS) with the suture placement. I do
not believe that an implant that is low because of exces-
sive inferior pocket dissection it can be superiorly reposi-
tioned by external support of the IM fold with either
Microfoam tape or Reston foam (3M Corp., St. Paul,
Minn.) placed externally and covered with an Ace wrap.
However, such dressing made with a thick foam rubber
sponge can help splint the lower pole (Fig. 8-14E) after it
has been surgically corrected but is unlikely to produce a
correction by itself.
FIGURE 3-55. Postoperative view reveals an asymmetry of the

levels of the lower poles of the implants, which at this early time
in the postoperative course is a technical error.
FIGURE 3-56. Maneuver to check symmetry of IM folds.

Patient is sitting at 90 degrees on the operating table. Assistant FIGURE 3-57. Suture reapproximation of subcutaneous tissues
places gentle pressure on the upper pole of the implants and sur- to the chest wall fascial layer. The purchase of the suture should
geon analyzes position of the lower poles of the breast implants be on the superficial fascia of the chest. The suture is not brought
and IM fold levels. through the skin but is anchored in the superficial Fascia.
Ch03.qxd 11/27/05 9:59 PM Page 109
In summary, experienced surgeons realize that asym- nal area as noted in the patient shown in Figure 3-59, who
metry following breast augmentation is not uncommon. was referred for evaluation. Although the incidence of
Minor postoperative asymmetries are usually accepted by implant malposition is difficult to discern from published
patients who are pleased with their new breast fullness. data (this condition is also referred to as implant displace-
In certain situations created by individual anatomic ment or dislocation in some reports), experienced sur-
variations patients will, in general, tolerate even more sig- geons realize that implant malposition is also not
nificant asymmetry following breast augmentation if its uncommon. An article studying the lifespan of silicone gel
likelihood was pointed out before surgery in an honest mammary prostheses by Beekman et al.61 refers to
consultation. implant dislocation as the second most common reason
for revisional surgery in their series, with a frequency of
23% in 182 breast augmentation and breast reconstruc-
IMPLANT MALPOSITION tion patients. The short-term saline implant studies by
McGhan17 (AR95) and Mentor (SPS)16 cited 6% and 8% of
Breast implant malposition may be the result of inade- reoperations respectively to treat implant malposition at a
quate planning, an inappropriate choice of implant, tech- 3-year follow-up.
nical error at the time of original implant placement, or The most common causes of breast implant malposi-
implant displacement at a later time due to factors related tion are using an inappropriate implant (usually too large),
to the implant such as implant size (i.e., weightespe- technical errors during pocket dissection, congenital
cially if it is a large smooth saline implant). Displacements deformities (asymmetries and constricted breast anom-
may also be due to capsular contracture. Malpositioned alies), capsular contracture (Fig. 3-60), rupture of a sili-
implants may be too high, too low, too lateral, or too cone gel implant (Fig. 3-61), and traumatic implant
medial. If both implants are too medial, they can encroach dislocation or displacementmost commonly seen in the
on one another and produce an appearance called sym- past after a closed capsulotomy (Fig. 3-62A,B). Closed cap-
mastia. Some patients exhibit a combination of malposi- sulotomy has been totally abandoned as treatment for cap-
tions that are noted to a greater degree in certain postures sular contracture and should no longer be done, thereby
or positions than in others. For example, significant lat- eliminating this as a potential etiology of this problem.
eral implant malposition (Fig. 3-58) is often more accen- Incorrect implant selection generally means using an
tuated in the supine position, in which case the entire implant that is too large for a particular patient. This
medial aspect of the breast is empty or flat in the paraster- situation most often occurs when a large (>400 cc) saline
implant is placed in a small-breasted patient with thin tis-
sues. Most often such a patients tissues cannot support
the implant, which will likely migrate in an inferior or lat-
eral direction, especially if it is a smooth-walled saline
implant. Guidelines for implant selection have been exten-
sively reviewed earlier in this chapter.
FIGURE 3-58. Marked lateral malposition of the left breast FIGURE 3-59. Lateral malposition significantly accentuated in
implant noted in AP view. the supine position.
Ch03.qxd 11/27/05 9:59 PM Page 110
Saline implants are typically surrounded by very thin 340-cc smooth-walled saline implants (Figs. 3-63AC and
capsules that do not provide support for the implant, 3-64A,B). As stated, this is not uncommon.
which migrates inferiorly under the influence of gravity To minimize this problem it is important for the sur-
and produces the clinical appearance of bottoming out. geon to carefully assess the patients tissues preopera-
This scenario is much more common than I have appre- tively, select an appropriately sized implant, and
ciated in the past; I have noted it often when using carefully mark and precisely dissect the implant pocket.
smooth-walled saline filled breast implants for breast The patients tissues are assessed in terms of their thick-
augmentation. Bottoming out of saline implants is ness, elasticity, and distensibility. I have found that using
illustrated in sequential photographs of this patient, who a modification of Tebbetts20 TEPID system has been
underwent a partial subpectoral breast augmentation with helpful.
FIGURE 3-60. Significant superior malposition of implant FIGURE 3-61. Lateral malposition of left breast implant pro-
produced by Baker IV capsular contracture, noted in patients duced by implant rupture with capsular contracture.
right breast.
FIGURE 3-62. Superior implant malposition resulting from closed capsulotomy 1 year following
bilateral transaxillary retropectoral breast augmentation with silicone gel implants. A, AP view.
B, Lateral view demonstrates it more dramatically.
Ch03.qxd 11/27/05 9:59 PM Page 111
As previously outlined, I believe that the dissected lowering the IM fold of a patient when using a saline
pocket should fit the implant almost precisely. There is no implant with a volume greater than 350 cc unless it is
evidence that creating excessively large pockets reduces absolutely necessary. In this case it can be done as care-
the incidence of capsular contracture, but plastic sur- fully planned pre-operatively. As mentioned, the lateral
geons have subscribed to creating a large pocket to pocket dissection should never go posterior to the midax-
encourage implant mobility as a way of promoting soft- illary line, and this has limited the occurrence of lateral
ness of the result. This practice would seem to invite dis- implant malposition. Tips for avoiding excessive medial
placement and malposition of the implant. The inferior dissection have also been extensively reviewed.
extent of the dissection should be carefully planned and Asymmetries of the IM fold, along with their implications
inscribed on the patients skin preoperatively. Because and their treatment, have been described. Particular
bottoming out is so common, I am now very cautious in attention should be given to any constriction of the IM
FIGURE 3-63. A, Two-month postoperative view of breasts fol-

lowing smooth-walled saline 330-cc implant placement.
Appearance at 8 months (B) and 22 months (C) postoperative.
Note significant bottoming out of the implants.
Ch03.qxd 11/27/05 10:00 PM Page 112
fold. In this situation, carefully planned appropriate PMM release), a constriction of the lower pole breast tis-
releases of fibrous tissue, the breast glandular tissue, and sues, capsular contracture, and implant rupture if a sili-
PMM should be done to address such constrictions at the cone gel implant has been used.
time of implant pocket dissection. It is important to realize that following subpectoral
Advanced capsular contracture (Baker III and IV) augmentation the implant commonly appears high. If the
may produce implant distortion and malposition (see implant position was correct on the operating table, at
Fig. 3-60). The most common form seen with silicone the end of the procedure it will descend as the PMM
gelfilled implants is superior malposition (see Fig. 3-60), stretches out and the surgical edema in the proximal
but lateral malposition (see Fig. 3-61) and other types of PMM resolves. This is especially true if a smooth-walled
distortion and malposition are also seen. With the exten- saline implant was used. Downward movement in the
sive use of saline implants in the United States over the pocket can be encouraged by wrapping the upper pole of
past 10 years, there has been a dramatic decrease in the the breasts with an elastic wrap (Fig. 3-65B). A slight
incidence of Baker III and Baker IV capsular contractures excess of superior fullness, if it is symmetric, is often not
and correspondingly less capsular contractureinduced objectionable to the patient and in fact is preferable to
implant malposition. The tradeoff has been an increased suboptimal upper pole fullness. If a textured implant was
incidence of inferior implant malposition as noted earlier. used and there is a superior malposition of the implant, it
I will now review a practical approach to the etiology is very unusual for this implant to obtain mobility and for
and treatment of the various breast implant malpositions correction to occur with external compression or dis-
I have encountered. placement exercises.
Inferior settling of a smooth-walled saline implant fol-
lowing subpectoral breast augmentation is seen in the
IMPLANT TOO HIGH patient shown in Figure 3-65. Her implants appear high
on postoperative day 4 (Fig. 3-65A), but by 6 weeks the
Excess superior fullness following breast augmentation breasts show an acceptable upper pole shape (Fig. 3-65C)
can be related to a variety of factors: inadequate inferior and by 3 months the upper pole shape is close to ideal.
pocket dissection, an implant that is too large (if a sub- Some of these superior implant malposition deformi-
muscular placement has been done or there is inadequate ties will persist, however. When analyzing such a patient,
FIGURE 3-64. Oblique views of patient in Figure 3-63 at 2 months A, and 22 months B, postoperative.
Ch03.qxd 11/27/05 10:00 PM Page 113
FIGURE 3-65. A, High-riding right breast implant 3 weeks fol-

lowing subpectoral breast augmentation. B, Elastic wrapping of
the upper pole of the breasts is routine in my practice. Such
wrapping promotes downward movement of a smooth-walled
implant in its dissected pocket. C, Spontaneous descent of
smooth-walled implant seen by 6 weeks postoperative with the
wrapping regimen.
Ch03.qxd 11/27/05 10:00 PM Page 114
the surgeon must key into both the breast shape and that was used for the augmentation procedure. The inci-
architecture, especially as it relates to the IM fold, so as to sion can be either periareolar or IM, which is more com-
formulate and propose an appropriate treatment plan to mon. Corrections should not be attempted through a
the patient. The surgeon must carefully analyze the posi- previous transaxillary incision. An inferior capsulotomy is
tions of the IM folds and compare them with the positions needed to release the scar tissue around the lower pole of
of the IM folds shown in the preoperative photographs. If the implant and reposition it in a more inferior location.
the IM fold levels were asymmetric before surgery, then The periprosthetic capsular space is accessed and incre-
this must be addressed surgically by releasing the inferior mental lowering of the IM fold and implant level is carried
tissue to lower the higher fold or raise the lower fold to out (see Fig. 3-66B). This is done very slowly and gradually
achieve IM fold symmetry (Fig. 3-66A). The surgeon must with the patient placed in the sitting position at 90 degrees
also be aware of nipple position on the breast relative to on the operating table. This inferior capsule release allows
the implant and realize that lowering the IM fold or the descent of the implant. The procedure should be carried
lower pole of the implant will raise the apparent nipple out under direct vision with a headlight or lighted retrac-
position (Fig. 3-66A). If such a maneuver is necessary, tor and is performed most accurately using electrocautery
however, then slight downward repositioning of the NAC dissection. If one chooses to reposition an implant that has
by resecting a crescent of infra-areolar skin is possible. been previously placed through a transaxillary approach, it
On the other hand, if the IM fold levels are symmetric is best to use an endoscope to facilitate the capsule release
but the implant is too high (i.e., there is an asymmetry of for repositioning this implant.
upper breast fullness) and the implant appears to have If a large superior recess of the periprosthetic capsular
ridden up, it is possible to encourage the downward space exists, it is sometimes helpful to close down this
movement of the implants by a combination of displace- recess by performing a superior capsulorrhaphy using
ment exercises and wrapping the upper pole (see permanent (3-0 Prolene) sutures (Fig. 3-67). If this is
Fig. 3-65B). If this is not successful, then the problem deemed necessary, the surgeon must check the shape of
may be due to excessive implant volume or incorrect the breast at the time of suture placement to ensure that
implant shape. In such a situation it may be necessary to an abnormality of superior breast contour has not been
reoperate and use either a smaller implant or an implant produced by these sutures.
with a different shape (i.e., different dimensions). As A final word of caution is in order. Inferior implant
noted previously, shaped implants often give the illusion malposition is an increasingly common problem when
of more projection and more lower pole volume with saline implants are used. This is especially true when
decreased upper pole fullness; therefore they may be a using large volume (>400 cc) smooth-walled saline
good option in this situation. It is important to choose an implants. Therefore, caution must be exercised when
implant that is not too tall. completely releasing the inferior capsular tissues when a
If an implant is too high and it has been determined smooth-walled saline implant is in place. If a small
that surgery is necessary to correct the asymmetry, the amount of correction is needed in the levels of the
exploration is most often performed through the incision implants, I often attempt to leave some portion of the
FIGURE 3-66. A, Lowering the level of the lower pole of an implant will elevate the apparent nipple
position. B, Patient marked for judicious lowering of lower pole of her implants, which is performed by
inferior capsulotomy.
Ch03.qxd 11/27/05 10:00 PM Page 115
ing a previous breast augmentation, as illustrated by this

patient (Fig. 3-68AC), who presented for a bilateral breast
augmentation. The patient had a pre-existing breast asym-
metry, with the left breast smaller in dimension and vol-
ume than the right. She underwent a bilateral partial
subpectoral breast augmentation through an infra-areolar
incision.
The patient was not satisfied with either the postoper-
ative volume or upper pole fullness (Fig. 3-69AC). The
plan was to replace both implants and raise the IM folds
using the suture capsulorrhaphy technique (see
Fig. 3-39). We used multiple 3-0 Prolene sutures. The
combination of inferior periprosthetic capsular reefing
and exchanging her implants for larger saline implants
(420 cc right, 460 cc left) produced the desired change in
her breast appearance (Fig. 3-70AC).
IMPLANT TOO LOWFRANK INFERIOR

MALPOSITION
If the previously placed implant is positioned too low, it is

a more difficult situation. Again, surgical reoperation is
FIGURE 3-67. Suture capsulorrhaphy closure of the upper needed to correct the problem. The incision is opened,
periprosthetic capsular space to close down this aspect of the
along with the periprosthetic capsule. In general the origi-
space.
nal incision is used, unless it was placed in the axilla. In
this case the patient is informed that an IM incision will
capsule intact to support the weight of a saline implant provide optimal exposure to achieve correction of the
and prevent unintended additional inferior malposition. implant malposition (Fig. 3-71A).
If complete release of the capsule is necessary, considera- Preoperatively, the surgeon must make an estimate of
tion should be given to suture support of the new fold how much the fold needs to be raised. This estimation is
level as discussed previously. In these cases I believe that obtained by manually pressing on the skin overlying the
the weight of the breast should be supported with a bra, lower aspect of the implant. Simultaneously the implant is
and the bra should be worn 24 hours a day for a month elevated and the skin is pressed against the underlying
following surgery. chest wall (Fig. 3-71B). Circular marks are placed on the
skin at the intended sites of internal suture placement
(Fig. 3-71C). Surgical elevation of the fold is then carried
IMPLANT TOO LOW out under direct vision. I find that it is very helpful to illu-
minate the operative field with either a lighted retractor or
Implants that are too low produce inadequate fullness and a headlight. The three options are to perform an inferior
suboptimal enhancement of the upper poles of the breast, capsulorrhaphy using permanent (3-0 Prolene) sutures
or they can produce frank breast asymmetries that are (see Fig. 3-39); a double capsular flap repair (Fig. 3-73),
unacceptable from an aesthetic standpoint, which in their approximating the edges of two concentric ellipses of the
most extreme form present problems with bra fit and periprosthetic capsular tissue also using permanent (3-0
appearance in swimwear. Inadequate upper pole fullness Prolene) sutures; or a resection of a strip of capsular tis-
can be due to implants that are positioned too low, are too sue and approximate raw edge to raw edge of capsular
small, or a combination of both. tissue as illustrated in Figure 6-38H,I. This technique
may have an advantage when a large volume saline
implant (>400 cc) is used, especially if it has a smooth
INADEQUATE UPPER POLE FULLNESS surface. With this approach the durability of the repair is
DUE TO INSUFFICIENT IMPLANT SIZE related to both the strength of the sutures and the colla-
AND INFERIOR MALPOSITION gen deposition, which is the bodys natural healing
medium.
The combination of inadequate size and inferior implant I find it most important to remove the implant while
malposition is a common indicator for reoperation follow- performing such corrections. Again, it is necessary to
Ch03.qxd 11/27/05 10:00 PM Page 116
FIGURE 3-68. A, Preoperative AP view of patient desiring

breast augmentation to C cup. B, Lateral view. C, Oblique view.
Ch03.qxd 11/27/05 10:00 PM Page 117
FIGURE 3-69. A, Postoperative AP view seen 8 months follow-

ing placement of 360-cc saline implant on left and 330-cc saline
implant on right in partial retropectoral position through the
infra-areolar incision. B, Lateral view. C, Oblique view.
Ch03.qxd 11/27/05 10:01 PM Page 118
FIGURE 3-70. A, Postoperative appearance 6 months on AP

view following revision of her breast augmentation with suture
capsulorrhaphy of the inferior capsular recess and placement of
420-cc implant on right and 460-cc implant on left. B, Lateral
view. C, Oblique view.
Ch03.qxd 11/27/05 10:01 PM Page 119
FIGURE 3-71. A, Inferior malposition of left breast 260-cc saline implant following unilateral subpec-
toral breast augmentation. B, Preoperative digital compression techniques for estimating position of
internal suture placement. C, The circles inscribed on the skin denote position of internal suture place-
ment in the capsular tissue. D, Intraoperative view (different patient) demonstrating the appearance of
the 3-0 Proline sutures in the capsular tissue (see Fig. 3-72 for the outcome of treatment).
Ch03.qxd 11/27/05 10:01 PM Page 120
incrementally elevate the fold and to check the correc- skin (see Fig. 3-71B). This guided the placement of a dou-
tions after they have been made. I usually do this by plac- ble row of 3-0 Prolene sutures to reposition the lower
ing only about four sutures along the course of the level of the periprosthetic capsular space. Conversion to a
planned correction. Following correction, the patient is 120-cc implant produced acceptable symmetry, which
placed in the sitting position at 90 degrees on the operat- was noted at a 9-month follow-up visit (Fig. 3-72).
ing table with one suture in the capsule and a staple clo-
sure of the skin. At this point the adequacy of correction
can be checked. If the correction is what I want to MARKED INFERIOR IMPLANT
achieve, I then place additional permanent sutures along MALPOSITION
the line of elevation of the periprosthetic capsular tissue.
Very often the tissues are thin. It is imperative that one The correction of significant implant malpositions
not dimple the skin when placing these sutures in the almost always involves two maneuvers. The first is to
capsular tissue. Following correction, the patient is close down the periprosthetic capsular space that results
placed in the sitting position at 90 degrees on the operat- from the abnormal position of the implant. Most of the
ing table with one suture in the capsule and a staple clo- time a second maneuver entails performing a capsulo-
sure of the skin. At this point the adequacy of correction tomy so that the implant may extend into a more appro-
can be checked and final adjustments can be made as priate position to produce the desired contour.
necessary. Additionally, changing the size, surface texture, or filling
Once adequate correction has been achieved, the substance of the implant may be part of the preoperative
wound is closed in customary fashion with a careful plan.
water-tight closure of the capsule. For this layer I prefer to Inferior implant malposition can be very dramatic at
use a coated polyglycolic acid suture, and 3-0 PDS or times. In general this is seen in conjunction with the
Maxon (Sherwood-Davis & Geck, St. Louis, Mo) is a good placement of extremely large implants, usually with
choice. This suture is strong and it slides through the tis- smooth surface textures. Correction can be achieved by
sues rather than sawing through them. This closure of the closing down the inferior extension of the periprosthetic
periprosthetic capsule is followed by closure of the deep capsular space (PPCS) and performing a superior capsu-
dermis; wound closure is completed by an intracuticular lotomy, while extending the superior pocket dissection to
suture approximation of the skin. If there is any concern accommodate the upper pole of the elevated implant. I
about oozing from the capsular tissue surface or possible find that resection of a horizontally oriented elliptical seg-
seroma fluid accumulation, a suction drain is placed. I ment of the capsule in the inferior recess of the PPCS and
prefer to use a 10-mm Jackson-Pratt drain. The drain is suturing fresh raw edge of capsule to raw edge of capsule
left in place until the drainage from it falls below 30 cc per to be the preferred technique in my hands (see Fig. 6-38,
24 hours. H, I). In extreme cases it is possible to perform two ellipti-
I believe that it is necessary to support the correction of cal excisions, one on top of the other, to achieve a correc-
the IM fold achieved at surgery with external application tion with sufficient strength to maintain the repair. Such a
of a foam dressing or tape. My preference is to use a thick case is illustrated next.
piece of foam rubber, which is cut to conform to the cur- I saw a 35-year-old patient 13 months after she had
vature and length of the IM fold (see Fig. 8-14). This foam undergone a bilateral subglandular breast augmentation
is placed within the circumferential dressing that is with 475-cc smooth-walled saline implants placed
applied at the end of the surgical procedure. The patient is through a periareolar approach (Fig. 3-74AC). She was
then encouraged to continue external support of the fold noted to have an extremely prolonged inferior-areola-to-
correction for at least a month following surgery by wear- IM-fold distance and virtually no upper pole fullness.
ing a bra to hold it in place. I have been successful in She requested correction and wanted a 700-cc implant
achieving a permanent elevation of the implant and IM placed. I advised her that placing an implant with such a
fold in most cases using this approach. volume was ill advised because her tissues could not
This young woman with a breast asymmetry (see Fig. support it.
3-71A) underwent unilateral left submuscular breast aug- After three consultations we formulated a plan
mentation with a 260-cc smooth-walled saline implant. whereby we would remove her implant and carry out a
Following this procedure the left breast was larger than pocket reassignment to a partial subpectoral position.
the right and the implant appeared too high (see Fig. 3- We performed a capsulectomy and sutured the posterior
71A). Over the next 4 months she exhibited progressive aspect of the breast parenchyma to the anterior surface
settling of her implant, which resulted in frank inferior of the PMM with multiple 3-0 chromic sutures (Fig. 3-75)
malposition of the lower pole. This problem eventually using an atraumatic needle to prevent potential prolapse
required correction. The recreation of an appropriate IM of the implant back into the subglandular space. We then
fold level was simulated with digital compression on the excised two ellipses of peri-prosthetic capsular (PPC)
Ch03.qxd 11/27/05 10:02 PM Page 121
FIGURE 3-72. A, AP view showing correction of IM fold level after internal suturing of capsule. B,
Side-by-side comparison of preoperative malposition and correction.
tissue on the anterior surface of the inferior recess of the uous activities and any displacement of the implants.
capsule and sutured them to corresponding excised She is seen in Figure 3-77 6 months following the correc-
areas of the posterior aspect of the inferior capsular tion with a much improved aesthetic appearance of the
recess with 3-0 Prolene sutures using interrupted suture breasts (Fig. 3-77AC).
technique. The moderate-profile saline implant was
replaced with a high-profile smooth-surfaced silicone gel
device with a volume of 550 cc. The correction of the IMPLANT TOO LATERAL
right side was carried out first, and the elevation of the
IM fold is noted in Figure 3-76. We asked her to wear a In addition to discrepancies of inferior pocket dissection
bra to support her breasts for 6 weeks and to avoid stren- producing the problems just described, there can also be
Ch03.qxd 11/27/05 10:02 PM Page 122
FIGURE 3-73. Double capsular flap technique for modifying periprosthetic capsular space. This tech-
nique combines suture strength and scar tissue repair to modify the space. It involves tracing an ellipse
within an ellipse on the periprosthetic capsular tissue. Both edges of the inner ellipse are elevated off
the deep tissue but stop well in front of the log axis of the ellipse. These edges are then sewn together.
The edges of the outer ellipses are then incised and sewn together. The result is a double suture line
repair that maximizes the suture-holding capacity of the tissue, which may be thin as in the case of the
medial periprosthetic capsule.
excessive lateral displacement of the implant, which also sulotomy may be needed if the medial movement of the
is most often related to imprecise pocket dissection. This implant is limited on physical examination.
situation is difficult to correct without surgical interven- I believe that lateral implant malposition is most often
tion because in many natural postures (such as sleeping a technical error due to dissection beyond the midaxillary
in the supine position), an implant will naturally fall lat- line at the time of implant placement. Therefore, this
erally under the influence of gravity (see Fig. 3-62B). For complication is usually avoidable and relates to the
this reason such a malposition usually requires surgical method of implant pocket dissection at the time of the
intervention, with the procedure being directed at closing original breast augmentation. As mentioned, I believe
down the lateral recesses of the excessively large that the medial dissection should be performed first in all
periprosthetic capsular space. A concomitant medial cap- cases, with the lateral dissection initially done conserva-
Ch03.qxd 11/27/05 10:02 PM Page 123
FIGURE 3-74. Marked inferior implant malposition seen 1 year following a subglandular breast aug-
mentation with 475-cc smooth-walled saline implants seen on AP (A), lateral (B), and oblique
(C) views.
tively based on the preoperative markings. The final lat- This problem of lateral implant malposition can also
eral dissection is done with the sample sizing implant or result from the use of an excessively large implant (espe-
the implant that has been selected in place, again with the cially if smooth saline implant is used), trauma to the
patient sitting up. The dissection should not go posterior implant, implant rupture, and capsular contracture.
to the midaxillary line, which is marked preoperatively in At times lateral malposition of the implant is seen
every patient who is to undergo breast augmentation. despite careful lateral dissection to establish the pocket.
In my opinion preoperative marking is important for Correction of this problem requires surgical interven-
achieving consistent results with breast augmentation. To tion. It is important for the surgeon to be aware of the
minimize lateral implant malposition I mark the lateral type and size of the implant used at the previous surgery.
extent of dissection with the patient in the sitting position As part of the corrective procedure it may be necessary to
by noting the midaxillary line (Fig. 3-78). This position is use a smaller implant, especially when a significant
located by drawing a vertical line midway between the lat- downsizing of the lateral capsular recess is planned. If
eral edge of the PMM [Fig. 3-78 (single arrow)] and the part of the patients problem includes folds that are visi-
anterior edge of the latissimus dorsi muscle [Fig. 3-78 ble through the skin, it may be necessary to change an
(double arrow)]. The surgeon should make a conscious implant from a textured-surface to a smooth-surface
effort not to dissect posterior to this line. implant. A substitution of a smooth-walled silicone gel
Ch03.qxd 11/27/05 10:02 PM Page 124
FIGURE 3-75. Suture closure of the subglandular space fol-

lowing implant removal. This is done to prevent accidental pro-
lapse of the implant back into this space after pocket FIGURE 3-76. Appearance on the operating table after the cor-
reassignment to the subpectoral position. rection of the right breast done by segmental horizontal resec-
tion of the inferior capsule and suture repair of the anterior raw
edge of capsule to the corresponding posterior edge with perma-
nent 3-0 Prolene sutures. Note differences in the lower level of
the breasts. Six-month follow-up appearance after this treat-
ment is shown in Figure 3-77.
implant for a saline-filled implant in these situations is replacing the implant. The implant is then replaced and
ideal. These considerations should be reviewed with the the wound is closed. I place a suction drain [10-mm
patient preoperatively. It is also important to convey to Jackson-Pratt or BLAKE (Ethicon, Inc., Somerville, NJ)],
the patient that a perfect correction may not be possible, which is removed when the output from the drain is less
and also that after an apparent good early result a slight than 30 cc per 24 hours. I also splint the correction with a
resubluxation of the implant is possible due to recurrent thick piece of foam rubber applied to the skin of the lat-
stretching of the lateral periprosthetic capsule and lateral IM fold and lateral breast area. I instruct the patient
eral chest wall tissues. to sleep on her back and to strictly limit any lateral dis-
This procedure is done by opening the patients previ- placement exercises. I ask the patient to refrain from
ous incision unless the original incision was in the axilla. heavy exercise for at least 6 weeks after surgery and also
In this case an IM incision is used because it provides the to wear a bra to support the implant during this initial
best exposure for the correction. It is important to explain phase of healing.
to the patient the need for this additional incision on the Correction of such a postaugmentation deformity is
breast. The periprosthetic capsule is opened and the illustrated by this 42-year-old patient who presented with
implant is removed. The lateral periprosthetic capsular a marked lateral displacement of her right breast implant
space is closed down by means of a double capsular flap and a mild displacement of her left breast implant. She
repair. This is done by tacking the anterolateral capsular had undergone a bilateral transaxillary retropectoral
tissues to the posterolateral capsule as illustrated in breast augmentation 3 years earlier with 350-cc smooth-
Figure 3-72. I sew raw edge of the divided capsule to raw walled saline implants. Her breasts were soft and she was
edge of capsule with interrupted suture technique using a satisfied with the volume, but she was always bothered by
permanent monofilament suture (3-0 Prolene). The the abnormal position of her right breast implant (Fig.
implant is then replaced and an assessment of improve- 3-79AC). Preoperative examination revealed that the
ment is noted. If further plication of the capsule is needed, right implant was located relatively far from the paraster-
this is carried out with the placement of additional nal area, and it could not be moved to within 3 cm of the
sutures. Additional rows of sutures confer additional lateral sternal border with medially directed external
strength to the repair. A smaller implant may be placed at pressure (Fig. 3-80A). Therefore a lateral closure of the
this point if the original implant is too large in its dimen- periprosthetic capsular space was planned, along with a
sion. If a release of the medial periprosthetic capsular tis- medial and inferior medial capsulotomy (Fig. 3-80B). The
sues is required (it very often is), I perform this before entire plan is schematically outlined in Figure 3-81. A
Ch03.qxd 11/27/05 10:02 PM Page 125
FIGURE 3-77. AC, Patient shown 6 months following reoper-

ative procedure with a dramatic improvement in breast shape
and excellent upper pole fullness and a well-defined IM fold
bilaterally.
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Despite careful pocket dissection by the surgeon, the

problem is occasionally noted following breast augmenta-
tion. It is most often due to unilateral implant malposition,
but it may be bilateral and present as symmastia. When
surgery is needed to correct this problem, there are three
options: pocket reassignment of the implant, suture cap-
sulorrhaphy, or capsular flap repair.
Perhaps the most consistently successful way of
approaching this problem is to perform an implant pocket
conversion. This allows creation of a new implant pocket,
i.e., moving a previous submuscular implant to the sub-
glandular space, or converting a subglandular implant to a
subpectoral position. In the former case it is not necessary
to perform a periprosthetic capsulectomy or to surgically
close-off the submuscular space. It is important to care-
fully dissect the submammary space and maintain at least
1.5 cm from the midline intact and undissected as empha-
sized earlier (see Fig. 3-19).
When performing a subglandular to subpectoral space
conversion, it is important to perform the appropriate
amount of medial submuscular dissection, again staying
1.5 cm from the midline, and it is also necessary to surgi-
cally close-down the subglandular space with multiple
sutures (see Fig. 3-82). These can be either 3-0 PDS or 3-0
chromic sutures, and they should be placed after implant
removal and before dissection of the submuscular plane.
FIGURE 3-78. Marking of the midaxillary line preoperatively It is necessary to do this to prevent the implant from slip-
in an augmentation patient to limit possibility of lateral implant ping back into the subglandular position. This is espe-
subluxation. The area lateral to the midaxillary line should not
be dissected. cially important if a smooth-walled implant is used.
The other treatment options are to close off the abnor-
mally positioned periprosthetic capsular space using
strip resection of lateral capsule and suture approxima- multiple (at least two) rows of permanent sutures (3-0
tion, along with an additional suture capsulorrhaphy, Prolene; see Fig. 3-39). Because the tissue in this medial
effectively closed down the lateral recess of the PPCS. The parasternal area is so thin, it is often difficult to achieve
medial capsulotomies provided a better and more sym- good suture purchase on the anterior tissues without cre-
metric definition of the cleavage. We replaced her ating dimpling in the overlying skin. Similarly, it is virtu-
implants with implants of the same dimension and added ally impossible to achieve a good suture purchase on the
20 cc of volume for a total of 350 cc. The patient is shown deep capsular tissues of the medial chest wall. When the
in Figure 3-82 5 months following surgery with an excel- tissues are thin medially and the thickness of the breast
lent correction of her malposition and improved overall tissue is minimal, it is necessary to maintain the implant
breast aesthetics (Fig. 3-82AC). in the submuscular position. It has been my experience
that even well-done suture repairs in this area generally
do not hold up. For this reason I have found that the dou-
MEDIAL MALPOSITION ble capsular flap technique (see Fig. 3-73), which is a two-
layered repair of capsular tissue technique, is most
If the implant is positioned too far medially, the cleavage helpful for correcting the problem of medial implant mal-
between the breasts can become very tight and undesir- position. It achieves the most secure apposition of the
able. The most pronounced form of this malposition, capsular tissues by providing the best suture holding
symmastia, is when both implant pockets are too medial. tissue elements for the repair. It also allows primary
The best way to manage the problem of symmastia is to apposition of fresh periprosthetic capsular tissue sur-
try to avoid it. If the surgeon carefully dissects the pock- faces. This increases collagen deposition and probably
ets as described earlier, i.e., taking care to stay at least 1.5 the long-term strength of the repair. It also has the least
cm from the midline during the dissection on each side, chance of producing dimpling deformities of the skin.
the potential for creating this deformity should be mini- The extra tissue used increases both the surgeons and the
mized. patients confidence in the repair. In most situations the
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FIGURE 3-79. Lateral implant malposition noted in patient 3

years following a transaxillary retropectoral breast augmenta-
tion with smooth-walled saline implants. This is present bilater-
ally but worse on the right side. A, Note wide cleavage and
laterally situated right breast implant. This is markedly accentu-
ated with shoulders abducted (B) and in the supine position (C).
FIGURE 3-80. A, The malpositioned right breast implant cannot be placed in the correct position rel-
ative to the parasternal area by digital compression on the lateral breast skin. B, This means a medial
capsulotomy as outlined on the skin will be needed as part of the correction.
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repair is combined with a lateral capsulectomy to permit attempting to place an implant that is too large for the
slight lateral flow of the implant (Fig. 3-83). anatomic confines of the existing breast.
A large suction drain (10 mm Jackson-Pratt) is usually The IM fold is formed by vertically oriented fibrous
placed through a laterally positioned small stab incision, connective tissue condensations extending from the der-
and it is removed when noted to drain less than 30 cc per mis superficially to the superficial fascia deeply. Some of
24 hours. Nonstick topical foam is placed over the sternal these fibers may extend to the muscle fascia, but the
area inside a circumferential dressing to help maintain majority insert into the superficial fascial system (SFS). It
appropriate position during the early postoperative is important to note that embryologically the breast devel-
period. The patient is asked to wear a bra to support the ops within the superficial and deep layers of the superfi-
implants for the first month following surgery and to cial fascia. Therefore the lower pole of the breast and IM
refrain from vigorous activity (e.g., heavy lifting, strain- fold has this relationship to the SFS.
ing, and bouncing activities) during that period. As discussed in Chapter 2, IM folds in different patients
Occasionally the plastic surgeon treating implant mal- exhibit different degrees of tightness, from none to a pic-
position encounters patients who have had several unsuc- ture of high-fold definition and significant tightness. This
cessful attempts at operative repair of their implant double bubble deformity is seen only in patients with
malposition. This is not uncommon in the case of medial extremely defined or very tight folds.
implant malpositions. In such situations the best strategy The inferior level of the breast and IM fold can be
may be to remove the implants and perform a total lowered during breast augmentation by extending the
periprosthetic capsulectomy with drain placement, submuscular dissection inferior to the IM fold in patients
allowing 6 to 12 months for complete tissue healing with no discernable fold, loose fold, or a moderately tight
before redoing the augmentation. This is a big decision fold. In patients with extremely tight folds it is often best
for the patient, and a detailed preoperative discussion to accept the existing fold and select an implant that will
must take place so that the surgeon can explain to the best fit the anatomic features and dimensions of the
patient the need for and shortcomings of this strategy, breast. A shaped textured implant or high-profile implant
including the surgeons inability to completely correct the often gives the illusion of more volume and projection for
problem. Medial implant malposition and its correction a given base width of the breast and is useful in these
is outlined in Chapter 6, Fig. 6-41AF. A similar approach patients.
is used if the surgeon encounters a postaugmentation
patient.
The simplest and most reliable method of treating TREATING THE DOUBLE BUBBLE
medial implant malposition is that of using a pocket re-
assignment. The implant is removed from the excessively When evaluating a patient with an established double
medial pocket and placed into a new or different virgin bubble, the choices are to attempt eradication or efface-
pocket in either the subglandular or subpectoral position, ment of the IM fold or to backtrack and accept the previ-
which has been dissected with careful attention not to ous fold by changing the implant and the periprosthetic
make it too medial. When the implant is removed from capsular space. The former approach involves meticulous
the subglandular space, this pocket is sutured closed with dissection aimed at releasing and detaching the insertion
interruped 3-0 chromic sutures (Fig. 3-84). of connective tissue fibers at multiple levels of the subcu-
A case illustrating the correction of medial implant taneous adipose layer, essentially, from the dermis to the
malposition performed with the double capsular flap SFS. The dissection is best done with scissors and must be
technique to close down the excessive medial recess of the thorough. In addition, it may be advisable to mold the tis-
PPCS, coupled with a lateral capsulotomy to achieve dra- sues internally with the implant or even a tissue expander
matically improved breast aesthetics, is demonstrated in (more often an option in breast reconstruction patients). I
Chapter 6, Fig. 6-41AF. This is also the approach that I have found that although some improvement results from
advocate for treating the problem following a previous this approach, very often some remnant of the IM fold
breast augmentation. persists, and this indentation is often objectionable to the
patient.
More commonly I recommend re-establishing the
THE DOUBLE BUBBLE DEFORMITY lower pole of the implant at the previous IM fold level.
This most often entails an internal suture capsulorrhaphy
A type of inferior implant malposition known as the dou- and a change of dimension and volume of the implant.
ble bubble results when the implant comes to lie below a The overall effect is most often a downsizing of breast vol-
tight previous IM fold that persists as a crease above the ume, which provides the restoration of a more natural
new lower level of the implant. It is seen only when the lower breast pole contour. Such a case is illustrated in the
submuscular position is used and usually results from next section.
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FIGURE 3-81. The plan for closing down the lateral capsular recess (here by resection of a strip of cap-
sule and suture repair [upper right figure]) and inferior-medial capsulotomy is seen in cross-section.
RIPPLES, RIDGES, FOLDS, AND Experience with saline implants obtained over the past
IMPLANT EDGE PALPABILITY 11 years has provided plastic surgeons with a better under-
standing of these problems and has given us a better
Since the FDAs 1992 directive3 to plastic surgeons work- insight into how to decrease their frequency.
ing in the United States to exclusively use saline implants
in patients seeking primary breast augmentation, the
postoperative problems of ripples, ridges, folds, and THEORIES ON THE ETIOLOGY OF THE
implant edge palpability have been more commonly PROBLEM
noted. The etiology of ripples, ridges, and folds (also
known as skin wrinkling) and of implant palpability are The presence of ripples, ridges, and folds that show
multifactorial. They are related to implant fill volume through the skin is the primary aesthetic drawback of
(underfilled implants), implant surface characteristics saline implants. It results from folds in the implant shell,
(more common with a textured implant surface), implant which are a function of the fill volume in the implant and
filler substance (incidence is inversely proportional to
increasing viscosity of the filler substance), and thickness
of the covering tissue envelope (more common with
implants in the subglandular position). In addition, I TABLE 3-3 Etiology of Ripples and Folds Following
Breast Implantation Multifactorial
believe that there is often implantpocket disproportion,
or a disproportion between the periprosthetic capsular Underfilled implant
space volume and the implant dimension. Although the Implant surface characteristicstraction rippling (textured,
problems of ripples, ridges, folds, and implant palpability smooth)
are far more commonly noted after the placement of a Filler substance (saline, silicone gel)
Thickness and quality of covering tissue envelope
saline-filled implant, they can also be seen following sili-
Implantpocket disproportion
cone gelfilled implant placement. See Table 3-3.
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FIGURE 3-82. A, Four-month postoperative view following correction of implant malposition noted
on AP view. B, Shoulder abduction view. C, Marked lateral subluxation of implants noted preoperatively
in the supine position. D, View with patient in supine position. Note marked improved when compared
to preoperative appearance in Figure 3-79AC.
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FIGURE 3-83. Schematic outline for correction of medial implant malposition. This includes closure
of medial capsular recess with double capsular flap technique (Fig. 3-73) and lateral capsulotomy.
FIGURE 3-84. A-B, When implant is removed from the subglandular space, the pocket is sutured
closed with interruped 3-0 chromic sutures. This strategy can also be used to treat ripples or folds in the
breast.
Ch03.qxd 11/27/05 10:03 PM Page 132
the viscosity of the filler substance. They are seen more implant use was so much higher when placed in the subg-
commonly when a textured-surface implant is used. A tex- landular position that the authors63 recommend against
tured-surface implant, whether it is silicone or saline placing them in the subglandular spaceespecially in
filled, can produce traction rippling due to the manner in thin patients.
which the textured surface is incorporated into the sur-
rounding tissue. The problem is distinctly less common
with silicone gelfilled implants; however, there was a par- MINIMIZING SKIN WRINKLING
ticular problem with the Dow Corning MSI implant (Dow
Corning Corp., Midland, Mich.), which had a textured sur- Because the optimal fill volume for some saline implants
face and was thought to be slightly underfilled in terms of may not be precisely known, it is essential that the plas-
its gel volume. tic surgeon never underfill a saline implant. I usually fill
I have come to believe that another etiology is that of the implant to between 10% and 30% greater than the
capsuleimplant disproportion when the capsule that suggested fill volume. It may be helpful surgeons to hold
the implant resides in is substantially larger than the a filled saline implant in their hand in the upright posi-
implant inside the space. This situation is commonly tion (using the Tebbetts tilt),64 observing the shape and
noted when a smooth-walled saline implant, which gen- inspecting the edges for rippling as the implant is filled
erates a much thinner and flimsy capsule, experiences to, and beyond, the maximum suggested fill volume for
gravitational settling, allowing the upper part of the the particular implant. High-profile round saline
capsular space to loosely drape over the edge of the implants may in fact show a tendency for less folding
implant. than regular-profile implants as they are filled beyond
Implant palpability refers to the ability of the patient, the maximum suggested implant fill volume depicted on
or the patients significant other, to feel the implant. This the box or in the package insert. However, the surgeon
is an unnatural and undesirable tactile sensation, and it must be aware that a saline implant will become progres-
usually involves the edge of the implant. It is more sively firmer as its volume increases. Technically, over-
common than ripples, ridges, and folds, but not as objec- filling beyond 10% may void the warranty, but up to this
tionable. It is mostly related to inadequate soft tissue point the manufacturers have been lenient with this
padding, position of placement (it is seen far more com- transgression.
monly following breast reconstruction or after subglandu- Additional maneuvers to limit the incidence of rippling
lar placement of a breast implant during augmentation), with saline implant breast augmentation predominantly
and surface texture characteristics of the implant (it is involve maximizing tissue padding in each patient. I do
decidedly more common when textured-surface implants this by using the subpectoral position almost exclusively
are used). Patients who are thin (Fig. 3-85A,B) are very for breast augmentation, as previously noted. This is true
likely to feel their implants in the inferolateral aspect of unless the patient has pre-existing B cup or greater breast
the breast [Fig. 3-86A,B (arrows)]. I inform such patients tissue volumean unusual situation in my breast aug-
about this preoperatively. mentation practice. The use of the subpectoral position
for augmentation is especially true with a thin PMM and
subcutaneous tissue layer on or adjacent to the breast.
FREQUENCY OF THE PROBLEM I find these patients to be particularly tough candidates
for breast augmentation, and I routinely tell them preop-
The commonality of postoperative ripples, ridges, folds, eratively that they will feel their implants postoperatively
and implant edge palpability following saline implant in the lower outer aspect of their augmented breast (see
placement has been studied by Young et al.63 They com- Fig. 3-86A,B).
bine the ripples, ridges, and folds problem under the I almost exclusively use smooth-walled saline implants
heading of skin wrinkling and have devised a scale of I for primary breast augmentationmainly to limit ripples,
to III for grading each of these problems (I = none, II = ridges, and folds, as well as to minimize the occurrence of
mild, III = significant). implant palpability.
In the study by Young et al.,63 rippling of the skin over
an implant was noted significantly more often with the
use of textured implants than with the use of saline SURGICAL TREATMENT OF RIPPLES,
implants. In terms of implant palpability, here too there RIDGES, AND FOLDS
was a greater incidence of the more advanced forms of
implant wrinkling (levels II and III) after the placement The treatment of ripples, ridges, and folds usually involves
of textured implantsespecially if they were placed in the changing the implant surface characteristics from a tex-
subglandular position. In fact, the incidence of undesir- tured implant to a smooth-surface implant. In addition
able implant wrinkling and palpability with textured reassigning a previous subglandular implant to the sub-
Ch03.qxd 11/27/05 10:03 PM Page 133
FIGURE 3-85. AB, Extremely thin patient who requests an augmentation mammoplasty with saline
implants. Such a physical habitus places these patients at great risk for implant edge palpability and for
the visual appearance of ripple or folds.
FIGURE 3-86. The patient in Figure 3-86 is shown 1 year postoperative following a partial retropec-
toral breast augmentation with smooth-walled saline implants with a volume of 330 cc. A, AP view. B,
Lateral view reveals implant palpability laterally (arrows), which are present but do not bother patient
because she was informed about them preoperatively.
Ch03.qxd 11/27/05 10:04 PM Page 134
pectoral space is helpful in that it increases the thickness Although I have had little experience with synthetic tis-
of the padding tissue (see Fig. 3-84A,B). Finally, I believe sue substrates such as allogenic dermal grafts,59,60 their
that decreasing the volumetric dimensions of the peripros- use may hold promise in the treatment of ripples, ridges,
thetic capsular space by suture tightening the capsule, in and folds, and I suspect that they will have more wide-
addition to using a slightly larger-sized implant, may be of spread use following implant breast surgery in the future.
real benefit in certain patients. These are the individuals in The case just illustrated shows a pronounced fold prob-
whom capsuleimplant disproportion is an issue. This lem. The vast majority of cases that I have encountered
problem is almost exclusively seen with saline-filled breast have folds that are far less pronounced, however. Such a
implants. case with more subtle folds is seen in the patient shown in
Problems with ridges, ripples, and folds can be dra- Figure 3-89, who presented with symmastia and visible rip-
matic, as noted in the patient in Figure 3-87, who ples in the superior medial aspect of her breasts following a
has underfilled saline implants in the subglandular subglandular breast augmentation with textured round
position after three previous augmentation procedures. saline implants (Fig. 3-88A,B). This combination of prob-
Treatment entails improving the quality of the tissue lems was addressed by the repositioning of smooth-walled
padding overlying the implant and often changing the implants into the subpectoral position (see Fig. 3-84). The
implant itself. There may be an emerging role for syn- PMM provides an increased tissue layer to limit fold visibil-
thetic tissue substitutes in this area. Dowden60 has ity in this location, and the medial (parasternal) origin of
reported on the use of AlloDerm to increase the thickness the muscle is an anatomic barrier that limits the problem of
of the soft tissue between the implant and the skin to treat symmastiaproviding that the PMM is not released from
folds in patients who have previously undergone breast the sternum. Postoperatively there is more space between
augmentation. In another similar publication Baxter59 the breasts (albeit with a good cleavage), and the superior
outlines the use of AlloDerm acellular dermal grafts as an medial folds are gone (Fig. 3-89A,B).
inlay graft to the superior and inferior aspect of the
periprosthetic capsule to improve rippling following a
saline implant breast reconstruction. The series is small, CAPSULAR CONTRACTURE
but the results are encouraging.
Capsular contracture has always been the most common
inherent risk or adverse side effect of breast augmenta-
tion. It is often referred to as a complication, but in fact I
believe it is an inherent risk of every breast implantation
procedure. In most series it maintains a frequency of up to
30%24,66 when silicone gel implants are placed in the sub-
glandular position and 15% to 20% 24,25 when breast
augmentation14,15 is performed with saline-filled breast
implants in the same location. It is an exaggerated form of
the collagen fiber deposition, which occurs as part of the
foreign body reaction that occurs in all patients when a
breast implant is placed.67 Advanced forms of this process
produce an unnatural feeling of firmness in the breast,
distortion, and even discomfort68 (Baker IV) (Fig. 3-90).
The etiology of capsular contracture remains unknown.
The two most commonly held hypotheses as to its etiology
are hypertrophic scar formation69,70 and subclinical infec-
tion.71,72 The latter is felt to be due most often to contami-
nation of the periprosthetic capsular space with
Staphylococcus epidermidisan organism commonly cul-
tured from the periprosthetic capsule of encapsulated
breast implants. The major difficulty with the hyper-
trophic scarring hypothesis is that it does not explain the
commonly observed unilateral occurrence of the process.
In addition, there is no consistent correlation between
capsule thickness and firmness of the implant. The pri-
FIGURE 3-87. Significant ripples and folds seen in this
patient who has had several breast augmentation procedures. mary difficulty with the subclinical infection hypothesis is
She has underfilled, textured saline implants in the subglandu- that many patients with advanced capsular contracture
lar space. have negative cultures of the intracapsular space.
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The severity of the capsular contracture process noted to what many patients may have had at the time of
clinically is classified into four types: none, mild, moder- puberty) may be desirable. It is the more severe types of
ate, and severe. The most commonly used system for grad- capsular contracture (Baker III and IV) that are most
ing the severity of the process is that proposed by James bothersome to the patient because these tend to produce
Baker68 (Table 3-4). The most commonly seen variety is distortion of the implant and result in asymmetry. The
the mild type (Baker II), which is often not offensive to the most severe may also produce pain (Fig. 3-90).
patient because some element of breast firmness (similar
FIGURE 3-88. Patient presenting with symmastia and upper pole rippling in the medial aspect of the
breast following previous subglandular augmentation with a textured round saline implant. A, AP view.
B, Oblique view.
FIGURE 3-89. Successful revision was accomplished by placing smooth-walled implants into subpec-
toral position. A, Two-year postoperative AP view. B, Two-year postoperative oblique view.
Ch03.qxd 11/27/05 10:04 PM Page 136
TABLE 3-4 Classification of capsular concentration certainly I can attest to its validity in my own patients.
There may be an advantage to using a textured-surface
Baker I The breast is soft and there is no evidence of capsular
contracture
implant, especially when the implant is positioned in the
Baker II The implant can be easily palpated by the surgeon and subglandular space. There does not seem to be a benefit
the patient from textured-surface implants when these devices are
Baker III There is evidence of a capsular contracture that is firm placed in the submuscular position, however.
and gives the breast a round appearance
Baker IV The breast is hard, distorted, and may be painful or cold
EARLY CAPSULAR CONTRACTURE
The early occurrence of capsular contracture is of particu-

lar concern to both the patient and the surgeon. Using the
early intervention of diligent displacement exercises and
vitamin E in large doses may be beneficial. I prescribe a
dose of 1,000 IU per day for 6 weeks. I believe that in addi-
tion to this pharmacologic intervention, having patients
sleep in the prone position and perform frequent displace-
ment exercises has been helpful in many patients.
The beneficial effect of intensified vigorous implant
displacement exercises and vitamin E therapy was real-
ized in this patient who exhibited a Baker III contracture
of the left breast implant 1 month after a partial retropec-
toral augmentation with a smooth-walled saline implant
(Fig. 3-91A,B). This was despite displacement exercises
done only once a day. She was begun on vitamin E 1,000
FIGURE 3-90. AP view of patient who exhibits a Baker IV cap- IU b.i.d. and instructed to vigorously move her implants
sular contracture of a left breast implant following previous sub- and gently squeeze them with the superior displacement
glandular augment with silicone gel implant. maneuver (Fig. 3-92). This regimen of treatment was suc-
cessful in restoring a Baker I status to the left breast
within 4 weeks (Fig. 3-93). I do not have controlled study
To date there is no known way to eliminate the occur- evidence that this is a consistently predictable effect, but it
rence of capsular contracture, but certain maneuvers has been helpful in many of my patients.
seem to decrease its frequency and minimize its presence. Most recently there have been reports that the asthma
The extensive literature on the occurrence of capsular medication alclometasone dipropionate (Aclovate) may
contracture seems to consistently record a decreased inci- decrease the incidence of capsular contracture or reverse
dence with the submuscular placement of the breast the process in some patients. I do not believe that this
implant. The exact reason for this reduction when drug, with significant medical side effects (e.g., hepatotox-
implants are positioned beneath the PMM is unknown, icity), should be prescribed for off-label use.
but it is likely that muscle contraction produces a con- Most of the time when a breast implant exhibits signifi-
stant message that may maximize pliability of the capsule cant contracture, it will be seen by 1 year postoperative.
and act to keep the implant as soft as possible. I personally After that time it is relatively uncommon for a patient to
believe that positioning of the implant beneath the PMM manifest advancement of the capsular contracture
may make it more difficult to appreciate capsular contrac- process. However, there are certain conditions and events
ture, especially in those patients who have a significant that may lead to a late onset of increased breast firmness.
amount of their own breast tissue. Events that may produce an accelerated delayed contrac-
There is a school of thought that proposes that main- ture include trauma to the breast with delayed hematoma
taining both maximal pocket distensibility and dimension or seroma and intercurrent infection.65
along with implant mobility by means of displacement
exercises contributes to implant (and breast) softness. I
subscribe to this hypothesis29,30 and instruct my patients to ESTABLISHED CAPSULAR
begin implant displacement (see Fig. 3-23AC) as soon as CONTRACTURE
possibleusually by the third postoperative day.
The incidence of capsular contracture has been reduced Once contracture has been established, it is difficult to
with the more widespread use of saline implants.14,15 This treat. There has been some enthusiasm for high doses of
observation has been borne out in numerous reports, and vitamin E therapy; however, the beneficial effects of this
Ch03.qxd 11/27/05 10:04 PM Page 137
FIGURE 3-91. A, Preoperative view of patient during breast augmentation. B, One month postopera-
tive AP view showing Baker III capsular contracture of left breast with asymmetry.
FIGURE 3-92. Vigorous superior displacement exercises

carried out.
Ch03.qxd 11/27/05 10:04 PM Page 138
FIGURE 3-93. Pretreatment and posttreatment appearance of breasts on AP view showing resolution
of the capsular contracture 4 weeks after institution of vigorous displacement exercises done t.i.d.
therapy remain unproven. In my opinion, capsular con- (Fig. 3-95), being especially careful to remove as much of the
tracture that presents with implant deformity and breast capsular tissue as possible, especially on the anterior surface
asymmetry, or symptoms that may include tightness, cold- of the capsule. The exceptions to this are patients who have a
ness, or frank discomfort, is an indication for surgery. The thin covering envelope. Most commonly this is either a
surgical approach must be carefully tailored to the indi- patient with very limited breast tissue who has undergone
vidual patient and, more important, the patient must be subglandular breast augmentation, or a patient who has had
advised that no guarantee for increased softness can be a previous subcutaneous mastectomy. In these situations,
made. The rate of recurrence of capsular contracture after performing an anterior capsulectomy may impair the circu-
surgery is high. lation to the overlying tissue and create problems with heal-
My approach to capsular contracture has been to care- ing that may lead to skin loss and tissue atrophy.
fully evaluate the patient preoperatively, advise the patient I have had success in performing total capsulectomy
as just stated, then look at each case with the idea of surgery to treat advanced capsular contraction, as noted
changing something. In my experience, the operation is in the case of a young patient who had undergone a bilat-
best performed under general anesthesia. It usually eral silicone gel subglandular breast augmentation 11
involves reopening the incision made for placement of the years before her consultation with me. Over the preceding
previous breast implant, then identifying the peripros- 18 months she had experienced progressive firmness and
thetic capsule. Although some of my colleagues have distortion of her left breast (see Fig. 3-90). She recalled
touted the benefits of capsulotomy or multiple capsulo- that this breast was firm immediately following surgery,
tomies (Fig. 3-94) with the immediate institution of dis- and she had undergone two attempts of closed capsulo-
placement exercises, in my experience the rate of tomy. This seemed to make her breast somewhat softer
recurrence of firmness when only this is done has been but it was never as soft as the opposite right breast. She
high. Therefore I routinely perform a capsulectomy presented with a Baker IV capsular contracture of the left
Ch03.qxd 11/27/05 10:05 PM Page 139
breast implant, which produced a visible distortion of the

left breast with superior implant malposition on that side
[see Figs. 4-25 and 4-28 (left side of composite)]. The breast
implant was intermittently painful and was uncomfort-
able to touch. She underwent a total periprosthetic cap-
sulectomy (Fig. 3-96) and implant removal, followed by
the reinsertion a new smooth-walled silicone gel breast
implant. This was successful in restoring softness and a
more symmetric appearance to the breasts (see Figs. 4-26
to 4-29).
If the capsule is to be left in place in a thin patient with
a previous subglandular implant, it is often possible to
change the position of the indwelling implant. Most com-
monly, this is a change from the subglandular to the sub-
FIGURE 3-94. Multiple capsulotomy technique that can be pectoral position. When placing an implant in this
used in reoperation to treat established capsular contracture. location, it is important to release the origin of the PMM
inferiorly as already discussed. This will result in the
upper 70% of the implant being submuscular, with the
lower 30% lying under the lower pole of the breast tissue
or in the subcutaneous tissue, resulting in dual plane
repositioning. If such a repositioning is carried out, it is
not necessary to perform a capsulectomy. The exception
to this would be a situation with significant silicone gel
bleed or intracapsular rupture where, if silicone gel is
contained within the periprosthetic capsule, this gel
could lead to the formation of a siliconoma or problems
with chronic seroma accumulation because of silicone in
the scar tissue space, which will not undergo any type of
reabsorption.
Relocation to the submuscular space is helpful in
FIGURE 3-95. The technique of total or subtotal capsulectomy
is an alternative to multiple capsulotomies.
achieving the interposition of additional soft tissue
between the implant and skin surface. This dual plane
repositioning alone can confer to an implant more of a
feeling of softness (Fig. 3-97). Spear et al. 73 have
FIGURE 3-97. Schematic outline of the dual plane technique

used to treat capsular contracture. It involves increasing the vol-
FIGURE 3-96. The technique of total periprosthetic capsulec- umetric dimension of the periprosthetic capsular space and
tomy done through an IM incision illustrated a contracted cap- increasing the distensibility of the tissue in the breast as a means
sule around the implant. of help promoting a softer texture to the breast.
Ch03.qxd 11/27/05 10:05 PM Page 140
recently touted this dual plane approach as a reliable In my experience, textured implants do seem to incite
method of surgically treating established capsular con- more of a problem with seroma formation. Because of
tracture. The technique for the procedure includes this I make liberal use of drains and routinely drain
recreating the PPCS so that it is partially subpectoral patients after implant exchange surgery when a textured
and subglandular. The procedure acts to increase the implant has replaced a smooth implant. The drains are
internal volume of the PPCS and to increase the disten- left in place until they drain less than 30 cc of fluid per 24
sibility of the tissues so as to increase the softness of the hours. This indicates that the elaboration of serous fluid
implant. My early experience with this technique has is at its minimum and the stage has been set for incorpo-
been positive. ration of the implant and good tissue to implant inter-
Removing the periprosthetic capsular tissue is impor- face healing. The drains are routinely removed within
tant. It can be carried out through either an IM approach the first week (usually between the third and fifth post-
(which in my experience is ideal) or a periareolar operative day), but it is not uncommon for a drain to be
approach. I find it impossible and therefore ill advised to left in for more than a week. Obviously the patient must
attempt a capsulectomy through an axillary incision, even keep the drain clean and dry. I routinely maintain
with the use of an endoscope. patients on oral antibiotics while the drains are in place
The procedure entails the use of a headlight that will [cephalexin (Keflex) 500 mg PO q.i.d.]. I do not have
facilitate direct visualization of the entire dissection. The patients massage their implants unless they are smooth
dissection is carried out with a combination of electro- surfaced.
cautery dissection and blunt fingertips (see Chapter 4).
The latter maneuver is possible if the plane between the
breast tissue and the periprosthetic capsule can be easily SUMMARY STATEMENT ON
developed. Should this plane not lend itself to easy dissec- CAPSULAR CONTRACTURE
tion, the electrocautery is indicated to maintain hemosta-
sis and to facilitate the dissection. Capsular contracture remains the most prevalent undesir-
When the implant is already below the PMM, I believe able side effect of breast implant placement for either
that at a minimum it is important to remove the anterior breast augmentation or breast reconstruction. Its etiology
capsule. If the posterior capsule lends itself to safe exci- is unknown. Maintaining strict sterile technique using
sion (and most often this has been the case in my experi- barrier drapes on the skin and antibiotic irrigation of the
ence), then it too should be excised. This will provide a dissected space, along with minimal handling of the
neo-virginal space in which to place the new implant. implant, may reduce its incidence.
Although I have previously stated that in most cases plac- Established contracture that is bothersome to the
ing a textured implant in the subpectoral position is not patient can be surgically treated, often with improvement.
beneficial in the setting of a previous capsular contrac- The concept of changing some element of the previous
ture, it may be wise to change the implant surface texture treatment schema is important, and this has been reviewed.
as part of the procedure. Substantial decreases in capsular contracture rates will
If implant replacement into the subglandular space is probably require an increased understanding of how to
planned, then a total capsulectomy will allow placement pharmacologically or chemically manipulate the foreign
of a new implant into a neo-virginal pocket. This can be body reaction. Such may be possible with an increased
helpful in perhaps altering the healing process that has understanding of cytokine interactions and effects on the
resulted in a capsular contracture. Meticulous hemosta- biology of wound healing. Alternatively, new directions
sis should be procured. If I perform a total capsulec- regarding implant design and manufacture will likely be
tomy, I routinely place a suction drain through a short necessary.
incision located laterally within the shadow of the
breast.
After the implant has been explanted, the new implant IMPLANT FAILURERUPTURE OR
is put into position. Conversion to a different location is DEFLATION
helpful. Additionally, there is some published evidence
that use of a textured-surface implant may decrease the An inherent risk of breast implant placement is implant
rate of capsular contracture. Should a textured implant failure. This occurs with all types of biologic implantation
be used, it is important for the surgeon to precisely dis- devices. The subject of silicone gel implant rupture is
sect the accepting pocket to the dimensions of the extensively reviewed in the Chapter 4.
implant. This will minimize the incidence of implant mal- Saline implants also fail or exhibit deflation. As of this
position, palpability, and pocket disproportion but writing the deflation rate appears to be 2% per year per
increase the chance that ridges, ripples, and folds will implant.14,15 This seems to be a linear relationship when
develop. the patients are followed for a period of 12 years.
Ch03.qxd 11/27/05 10:05 PM Page 141
FIGURE 3-98. AP (A), oblique (B), and supine (C) views of

patient presenting with partial deflation of her right breast
implant. Note the folds in the inferior aspect of the breast during
supine posture.
FIGURE 3-99. AP (A), and oblique (B), views of patient following removal of partially deflated
implant and replacement with a new saline implant with dimensions and volume identical to the oppo-
site breast.
Ch03.qxd 11/27/05 10:05 PM Page 142
Most saline implant deflations result in complete less volume on that side 2 years after an initial breast aug-
flattening of the breasts. I advise patients that if saline mentation (Fig. 3-98A,B). At surgery she was found to
implant failure occurs, they should seek correction have tissue ingrowth into the nipple valve of her implant.
(implant replacement) within the first week. This is This was removed and replaced with an implant of the
because if the problem is ignored and is not treated dur- same dimension and volume as that present in the oppo-
ing that time, then the periprosthetic capsule around the site breast, with the restoration of satisfactory symmetry
implant contracts. This will require much more exten- and the elimination of the folds in the breast contour
sive surgery, including capsulotomy or even capsulec- (Fig. 3-99A,B).
tomy, to restore the dimensions and distensibility of the The message here is that partial deflations with
PPCS. saline-filled breast implants can occur. In the situation
Partial implant deflation can also occur with saline of saline implant deflation following breast aug-
implants. This is far less common. I estimate that it mentation (or breast reconstruction), a better result
accounts for 0.5% of such deflations. A patient exhibiting with much less surgery usually is realized with early
this problem is illustrated in Figures 3-98 and 3-99. She (within the first week) rather than late surgical
presented with folds in her right breast implant and much intervention.
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A p p e n d i x A
Consent To Surgery And Anesthesia
I, ________________________ authorize Dr. Kenneth C. Shestak and/or such assistants

[Name of Patient]
and other physician(s) as may be designated by him, to perform the following surgical procedure(s), which I understand
to be: Breast augmentation
The above procedure(s) have been fully explained to me by Dr. Kenneth C. Shestak and I understand the risk of the pro-
cedure to be as follows: Bleeding hematoma, seroma, infection, wound separation, implant exposure, loss of implant if
exposure or infection occurs, capsular contracture (possibly advanced), altered nipple sensation, contour asymmetry,
ripples, ridges or folds in skin, pain, rupture or deflation, allergic reaction to medications, unfavorable scar position or
formation, need for unplanned additional surgery, suboptimal cosmetic result
And the consequences of the procedure(s) to be as follows: ____________________________________________________
1. I acknowledge that I have discussed alternative treatment and options of no treatment with my physician.
2. I understand that during the course of the procedure, unforeseen or unexpected conditions may arise which neces-
sitate additional or different procedures immediately necessary to treat my medical condition and to preserve my
life or health. I request and authorize my physician(s) to perform such procedures which in the physicians profes-
sional judgment are deemed medically necessary.
3. For the purpose of advancing medical education, I consent to the admittance of observers and discussion of my
procedure with others who may not be directly responsible for my care.
4. I understand that my physician(s) or others under the direction of my physician may choose to record, photograph,
televise or videotape all or any portion of my operation for medical, scientific or educational purposes. I consent to
the recording, photographing, televising and videotaping of the operations or procedures to be performed, includ-
ing appropriate portions of my body, provided my identity is not revealed. I understand and agree that 1) any pho-
tographs, films, videotapes or other audio or visual recordings will be the sole property of Magee-Womens Hospital
and will not become part of my medical record; and 2) Magee-Womens Hospital or any appropriate staff member
may edit, preserve, destroy or release to my physician all or any part of the photographs, films, videotapes or other
audio or visual recordings.
Ch04.qxd 11/28/05 1:36 AM Page 146
C h a p t e r 4
Evaluating Implant Integrity and

Explantation Options and Techniques
Diagnostic Approach 146 Explantation Alone 159
Physical Examination 147 Explantation with Implant Reinsertion 161
Imaging Modalities for Breast Implants 149 Explantation with Mastopexy Alone 167
Indications for Explantation 152 Explantation with Augmentation Mastopexy 175
Implant Failure 153 Explantation with Autogenous Tissue

Conversion 177
Treatment of Implant Failure 153
Autogenous Conversion Following Previous
Management of the Periprosthetic Capsule 154 Breast Augmentation 177
Technique of Capsulectomy 158 Autogenous Tissue Conversion Following

Suboptimal Implant-Based Breast
Summary Statement on Capsulectomy 159 Reconstruction 179
Treatment Options Following Explantation 159 References 182
Over the past decade, many plastic surgeons have seen a This analysis is directed at establishing the status of
number of patients with concerns about or problems with a implant integrity and entails a careful evaluation of the
previously placed breast implant. In the early 1990s many patients breasts from an aesthetic and general breast
of these consultations were prompted by the adverse pub- health perspective.
licity1 surrounding breast implants, such as concerns about
safety issues,2 especially with regard to any link between
the presence of silicone gel breast implants and the devel- DIAGNOSTIC APPROACH
opment of connective tissue disease or other diseases.
These patients were extremely anxious and even angry In my practice the approach to the potential explantation
about presumed health problems with their breast patient entails taking a careful history, noting the chief
implants. Two extensive reviews of virtually all the data on complaint and other complaints, and a detailed review of
silicone gel implants published in the medical literature3,4 past breast health history (including all mammograms,
and many other peer-reviewed studies58 have now dis- biopsies, and operations) and other medical conditions,
proved the potential induction of or link between any followed by performing a careful physical examination.
known disease process and silicone implants, thus making Appropriate laboratory and breast imaging studies are
it possible now to reassure patients who have had implants then recommended and additional consultations sought if
placed for any reason about the safety of these devices.9 indicated. The goal is to make a diagnosis regarding any
Nevertheless, it is imperative that the plastic surgeon implant problem.
employ a thorough and systematic evaluation of all The history is very important. It must include details of
patients who have undergone previous breast implanta- the previous operation(s), the type of implant, anatomic
tion if there is a suspected problem with the implant(s). position of the implant, complications of the previous
146
Ch04.qxd 11/28/05 1:36 AM Page 147
Chapter 4 Evaluating Implant Integrity and Explantation Options and Techniques 147
procedure and any related incidental occurrences such as whether the implant is frankly visible or causing distortion
trauma to the breast, particularly searching for a history of the breast (Fig. 4-1), implying an advanced capsular con-
of closed capsulotomies, etc. A review of previous opera- tracture or perhaps rupture. Perhaps most important is
tive reports and physician records is the most precise way noting the location of previous scars and taking into
of gaining the most accurate knowledge about the previ- account their potential effect on the blood supply of the
ous surgery(ies). Specific complaints or problems related nipple areolar complex (NAC). Any asymmetry, distortion
to the breasts most often include firmness as the result of of the breast tissue, and nipple irregularities are also noted.
capsular contracture, asymmetry, nipple or skin sensory Next, the relationship of the NAC to the breast mound
changes, breast pain, and changes in implant position or and implant is noted. It is also important to note the rela-
the development of a mass in the breast or an irregularity tive degree of ptosis and to determine the relationship of
that may be related to the implant edge. The physician the existing breast tissue to the underlying implant. It is
must key into symptoms of pain, especially the occur- relatively common for the breast tissue to settle away from
rence of burning pain that may involve the breast, lateral the implant (see Fig. 4-1), especially in patients approach-
chest area, or axillary region. This symptom can result ing the fifth decade, or in situations in which the implants
from implant rupture. Previous breast problems are also have been in place for more than 15 years. Very often the
important to note. Such problems include any history of breast will exhibit a dependent appearance, especially if
previous breast masses, imaging studies, and all breast the implants are of the smooth-walled saline variety. In
biopsies and pathology reports pertaining to them. these cases some form of a mastopexy may need to be
Changes in the patients breast examination (noted by incorporated as part of the surgical plan.
either the patient or the physician) and the new onset of A worksheet with a breast diagram (Fig. 4-2) is com-
pain symptoms in the breasts are important to catalogue. pleted detailing the anatomic and tissue features of the
Obviously any family history of breast cancer is also breast, including the base width and the relationship of the
important to note. NAC to the inframammary (IM) fold and the suprasternal
The presence of generalized systemic symptoms must notch (SSN), with notations about the breast skin and
also be noted. These include any history of myalgias, parenchyma. The location of all previous breast scars is
arthralgia, fatigue, hair loss, and dryness of mucous mem-
branes, as well as any neurologic complaints. It is impor-
tant to thoroughly review previous diseases, including the
presence of known connective tissue disease, cardiac dis-
ease, respiratory disease, thyroid problems, and other
endocrine diseases, during the initial evaluation.
In my practice most often the typical patient has expe-
rienced no specific breast complaints but is referred for
evaluation after breast imaging studies have suggested the
diagnosis of implant rupture.1014 Importantly, although
patients experiencing local discomfort in the breast
related to capsular contracture or implant rupture might
be improved by implant removal, it has been my experi-
ence that patients who are experiencing any systemic
complaint(s) are rarely improved by the removal of the
implants. Patients are informed of this before any planned
explantation procedure.
PHYSICAL EXAMINATION
As with all plastic surgery evaluations, the first part of the

examination entails careful inspection. For the patient with
a possible implant problem, this begins with observing the
movement and posture of the patient, as well as her general
appearance. Vital signs are recorded, along with height,
weight, and bra size. Next, the appearance of the breasts is FIGURE 4-1. Anteroposterior (AP) view of breasts in 47-year-
old patient who underwent a breast augmentation 12 years
analyzed for any asymmetry in volume, skin envelope earlier. She displays settling of her breast tissue away from her
dimension or quality, nipple areola size or location, and implants and a visible abnormality in the right breast that was
degree of mammary ptosis. It is important to assess due to an implant rupture.
Ch04.qxd 11/28/05 1:36 AM Page 148
FIGURE 4-2. Breast worksheet for potential explantation patient.

Ch04.qxd 11/28/05 1:36 AM Page 149
also recorded on the diagram. In addition, information The mammogram remains the standard way to image
about the patients past breast history, including details of the breast tissue in every womans breast,10 regardless of
the previous surgery(ies), is entered. As mentioned in whether an implant is present.16 It is the only method by
Chapter 3, this includes the type, size, and position of the which microcalcifications in the breast can be visualized.
indwelling implant and notations regarding incisional It employs x-rays of the breast in various planes, including
approaches along with any information about previous the craniocaudad and mediolateral views (Fig. 4-3A,B).
mastopexies. Sensation of the breast skin and nipple are- I instruct patients to follow the mammography schedule
ola area is also noted. as proscribed by the American Cancer Society.16 I instruct
Following this the breast is palpated for any abnormal- the patient to have the first mammogram performed at
ities in the parenchymal tissue or on the surface of the age 35, the next at age 40, mammograms every other year
implant itself. The patient is asked to contract her pec- until age 50, and yearly studies thereafter.16
toralis major muscles (PMMs) and in this way whether the The presence of a breast implant limits the amount of
implant is located in the subglandular or submuscular breast tissue that can be imaged to a variable extent due to
position is suggested (if such information cannot be the radio-opacity of the implant itself.10 The amount of
obtained from the previous records). This maneuver gives breast tissue that is concealed varies from approximately
the surgeon an insight into the degree of distortion of the 9% to 49%17 depending on the position of the implant and
breast with contraction of the PMM. The examiner then whether capsular contracture exists.18 To increase the
notes the degree of firmness in the implant. The firmness amount of tissue that can be imaged, special displacement
is graded on a spectrum of none to severe and is recorded views, as described by Eklund10 (Fig. 4-4A,B), are widely
in the form of the widely accepted Baker Classification used. With this technique the implant is pushed posteri-
Score15 (Table 4-1). The edge of the implant is then care- orly toward the chest wall and the breast tissue is dis-
fully palpated for, specifically to assess for any evidence of tracted anteriorly to obtain increased visualization of the
irregularity, rippling or undulations, firmness, or discrete breast parenchymal tissue. This must be done gently in a
masses that might be adjacent to the implant. Next, the radiology unit experienced in performing mammography
surgeon observes for the presence of any nipple discharge in patients with implants because implant rupture is a
or nipple irregularity. The skin is carefully observed for rare reported complication of mammography.19
any distortion or mass. The axillary area is carefully evalu- The breast tissue that is most concealed is that area
ated for any sign of palpable abnormality, including alongside the implant itself11 (Fig. 4-5). To obtain the best
lymph nodes, masses, and previous scars. visualization of this area, ultrasound or breast sonogra-
phy has been widely employed. It provides a valuable
adjunct to the mammographic imaging studies.
IMAGING MODALITIES FOR BREAST Sonography relies on transmitted sound waves, which are
IMPLANTS directed through the breast and reflected back to a receiv-
ing probe. It has long been used to aid in the diagnosis of
I believe that the diagnostic impression of whether the breast pathology because it can provide information as to
implant is ruptured or intact is almost never obtained whether a palpable or mammographically demonstrated
from physical examination alone. The exception to this is lesion is cystic or solid (Fig. 4-6).
the case of an easily palpable abnormality in the breast tis- In a similar way sonography is helpful in imaging a
sue (especially if it is an acute change) related to an breast implant because there is differential sound wave
episode of direct trauma to the breast. More often the transmission through the breast tissue and breast
diagnosis of implant integrity can only be obtained from implant. Therefore, the sonography examination of the
an interpretation of imaging studies of the breast, which breast produces an image of the implant that is separate
include a combination of mammography,10 breast sonog- and distinct from the surrounding breast tissue. The
raphy,11,12 and magnetic resonance (MR) scanning.13,14 implant appears as a nearly anechoic structure that is
dark on the sonographic image. In contrast, the breast tis-
sue is hyperechoic (or appears white). This yields a pic-
ture of the implant as sharply distinct and contrasted
TABLE 4-1 Baker Classification of Capsular from the surrounding breast tissue11,12 (Fig. 4-7).
Contracture
Sonography of the breast is highly operator depend-
Baker I No evidence of firmness; breast feels as soft as a normal ent.11,12 It yields the most useful information when
breast performed by a radiologist who has taken a history, per-
Baker II Examiner and patient can feel implant sonally examined the patient, and evaluated the mammo-
Baker III Breast is moderately firm and may exhibit distortion of grams. This allows a careful, focused examination of a
contour
specific area of the breast that may require that the patient
Baker IV Breast is hard, painful, or cold
be placed in various positions (Fig. 4-8).
Ch04.qxd 11/28/05 1:36 AM Page 150
As previously noted, because of the differential sound lar breast rupture with confidence, and therefore it allows
wave transmission characteristics of breast tissue and sili- him or her to recommend implant removal to the patient.
cone, in the hands of an experienced operator the tech- Intracapsular rupture is more difficult to image with
nique of sonography is highly reliable for making the sonography of the implant. With intracapsular rupture a
diagnosis of extracapsular implant rupture. In this situa- tear has occurred in the elastomer shell of the silicone gel
tion, silicone gel has moved beyond the confines of the
periprosthetic fibrous capsule into the breast tissue and
usually lies adjacent to the implant. The ultrasound
appearance of such a condition is that characteristic of a
snowstorm12 (Fig. 4-9). It is different from the sharply
marginated interface between the implant and the
surrounding breast tissue. Our experience reflects that
such a finding is highly predictive (>98%) of extracapsular
rupture that has been confirmed at surgery.11,12,20 We
believe that the presence of this snowstorm appearance
allows the physician to make the diagnosis of extracapsu-
FIGURE 4-4. AB, Eklund displacement views illustrating the

FIGURE 4-3. Standard mammographic views for screening increased visualization of the breast tissue (A) over the standard
mammogram. A, Craniocaudal view. B, Mediolateral view. compression view as the implant is displaced posteriorly.
Ch04.qxd 11/28/05 1:36 AM Page 151
implant, but there has been no egress of the silicone gel this condition is difficult to establish with certainty
outside the periprosthetic capsule surrounding the because most often these patients do not have any symp-
implant. Because the gel is confined within the peripros- toms and there are no changes in the appearance or feel of
thetic capsule (the rupture is contained within the colla- the breast. With intracapsular rupture the sonogram may
gen envelope surrounding the implant), it is called an show an abnormal reflectance of sound waves, referred to
intracapsular rupture. The prevalence and incidence of as a stepladder sign12 (Fig. 4-10), which is the result of
FIGURE 4-7. Breast sonogram in patient who has had a previ-

ous augment. Note the different signal characteristics at the
interface of the implant and breast tissue. The implant is hypo-
FIGURE 4-5. Breast tissue, which is most obscured by the echoic and marked as xx. The skin is marked as xxxx.
implant, is alongside and posterior to the implant as seen on
these x-ray films.
FIGURE 4-8. The utility of breast sonography is highly opera-

tor dependent. Photograph shows a radiologist carefully per-
FIGURE 4-6. Ultrasound of the breast in patient with a cystic forming a breast sonogram to delineate a lesion. The radiologist
lesion anterior to the breast implant. This method delineates the has taken a history and examined the patient and is focusing the
implant and identifies the breast mass as cystic. examination.
Ch04.qxd 11/28/05 1:36 AM Page 152
sound reflecting off the surfaces of the elastomer shell named the linguini sign13 (Fig. 4-11). It is highly suggestive
that lies within the aggregate of the gel. of intracapsular rupture. I use MRI as my second modality
A more sensitive, specific, and accurate way to image a for establishing the diagnosis of intracapsular rupture and
breast implant, especially with regard to the diagnosis of will order this study if the sonographic evaluation of the
intracapsular rupture, is by using magnetic resonance implant is equivocal or nonconclusive. Our data20 indi-
imaging (MRI).13,14 This modality allows more precise cate that the sensitivity and specificity of MRI exceed 90%
delineation of the elastomer shell, periprosthetic capsule, in the diagnosis of intracapsular rupture, and this is con-
and gel within the implant. In situations where there is a sistent with other findings recorded in the literature.
frank tear of the elastomer membrane, the shell appears to It is most common to use a number of these studies to
become intermingled within the central portion of the gel establish a diagnosis of implant integrity or loss of
and appears as a serpentine group of lines, which has been integrity. I subscribe to the algorithm proposed by Cheung
et al.21 when ordering imaging studies to evaluate a poten-
tial breast implant problem.
Finally, I believe that intracapsular rupture of a silicone
gel implant represents a failure of the implantation device
(and the U.S. Food and Drug Administration [FDA]
defines this as such), and it is my practice to recommend
the removal of such an implant to the patient. However,
at the time of this writing there is no uniformity among
plastic surgeons as to the treatment of this entity. That is
to say, some surgeons will explain the problem to the
patient and give them a major part in any decision to
maintain or remove the implant when an MRI suggests
rupture. Therefore, the ultimate decision to remove or
retain such an implant is a collaborative decision between
the patient and the surgeon.
INDICATIONS FOR EXPLANTATION
Patients request explantation for a multiplicity of condi-

FIGURE 4-9. Characteristic snowstorm appearance of an tions. The primary reasons for implant removal are listed
extracapsular rupture as imaged by breast sonogram. in Table 4-2. The most common indication in my practice
FIGURE 4-11. MRI image of a breast implant that displays an

intracapsular rupture showing the linguini sign. This indicates
FIGURE 4-10. The characteristic stepladder sign of intra- that the shell of the implant has come to lie in the substance of
capsular rupture of a silicone gel implant seen with breast the gel that is contained within the periprosthetic capsule
sonography. around the device.
Ch04.qxd 11/28/05 1:36 AM Page 153
TABLE 4-2 Indications for Explantation If, despite these reassurances, the patient persists with
Rupture
any questions about the severity of constitutional symp-
Symptomatic capsular contracture toms and the presence of other medical problems and
Pain their potential relationship to her implant(s), I will most
Breast distortion often recommend a formal consultation with an internal
Implant malposition medicine specialist for an additional evaluation.
Patient requests change Preferably this referral should be to a well-trained, experi-
Patient anxiety or fear about implant-induced diseases enced internist with special knowledge in rheumatology
who keeps current with the medical literature regarding
silicone gel breast implants.
is that of implant rupture or suspected rupture, which is

normally suggested by a combination of history, physical IMPLANT FAILURE
examination, and most importantly the breast imaging
findings as noted earlier. Additional implant-related prob- Failure of a breast implant means either deflation of a
lems leading to explantation are local pain or discomfort; saline implant or rupture of a silicone gel device. The for-
capsular contracture, which may produce breast distor- mer problem is most often immediately obvious to the
tion; implant malposition; breast asymmetry; and patient patient, who notes a decrease in breast fullness on the
desire for an increase in size. Anxiety about the silicone affected side. A deflation rate of 1% to 2% per year per
gel breast implant is no longer anywhere near as common implant appears to be an accurate description of the cur-
an indication for implant removal as it was in the early rent failure rate for these saline devices.23
part of the 1990s.22 The rupture rate for silicone gel implants is much
To reiterate what we have just discussed, it is impera- more difficult to accurately characterize. This is because
tive for the plastic surgeon to listen carefully to every the majority of these device failures are related to a small
patient with a self-perceived or radiologically established tear in the elastomer shell, after which the gel is con-
problem with a previously placed breast implant and to tained within the periprosthetic scar tissue capsule. This
perform a thorough evaluation of each patient. This evalu- produces the so-called silent or intracapsular implant
ation must be focused on making a diagnosis. I have rupture, which is most often asymptomatic and not
removed implants for all of the reasons cited previously. reported. In addition, the data used to compute silicone
In my experience the most common reasons for removal gel implant rupture prevalence are derived from the
and reinsertion of an implant are actual or suspected patient seeking treatment for new symptoms, changes
implant rupture and advanced (Baker III or IV) capsular noted in breast appearance, or patients presenting after
contracture. an abnormal imaging study of the breast implant.
When encountering patients with anxiety related to a Therefore the sample of patients used in the calculation
previously placed breast implant, it is very worthwhile to of the rupture incidence is a biased self-selected cohort.
spend time being a doctor and reassuring patients about What is needed is a prospective study relying on careful
what has been published in the peer-reviewed medical lit- follow-up examinations and MRI studies. Such data are
erature regarding the safety of silicone implants because in beginning to evolve from at least two of the Scandinavian
all likelihood the patient has been exposed to a lot of countries, namely Denmark24,25 and Finland.
adverse and completely unfounded conjecture about At present it is fair to say that the incidence of silicone
potential side effects of silicone breast implants found in gel implant failure increases with time.26 Many surgeons
the lay press, on the Internet, and in television media.1,22 At believe that the chance of rupture probably approaches
the time of this writing all of the scientific evidence39 50% once the prosthesis has been in place for 12 years or
shows that there is no link between the presence of silicone more.27
in the body and the production of any recognized disease
entity in humans. Also important is the fact that there are
very strong data to show that there is no connection TREATMENT OF IMPLANT FAILURE
between silicone and the production of breast cancer in
humans.7,8 Similarly, several studies have demonstrated When a saline implant deflates, it is immediately apparent
that there is no link between silicone gel and the induction to the patient, who notices less breast fullness. This most
of connective tissue disease.5,6 There are a number of other often rapidly progresses to total deflation. When this situ-
symptoms that patients have been said to complain about, ation is reported to the plastic surgeon early in its course
such as fatigue, hair loss, and skin changes. These also do (within the first several days), the procedure to replace the
not appear to be related in any sort of a consistent or implant is straightforward and can most often be done
cogent way to the presence of a silicone gel breast implant. through a small incision under local anesthesia. Minimal
Ch04.qxd 11/28/05 1:36 AM Page 154
capsulotomy incisions (or none at all) in the capsule are breast tissue. Occasionally a small portion of the PMM
all that is needed if the problem is addressed promptly. may require resection if a subpectoral implant rupture has
When such an event is neglected or not reported for occurred, producing an extracapsular granuloma involv-
even 1 week, the capsular tissue begins to contract. This ing the muscle tissue.
sets up a situation where multiple capsulotomies or cap- Total periprosthetic capsulectomy can be carried out
sulectomies and increased dissection are necessary to using either an inframammary (IM) or a periareolar inci-
restore the dimensions of the periprosthetic space. Such a sion, though the latter is far more difficult. It cannot (and
procedure usually requires a general anesthetic, and the should not) be done using an axillary incision. My stan-
use of a drain may be involved. Therefore, after I inform dard approach is to use a pre-existing IM incision (Fig. 4-
all of my patients about the rupture rate of saline 12). It is usually necessary to make such incisions
implants, I tell them that should such an event occur, they considerably longer (Fig. 4-13) than the previous incision
should report it as soon as possible to minimize the degree used for breast augmentation. This should be explained to
of surgery necessary to replace the implant. the patient preoperatively.
Rupture of a silicone gel implant requires implant If there is a planned mastopexy, which will entail either
removal and removal of as much of the silicone as possi- a vertical or an inverted T (Wise) incisional pattern, the
ble. For an intracapsular rupture a total periprosthetic
capsulectomy (TPPC) essentially removes the gross sili-
cone. This then allows placement of a new implant, either
a silicone or saline device. An intracapsular rupture has
already been cited in the literature28 as an indication for a
TPPC (see below).
The situation of an extracapsular rupture is often a lit-
tle more involved in terms of the procedure needed to
remove the silicone. There is often a silicone granuloma,
which is an aggregate of scar tissue adjacent to the
periprosthetic capsule or within the breast tissue. This sit-
uation requires both a TPPC and resection of the silicone
granuloma, which may require a sacrifice of breast tissue.
In this situation I always mention to the patient that it
may be impossible to remove all of the silicone from her
breast tissue. Therefore, the possibility of residual silicone
in the breast tissue exists, and this may represent a nidus
for additional scar tissue deposition, resulting in a sili- FIGURE 4-12. The customary approach is to use a previous
inframammary incision to perform the implant removal.
conoma or a mass in the breast that requires a workup
and most likely another surgical procedure for excision.
MANAGEMENT OF THE
PERIPROSTHETIC CAPSULE
After explantation is elected the surgeon must decide

whether to perform a complete capsulectomy at the time
of implant removal. In my practice I do this in almost
every case when a silicone gel implant is removed. Overall
I subscribe to the guidelines espoused and published by
Young28 in making decisions regarding capsulectomy.
The operation is routinely done (and best tolerated)
under general anesthesia. The procedure virtually always
involves a meticulous dissection of the periprosthetic cap-
sule away from the surrounding breast tissue. It is unusual
and generally unnecessary to sacrifice breast tissue unless
there is evidence of extracapsular rupture that has pro-
duced silicone granuloma(s), in which case the resection FIGURE 4-13. Often the inframammary incision must be
of these extracapsular masses might include some breast made considerably larger to provide the necessary exposure for a
tissue, usually in the form of a small rim of the adjacent complete capsulectomy.
Ch04.qxd 11/28/05 1:37 AM Page 155
capsulectomy can be performed through the vertical inci- the indications for capsulectomy as outlined by Young.28
sion, which can be extended superiorly in continuity with I believe that the periprosthetic capsule should be entirely
a portion of either a lateral or medial periareolar incision removed when there is evidence of a silicone gel implant
(Fig. 4-14). In such a situation the new nipple position is rupture to diminish the possibility of silicoma formation. In
established first. Although this is usually above the upper any situation where an implant is strongly suspected to be
margin of the existing areolabreast skin junction, the ini- ruptured, complete or total capsulectomy is the best way of
tial incision must be kept below this point (Fig. 4-15). removing all of the gross silicone and preventing or mini-
Next a line is drawn along either the medial or lateral are- mizing any potential for silicone spill into the breast tissues
olar border and is extended tangentially toward the IM or the occurrence of residual silicone in the breast tissues.
fold area in the midmeridian of the breast (perpendicular I try to perform as much of the dissection as possible with
to the IM fold) in a vertical orientation (see Fig. 4-15). the implant within the capsule because I believe that this
Some adaptation of these incisions will be used for either facilitates the dissection. I also try to deliver the implant with
a vertical or inverted T mastopexy. This unusual approach the surrounding capsule intact, which also limits the possi-
tremendously facilitates the surgical exposure for the bility of residual silicone in the breast tissues (Fig. 4-17).
TPPC (see Fig. 4-14). Following completion of the TPPC In addition, a TPPC should be performed if the capsule
and implant removal, either a mastopexy alone or an aug- is thick or calcified (Fig. 4-18), when an established sili-
mentation mastopexy can be completed in a straightfor- cone granuloma is to be removed, when there is infection
ward manner using the tailor-tacking method of around an implant, and when there is carcinoma adjacent
estimating breast shape (Fig. 4-16). to the implant. More common indications in my practice
As noted, in general I prefer to remove as much of the are for the treatment of a Baker III and Baker IV capsular
periprosthetic capsule as possible unless there is an contracture or when exchanging a smooth device for a
anatomic or surgical reason not to. I agree in general with textured implant regardless of the degree of capsular
FIGURE 4-14. Use of a vertical incision to facilitate a total periprosthetic capsulectomy in a patient
who will have a mastopexy as part of her treatment. This provides optimal exposure for the explantation.
Ch04.qxd 11/28/05 1:37 AM Page 156
contracture. Finally, polyurethane-covered implants are

best removed by performing a TPPC.
In all cases surgical judgment must be exercised when
deciding to perform a complete capsulectomy because at
times it may be ill-advised to perform a TPPC procedure.
The most common example of this is when there is any
evidence of significant attenuation of the overlying
breast tissue. In such cases the dissection necessary to
complete the TPPC might lead to compromise in the vas-
cularity of the overlying skin tissues; wound breakdown;
and, if an implant replacement is requested by the
patient, implant exposure and ultimately implant loss.
This can occur in situations of long-standing subglandu-
lar breast implantation complicated by severe capsular
contracture with markedly thin overlying tissues. More
commonly, however, the circumstance of thin overlying
soft tissue with adherence of the implant to the tissue is
noted in the setting of a previous subcutaneous mastec-
tomy with implant reconstruction. This setting poses a
separate set of problems, especially if multiple incisions
have been made on the breast to diagnose breast
parenchymal lesions. Such a patient may be particularly
FIGURE 4-15. In designing mastopexy incisions the vertical
incision should hug the areolar margin and should not be
vulnerable to skin breakdown following a TPPC, and
extended more superiorly than the upper margin of the areola. hence it may be advisable to leave portions of the capsule
beneath the skin intact (Fig. 4-19). This situation is
FIGURE 4-16. The tailor-tacking maneuver is an ideal way to optimize breast parenchymal shape and
to estimate the amount of skin to be excised.
Ch04.qxd 11/28/05 1:37 AM Page 157
illustrated by the patient shown in Figure 4-20, who pre-

sented to the office with left breast discomfort, a pro-
gressive deformity of the inferior pole of the breast, and
the MRI findings of an extracapsular rupture of a sili-
cone gel breast implant placed 26 years earlier as a form
of reconstruction after a subcutaneous mastectomy
(Fig. 4-20). Her treatment entailed an incomplete ante-
rior capsule resection so as to limit the possibility of
damaging the skin on the lower pole of the breast.
Suffice it to say, surgical judgment regarding treatment
of an established periprosthetic capsule must be exercised
for each individual patient who undergoes breast implant
removal.
FIGURE 4-19. Explanted specimen in patient in Fig. 4-20.

Note a portion of the anterior periprosthetic capsule has been
left behind (arrow) to limit the possibility of injury to the skin of
the breast.
FIGURE 4-17. Delivered breast implant with surrounding

periprosthetic capsule.
FIGURE 4-18. This explant specimen shows severe calcifica- FIGURE 4-20. Previous subcutaneous mastectomy patient
tion in the periprosthetic capsule. It is especially important to who shows marked adherence of her breast skin to the capsules
remove such calcified capsules. in the inferior aspect of both breasts (arrow).
Ch04.qxd 11/28/05 1:37 AM Page 158
TECHNIQUE OF CAPSULECTOMY
A capsulectomy is most easily performed using a generous

incision, a headlight and/or a lighted retractor for illumi-
nation of the breast wound, and the electrocautery device.
Using the cautery (in coagulation mode) will allow a sepa-
ration of the tissues at the capsulebreast tissue interface
and prevent injury to the implant. I use a Valleylab
(Valleylab, Boulder, Colo) electrocautery unit with the
coagulation mode set to 30 or 35.
The previous incision is reopened by excising the skin
scar. If an IM incision has been made, it most often needs
to be extended as mentioned earlier. The dissection is
deepened through the subcutaneous tissue and breast tis-
sue by inclining the plane of dissection slightly cephalad
so as not to inadvertently lower the IM fold and level of
the implant. The layer of the periprosthetic capsule is eas-
ily identified because it has a slightly bluish hue. The
plane between the capsule and surrounding tissue is
developed initially with the electrocautery set to coagula- FIGURE 4-21. Diagram illustrating the incorrect (A) and
tion mode with illumination provided by a headlight or correct (B) way of performing finger dissection to achieve
lighted retractor. periprosthetic capsule removal.
When the IM incisional approach is used, the most dif-
ficult aspect of the capsulectomy procedure is the dissec-
tion over the top of the implant, where visibility is difficult the capsular tissue. The latter is usually the preferred
despite the use of multiple retractors and adequate illumi- option, and it can be done with minimal to no silicone
nation. This is often best accomplished by careful digital gel spilling.
dissection to separate the planes in this location. The sur- More commonly the problem is an inadvertent capsu-
geon must be careful when using digital dissection to not lotomy with leakage of the silicone gel. Suture repair of
create false passages into either the inside of the capsule this small capsular rent with a 4-0 chromic suture on a
itself or the breast tissue. Using the technique illustrated noncutting needle can be attempted. In my hands this is
in Figure 4-21, the surgeon places his or her gloved index often unsuccessful, and I then find it necessary to perform
fingernail on the capsule and presses down on the encap- a formal capsulotomy with a Bovie (Bovie Medical Corp.,
sulated implant. The edge of the surgeons fingernail is St. Petersburg, Fla) on coagulation mode or the electro-
used in a manner similar to a periosteal elevator. The cautery device (Valley Lake, Colo) by extending this small
breast tissue is thereby elevated above the capsule with rent in the capsule and removing the contents of the cap-
the fingernail from the dome anteriorly extending superi- sule, namely the silicone gel and elastomer shell. Before
orly to the superficial cephalic margin of the capsule edge. executing this maneuver the surgeon should have a kidney
This method of dissection may not be possible when frank basin in the operative field, along with a suction device, to
extracapsular rupture is present because the planes may most expeditiously remove the free silicone material. It is
be sticky in this circumstance. Most often I have found usually a good idea to change surgical gloves and some-
this maneuver very helpful in performing the dissection times the surgical instruments if they have been exten-
on the upper part of the implant from an IM incision. sively coated with silicone. Following the removal of this
When the capsule has been completely freed from the sur- material the remainder of the capsulectomy is completed,
rounding breast tissue, the capsule-encased implant will again with care being taken to remove capsular tissue only,
have achieved a significant amount of mobility. At this while preserving breast and PMM tissue. Hemostasis
point it can usually be delivered through the wound below should be sought and obtained as the capsular tissue is
(see Fig. 4-19). removed and the interface of the muscle or breast tissue
Occasionally the implant cannot be delivered has a chance to retract. I find that using the capsular tis-
through the wound below because of its size, degree of sue as a handle prevents retraction of the breast
encapsulation, or amount of calcification surrounding parenchyma and muscle tissue deep within the wound
it. At this point there are two options, namely to either (superiorly and laterally). Therefore, meticulous hemosta-
make the skin incision (which is longer than the previ- sis should be obtained before completely delivering the
ous skin incision) longer still or to perform a capsulo- capsule. A suction drain (10-mm Jackson-Pratt [Ethicon,
tomy and remove the implant contents before removing Inc., Somerville, NJ]) is placed in all cases.
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SUMMARY STATEMENT TABLE 4-3 Treatment Options Following Explantation

ON CAPSULECTOMY Explantation alone
Explantation with implant reinsertion
Is it necessary to remove the entire capsule? It is helpful to Mastopexy alone
remove the capsular tissue completely, especially in the Mastopexy plus new implant placement
situation of implant rupture. But it is not imperative that Autogenous conversion
all of this periprosthetic scar tissue be removed in every
case. This pertains most often to the area of the posterior
capsule in cases of previous subpectoral implantation insertion of new implants is by far the most commonly
where the capsule may be quite adherent to the chest wall. requested option.21 Explantation alone is the next most
It is important to avoid injury to the cartilage, rib, or inter- commonly requested procedure, but it is relatively rare
costal musculature of the chest wall or risk the production among patients less than 50 years of age.
of a pneumothorax while removing the capsular tissue. As
implied, the surgeon will encounter the occasional case
where the planes are very indistinct, and in these situa- EXPLANTATION ALONE
tions it is better to leave small areas of capsular tissue
adherent to the chest wall than to risk chest wall injury. As In my experience the option of explantation alone is cho-
previously noted, the same holds true for patients with an sen by approximately 20% of patients undergoing breast
extremely thin layer of breast tissue and skin where the implant removal. It produces a significant change in the
assiduous removal of capsular tissue might result in dam- patients body image, and it is imperative that this be com-
age to the overlying skin. This situation is most commonly municated to the patient preoperatively. The surgeon
encountered in the setting of a previous subcutaneous should have a firm belief that the patient clearly under-
mastectomy where the majority of the breast tissue has stands this and is willing to accept this drastic change in
been removed. An additional hazard for producing tissue her appearance.
loss is the presence of scars on the breast skin from previ- In my experience this option is most often chosen by
ous biopsies that are commonly seen in patients who have patients who are slightly older (>50 years), are psychologi-
undergone subcutaneous mastectomy. cally stable and well-adjusted individuals, and have most
Finally, it may be helpful to maintain remnants of the often been in long-term marital relationships. Even in this
capsule to use in a capsular flap repair (Chapter 3) or to subset of patients, the effect of explantation without new
serve as a better anchor for sutures used for a capsulor- implant insertion can precipitate feelings of depression. If
rhaphy technique when it is necessary to alter the dimen- there is concern on the part of the surgeon preoperatively
sions of the periprosthetic capsular space. This is that professional psychological support may be needed,
particularly important when the surgeon needs to either such arrangements should be undertaken preoperatively
raise the level of the lower pole of the implant or position or instituted early postoperatively if depression becomes
the implant in a more medial location by closing down the clearly evident.
lateral periprosthetic capsular space with sutures. As noted, the technique of explantation most often
involves lengthening the incision used to place the
implant. The procedure is most readily accomplished
TREATMENT OPTIONS FOLLOWING through an IM incision (unless the areolas are very large),
EXPLANTATION and it should not be done through an axillary approach
unless the surgeon is removing saline implants and does
Treatment options for patients who desire or require not plan to perform a capsulectomy. In the latter case the
explantation are as follows: explantation alone without the use of the endoscope can facilitate implant identification
placement of new implants, explantation with reinsertion and removal. Capsulectomy in this setting is not neces-
of new breast implants (most often saline, but in the sary, and therefore this approach is reasonable. As previ-
United States such patients are candidates for replacement ously described, a capsulectomy procedure is greatly
with silicone gel implants under the FDA adjunct study of facilitated with the use of a headlight and lighted retrac-
silicone-filled breast implant protocols), mastopexy alone tor. The dissection is best done with the electrocautery
without new implant placement, mastopexy done at the using the coagulation setting. Following implant removal
time of the reinsertion of new implants (augmentation a suction drain is placed. I believe that it is important to
mastopexy), and autogenous conversion. The latter option remove as much of the capsule as safely possible, espe-
is most often (almost exclusively) performed in patients cially in the setting of implant rupture, because the com-
who have undergone previous implant-based breast recon- bination of free gross silicone gel and retained capsular
struction. These options (Table 4-3) must be individualized tissue can predispose the patient to siliconoma forma-
for the specific patient and her needs. In my experience the tion. The drain is left in place until it drains less than 30
Ch04.qxd 11/28/05 1:37 AM Page 160
cc in a 24-hour period. I find it especially important to (Figs. 4-22 and 4-23). Her implants had become progres-
adhere to this policy in this setting because there is no sively firmer and uncomfortable, especially when she lay
potential tamponade effect provided by a breast implant, on them while sleeping. A sonogram suggested intracapsu-
and chronic seroma formation is a more likely possibility lar rupture of the left breast implant. Her preoperative
following explantation without implant reinsertion. examination demonstrated Baker IV capsular contracture,
A typical example of a patient electing explantation but the breasts were relatively symmetric (Fig. 4-22A,B).
without new implant placement is this 63-year-old The patient decided to have her implants removed and did
woman who had undergone bilateral subglandular breast not wish to have replacement. This produced the expected
augmentation with silicone gel implants 26 years earlier significant change in her breast appearance (Fig. 4-23A,B).
FIGURE 4-22. Preoperative AP (A) and oblique (B) views of patient with hard, painful subglandular
silicone gel breast implants that were inserted 26 years before.
FIGURE 4-23. AB, Patient elected to have bilateral explantation without new implant insertion.
Photos show the expected dramatic change in her breast appearance with complete lack of fullness.
Ch04.qxd 11/28/05 1:37 AM Page 161
EXPLANTATION WITH IMPLANT

REINSERTION
My experience over the past decade reflects the fact that

implant reinsertion is the most commonly chosen option
following explantation. In my practice approximately two
thirds of patients choose this option. It is by far the most
popular choice in patients less than 50 years of age who
have become accustomed to and enjoy the breast fullness
provided by implants. Patients in this age group most
often wish to maintain breast fullness after implant
removal.
Replacement implants can be either silicone gelfilled
or saline-filled devices. In the early 1990s this procedure
most commonly entailed the removal of a silicone gel
implant and replacement with a saline implant. This was
largely because of the public hysteria surrounding silicone
gel implants.1,23 Most recently many patients in my prac-
tice are requesting new silicone gel implants as replace-
ment devices. Regardless of which implant is chosen, every
patient is clearly informed that any replacement implant is
unlikely to last the course of her lifetime. That is to say that
implant shell disruption is a likely event at some point in
time. Patients are informed that the two most common
long-term complications of implant placement are capsu-
lar contracture29 and the need for reoperative surgery
(20% at 5 years).23 In addition, the known risks and com-
plications associated with the placement of breast
implants (outlined in Chapter 3) are carefully reviewed.
Initially the replacement saline implants were placed in
the same position as the silicone implants that were
removed. However, it soon became apparent that in FIGURE 4-24. The pinch test is done to allow the surgeon to
patients with an insufficient amount of their own breast estimate the amount of breast tissue in the upper aspect of the
tissue, new implants placed in the subglandular position breast. It is important to do this in both primary and secondary
often showed signs of implant visibility, including ripples, cases involving breast implants.
ridges, and discernible edges of the implant. It is now very
apparent that patients who desire their replacement saline
implants be placed in the subglandular position must
have adequate tissue padding. It is necessary for the sur-
geon to make a determination preoperatively by using a saline implant selection is based on a patients dimensions
variation of the pinch test maneuver30 (Fig. 4-24) and requires careful measurement of the base width of the
described in Chapter 3. The surgeon must carefully pal- breast, the height of the breast, and the distance from the
pate the breast parenchyma overlying the implant by NAC to the IM fold (see Fig. 3-2).
grasping the tissue between the thumb, index, and middle In the absence of performing a mastopexy, when a
fingers (Fig. 4-24). I believe that a minimum of 2 cm of tis- new implant is placed into the same position as the
sue must be present to permit subglandular placement of implant that has just been removed, the new implant is
a new saline implant. If this is not the case, then the sub- generally slightly larger in size (dimension and volume)
pectoral placement of the new implant is preferable. than the previous indwelling implant. This is because the
When adequate tissue padding is present to allow dissection entailed with capsulectomy and implant
implant placement in the subglandular space and the removal always increases the dimensions of the peripros-
patient desires a saline-filled device, my preference is to thetic space to some degree. It is important to point this
use a smooth-surfaced implant filled 10% to 30% beyond out to the patient preoperatively. When using a saline
the manufacturers maximum suggested fill volume. This implant as the replacement device following removal of a
is the best way to minimize the tendency for rippling silicone gel implant, I believe that it is important to avoid
along the edge of the implant. As noted in Chapter 3, implantpocket disproportion, i.e., to relatively precisely
Ch04.qxd 11/28/05 1:37 AM Page 162
fill the dissected pocket with the new implant. As stated sular space modification and PMM elevation proce-
in Chapter 3, I believe that this is an important factor in dures with electrocautery. A multiple-layered wound
minimizing the problem of rippling or visible folds closure with polyglycolic acid suture is used, and a suc-
related to the saline implant placement. tion drain is always placed. This is introduced through
If the removed implant was originally in the subglan- a laterally positioned stab incision, which when possi-
dular position and the new implant is positioned in the ble is located in the shadow of the breast in the position
retropectoral location, it is important to close down the of the bra line. I prefer to use a 10-mm Jackson-
subglandular plane by suture fixation of the PMM to Pratt or BLAKE drain (Ethicon, Inc., Somerville, NJ).
the overlying breast parenchyma (Fig. 4-25A,B). This The drains are maintained in position until the out-
provides the best assurance that the implant will put from the drain is less than 30 cc per 24 hours. While
remain in the submuscular position and not slip back the drains are in place the patient is kept on oral antibi-
into the subglandular space. This is especially impor- otics and is instructed to keep the drains clean and
tant if a smooth-walled saline implant is used. Suture dry. Patency of the tubing is facilitated by stripping or
closure of the space is easily accomplished with 3-0 milking the drainage tube several times each day.
coated polyglycolic acid sutures on a noncutting Drainage through the Jackson-Pratt drains of more
needle [PDS (Ethicon, Inc., Somerville, NJ) or Maxon than 30 cc per day often persists for 10 to 14 days
(Sherwood-Davis & Geck, St. Louis, Mo); Fig. 4-25B]. It postoperatively.
is important not to dimple the overlying skin tissue with Drains are important to prevent seroma accumulation
this suture placement in patients with very thin breast and minimize the development of a biofilm around the
parenchyma. implant, thereby allowing the best chance of healing
As mentioned, I believe that most of the capsulec- between the newly placed implant and the adjacent tis-
tomy dissection is best performed with the electro- sue interface. This is especially important if a textured-
cautery device using the coagulation mode, along with surface implant is used. Following drain removal the
some element of digital dissection. The Bovie enables patient is permitted to shower and she is instructed to
the surgeon to achieve optimal hemostasis. Similarly, it wear a bra 24 hours a day for breast support for the ensu-
is my custom to perform additional periprosthetic cap- ing 4 weeks. Additionally, the patient is asked to avoid
FIGURE 4-25. Surgical maneuver to suture close the subglandular space in cases in which there will
be a conversion of a subglandular to a subpectoral implant position. This is shown diagrammatically
(A) and in the operating room in the accompanying photo (B).
Ch04.qxd 11/28/05 1:37 AM Page 163
any bouncing activities for a total of 6 weeks. This is

done to minimize the risk of delayed hematoma forma-
tion or the possibility of seroma fluid accumulation
around the implant. If a smooth-walled implant is used,
the displacement exercises outlined in Chapter 3 are
instituted 2 days following drain removal, and they are
continued forever.
In my opinion the easiest and best way of optimizing
breast aesthetics following implant removal in most
patients is by implant reinsertion. This involves the
minimum number of incisions, and the ones that are
made are most often concealed. The typical case scenario
is illustrated by the following three cases.
This first patient presented 11 years after undergoing
a subglandular silicone gel breast augmentation with a
Baker IV capsular contracture of the right breast
implant. She was bothered by the distortion of the breast
and the associated discomfort (Fig. 4-26) and requested a
surgical procedure to improve the appearance of the
breasts. She underwent a bilateral TPPC and removal of
her severely encapsulated implants through an IM inci-
sion. She had the placement of new smooth-walled sili-
cone gel implants placed in the subpectoral implants.
These were 300-cc regular-profile implants with a base
width of 12.1 cm. This procedure produced a good
restoration of symmetry, a return of softness to the
breasts, and an overall excellent appearance to the
breasts (Figs. 4-27A,B and 4-28A,B), albeit with a longer
IM incision (Fig. 4-29).
FIGURE 4-27. Preoperative (A) and postoperative (B) AP views

at 2 years.
FIGURE 4-26. Baker IV capsular contracture in right breast 11

years following subglandular silicone gel breast augmentation
with obvious distortion and asymmetry.
Ch04.qxd 11/28/05 1:37 AM Page 164
FIGURE 4-28. Preoperative (A) and postoperative (B) lateral views at 2 years.
FIGURE 4-29. The patient has a longer but almost impercepti-

ble IM incision.
Ch04.qxd 11/28/05 1:37 AM Page 165
This next patient was referred by the radiology depart- had a previous subglandular silicone gel breast augmenta-
ment after a mammogram and sonogram of the breasts tion with smooth-walled implants. She was found to have
suggested an extracapsular rupture of a previously placed probable extracapsular rupture of her right breast implant
subglandular silicone gel breast implant (Fig. 4-30A,B). on a sonogram done 16 years after the procedure. She had
She underwent TPPC and removal of both the capsules a Baker IV on the left side as well (Fig. 4-33A,B). After con-
and the previously placed implants (Fig. 4-31). She then siderable deliberation she underwent removal of her
had the insertion of saline implants placed in the subpec- implants without reinsertion (Fig. 4-34A,B). She was
toral position. Before assigning the implants to the new bothered by the change in her breast appearance and 3
position, the subglandular space was closed with sutures. years later she underwent redo breast augmentation with
This treatment produced a marked improvement in overall 360-cc smooth-walled saline implants placed in the partial
breast aesthetics (Fig. 4-32A,B). retropectoral position (Fig. 4-35A,B). This case illustrates
The final patient illustrates the point that, occasionally, that patients who have undergone explantation following
a patient will undergo explantation initially without a breast augmentation initially without reinsertion of new
implant reinsertion and then at a later date she may elect implants always have subsequent breast implant place-
to have breast implants replaced. This 45-year-old patient ment as an option.
FIGURE 4-30. This is a 44-year-old female 9 years following bilateral subglandular silicone gel aug-
mentation mammoplasty with bilateral capsular contracture and suspected rupture of her right breast
implant. A, AP view. B, Lateral view.
Ch04.qxd 11/28/05 1:38 AM Page 166
FIGURE 4-31. A, Preoperative skin markings for palpable mass in the upper outer aspect of her right
breast. B, Explantation specimen with silicone granuloma resected in continuity with capsule of right
breast implant.
FIGURE 4-32. Very satisfactory aesthetics restored by reinsertion of silicone gel implants into sub-
pectoral position. A, AP view. B, Lateral view.
Ch04.qxd 11/28/05 1:38 AM Page 167
FIGURE 4-33. This 45-year-old patient presented 16 months after previous bilateral silicone gel aug-
mentation. She had bilateral Baker III capsular contracture and suspected rupture of right breast
implant. A, AP view. B, Oblique view.
EXPLANTATION WITH MASTOPEXY sponding increase in the patients breast volume to the
ALONE point where explantation with mastopexy alone (without
new implant insertion) becomes a feasible and realistic
Often the plastic surgeon encounters patients who had option. This plan almost always provides a satisfactory
their breast implants placed in their late teens or early breast shape, albeit with scars in either a vertical
twenties and who present for evaluation of an implant mammaplasty or an inverted T incisional pattern.
problem in their late thirties or early forties. In the inter- The surgeon must carefully evaluate the patient preop-
vening 15 to 20 years many of these patients have gained a eratively to determine the amount of breast parenchyma
significant amount of weight (20 to 30 lb) since their present. This is done by distracting the breast tissue away
breast augmentation. Most often there will be a corre- from the implant with the examiners fingers (Fig. 4-36).
Ch04.qxd 11/28/05 1:38 AM Page 168
FIGURE 4-34. Patient had explantation alone, which resulted in a decreased breast size. A, AP view.
B, Oblique view.
FIGURE 4-35. Patient had a delayed subsequent redo breast augmentation with smooth-walled saline
implants placed into the subpectoral position. This produced a very nice appearance of the breasts.
A, AP view. B, Oblique view.
Ch04.qxd 11/28/05 1:38 AM Page 169
FIGURE 4-37. The presence of a subglandular implant signifi-

cantly decreases the blood supply to the NAC. The surgeon must
bear this in mind when planning a mastopexy in the setting of a
previous subglandular breast augmentation.
FIGURE 4-36. Method of evaluating the volume of a patients

own native breast tissue in the presence of a previous breast
augmentation. position is the most important step. After a previous breast
augmentation the nipple position may be too high, too low,
or appropriate. Precisely establishing the new nipple posi-
tion before the explantation is tricky due to the anticipated
This is the best method of estimating the volume of breast decrease in breast volume. However, an estimate must be
parenchyma and also the best way to evaluate it for breast made, and the apex of the vertical incision used for the
pathology. The surgeon can then demonstrate to the explantation (in fact for all incisions) should be kept below
patient how much breast tissue is available to recreate the this position (see Fig. 4-15). The only mistake that the sur-
breast without replacing the implant, emphasizing that geon must avoid is placing the initial incisions used for the
the new breasts will be smaller. explantation portion of the procedure too high. My experi-
If the patient is content with a smaller size and will ence is that the nipple position can be estimated by meas-
accept more extensive scars on the breasts, then explanta- uring the proposed new nipple from the fixed point of the
tion with mastopexy alone is an option. In my practice SSN. The surgeon can measure between 21 and 25 cm
mastopexy in this setting can be done using either a verti- from the SSN depending on the patients height in inches,
cal incision technique or an inverted T incisional pattern. as indicated in Table 4-4.
With either option a vertical incision between the areola I use these distances as estimates only. The final estab-
and the IM fold is part of the operative approach (see lishment of the nipple position is best done after the
Fig. 4-14). This vertical incision provides excellent expo- explantation and reconfiguration of the breast tissue with
sure for performing a complete capsulectomy. A small the patient sitting up at 90 degrees on the operating table.
portion of one side of a periareolar incision can be used as This is the position that is necessary to make an accurate
part of the incision for capsulectomy. estimate of appropriate nipple position.
Regardless of approach, careful pedicle selection with The breast tissue should be reconfigured to produce
a plan to maximally preserve nipple areola blood supply is the best possible shape by narrowing the base dimension
paramount. In most instances the surgeon can choose and optimizing projection of the breast. This usually
between a superior, inferior, medial, or lateral pedicleor entails central transposition of de-epithelialized segments
combinations of these. Once again a word of caution is in of lateral and medial breast tissue (see Fig. 4-35A) or clo-
order. That is, the surgeon must be very wary of perform- sure of medial and lateral pillars, which narrows the base
ing an aggressive mastopexy with a significant nipple dimension of the breast and increases breast projection.
transportation if a subglandular augmentation has been This is coupled with tailor tacking of the breast skin.
performed due to its interference with nipple areola blood Alternatively, projection of the smaller, uplifted breast
supply (Fig. 4-37). This warning goes double in a smoking mound may be optimized with a superior pedicle
patient, where the danger of tissue necrosis is extremely mastopexy technique (using either a vertical or an
great with this approach. inverted T skin incision pattern) using a de-epithelialized
Once the decision is made to proceed with a mastopexy inferiorly based rectangular flap of subcutaneous and
following explantation, establishing the correct new nipple breast tissue (Fig. 4-38) as a foundation on top of which
Ch04.qxd 11/28/05 1:38 AM Page 170
TABLE 4-4 Estimating Nipple Position Based on

Patient Height
Patient Height (in) Distance from SSN to Nipple
(cm)
5862 21
6266 2223
6670 2425
7072 2526
SSN, Suprasternal notch.
the superior pedicle is seated (Fig. 4-39). These are stan-

dard maneuvers to improve breast shape and increase
projection when revising a mastopexy or a breast reduc- FIGURE 4-38. Autoaugmentation of the breast can be achieved
following explantation when mastopexy is planned without a
tion and will be reviewed in Chapter 5. new implant. An inferiorly based rectangular flap of skin and
Examples of the previous surgical approach for an subcutaneous tissue and breast tissue is de-epithelialized and
inverted T and vertical scar mastopexy are illustrated by mobilized to its pedicle.
the following case. This patient presented at age 45 with a
suspected rupture of her right breast implant after a mam-
mogram and sonogram of the breasts. She had undergone
a bilateral subglandular breast augmentation using an
infra-areolar incision for postpartum involutional change
of the breasts at age 27. She had gained approximately 25
lb over the 17 years and her breasts were a D cup in size
and exhibited grade II mammary ptosis (Fig. 4-40A,B).
The plan was for implant removal and mastopexy alone
using an inverted T incisional pattern. The TPPC was per-
formed through the vertical incision while excellent expo-
sure was afforded during that part of the procedure
(Fig. 4-41). Because of the infra-areolar incision, a supe-
rior pedicle technique was selected for the mastopexy. The
tissue inferior to the areola was de-epithelialized and
served as a platform on top of which the reconfigured
breast tissue was seated. A tailor-tacking procedure was
FIGURE 4-39. This flap can be inserted beneath a superior
used to establish the final incisions (Fig. 4-42A,B), and the pedicle used for a mastopexy to increase the projection and
NAC was positioned at the appropriate height. The patient apparent volume of the breast. The flap is tacked to the chest
exhibited smaller but well-shaped symmetric and aesthet- wall with 3-0 PDS suture.
ically pleasing breasts postoperatively (Fig. 4-43A,B).
The vertical scar mammoplasty32,33 has increasing
application in this setting, as illustrated by the following
patient who requested explantation for symptomatic cap- pedicle vertical mastopexy. The skin inferior to the areola
sular contracture (Fig. 4-44AC). Twenty-two years before was de-epithelialized and the subcutaneous tissue and
her consultation she underwent a bilateral subglandular breast parenchyma of the central lower breast was folded
augmentation. She did well for many years and was up underneath the nipple and areola (Fig. 4-46) to maxi-
pleased with the result. She experienced an interval weight mize upper breast volume. Closure of the medial and lat-
gain of 15 lb and eventually developed a Baker III capsular eral pillars optimized upper pole fullness (Fig. 4-47). She
contracture on the right side and a Baker IV on the left, exhibited a very satisfactory result at 2 years following
which was marked by discomfort in the left breast. She surgery (Fig. 4-48AC). The advantages of this technique
requested implant removal and desired a decrease in are that it both minimizes the skin scars and in my opin-
breast size and a breast uplift. She was marked for a supe- ion optimizes shape. This is because of the suture fixation
rior dermoglandular vertical mastopexy (Fig. 4-45). of the pillars of the breast parenchyma. It is a good tech-
She underwent a total periprosthetic capsulectomy nique for patients desiring an uplift only following explan-
done through the vertical incision and had a superior tation.
Ch04.qxd 11/28/05 1:38 AM Page 171
FIGURE 4-40. A-B, 45-year-old patient with large, dependent, subglandular silicone gel implants
inserted through an infra-areolar incision into the subglandular space. She presented with bilateral
capsular contracture.
FIGURE 4-41. A mastopexy without new implant insertion is FIGURE 4-42. A-B, Tailor tacking of the parenchyma and skin
planned. The explantation is performed through the anticipated is done to estimate optimal shape of the gland for mastopexy and
vertical incision of the mastopexy. to guide skin excision.
Ch04.qxd 11/28/05 1:38 AM Page 172
FIGURE 4-43. Postoperative appearance at 9 months demonstrates excellent breast shape and sym-
metry. A, AP view. B, Oblique view.
FIGURE 4-44. Preoperative appearance of patient who had a

subglandular silicone gel breast augmentation 15 years earlier.
She has gained 15 lb, has bilateral Baker III capsular contrac-
ture, and desires explantation and mastopexy only without new
implants. A, AP view. B, Lateral view. C, Oblique view.
Ch04.qxd 11/28/05 1:39 AM Page 173
FIGURE 4-45. Marking is done for superior dermoglandular

pedicle vertical mastopexy.
FIGURE 4-46. Operative photograph following explantation

and elevation of a superior and medial pedicle.
FIGURE 4-47. Closure of the pillars and reshaping of the

breast.
Ch04.qxd 11/28/05 1:39 AM Page 174
FIGURE 4-48. Two years postoperative photographs demon-

strate a satisfactory appearance on, A, AP, B, lateral, and C,
oblique views following this vertical mastopexy.
Ch04.qxd 11/28/05 1:39 AM Page 175
EXPLANTATION WITH AUGMENTATION

MASTOPEXY
As previously noted, most women who experience a prob-

lem with their implant(s) that necessitates removal wish to
retain their breast fullness. This is also true for patients who
have the additional problem of settling of their breast tissue
away from the implant, producing the appearance of ptosis.
In these patients redo breast augmentation combined with
mastopexy is most often the treatment of choice.
The principles of this approach have been discussed in
the previous three sections and include a careful plan for
accurate positioning of the nipple and selecting the appro-
priate pedicle to carry it to its new position. In addition,
management of the new implant placement is important.
The options for implant reinsertion include maintain-
ing it in its original position and placing it in a new posi-
tion by reassigning it to a different position. When
operating to treat a ruptured prosthesis, if the implant
was in the subglandular position and there is sufficient
breast tissue overlying it and if there is more than 2 cm of
padding tissue, it may be feasible to maintain the implant
in this position. The same is true when the previous
implant was in the subpectoral space. However, if there is
insufficient or attenuated breast tissue, or if the procedure
is being done to treat capsular contracture, then a pocket
reassignment, i.e., converting a previous subglandular
implant to the subpectoral position before performing a
mastopexy, is often an advisable strategy.
Most often this maneuver involves relocating a previous
subglandular implant to the subpectoral position, which
entails releasing the origin of the PMM from the ribs inferi-
orly before performing the mastopexy. As noted previously,
in this situation I believe that it is helpful to suture the previ-
ous subglandular space closed (see Fig. 4-25A,B) as the inci-
sions used for the mastopexy are closed. This prevents the
implant from slipping back into the subglandular position.
The following patient who was treated for posttrau-
matic silicone gel implant rupture illustrates many of
these points. This 44-year-old female had undergone a
bilateral subglandular breast augmentation with smooth-
walled silicone gel implants 8 years earlier. She was
involved in an automobile accident that caused chest
trauma and resulted in a rupture of her right breast
implant. She presented for consultation with an obvious
deformity of the right breast (Fig. 4-49AC) and an obvi-
ous asymmetry. She was also noted to have some settling FIGURE 4-49. Patient 8 years following bilateral subglandular
breast augmentation with silicone gel implants. She sustained a
of her breast parenchyma away from the implants. She trauma to the right breast with MRI-proven rupture of her right
was marked for a redo augmentation mastopexy with breast implant. She is seen with distortion of the right breast and
implant reassignment and TPPC. Her markings are illus- settling of the tissue away from the implants. A, AP view. B,
trated in Figures 4-15 and 4-50. She underwent a peripros- Lateral view. C, Oblique view.
thetic capsulectomy and focal removal of silicone, which
was dispensed into the surrounding breast parenchyma.
She then had insertion of saline implants into the subpec-
toral position, suture closure of the subglandular space,
Ch04.qxd 11/28/05 1:39 AM Page 176
FIGURE 4-50. Markings for inferior pedicle mastopexy,

oblique view.
and a simultaneous mastopexy using a superior pedicle

technique. Combining a redo breast augmentation and a
mastopexy adds to the complexity of the procedure. It is
indeed a balancing procedure, which in my hands
requires adjustments made on the operating table using
the tailor-tacking technique (see Fig. 4-16). Time spent fin-
ishing the procedure most often pays dividends in
optimizing breast appearance and symmetry. This resulted
in restoration of a good breast shape and symmetry
(Fig. 4-51). FIGURE 4-51. Patient shown in Fig. 4-49 underwent TPPC,
reinsertion of subpectoral saline implants, and inferior pedicle
The results of this combination are often gratifying for mastopexy with inverted T incisional pattern. She is pictured
the patient and the surgeon. As previously noted, I am in AP view (A), lateral view (B), and oblique view (C) 2 years
careful to never promise precise breast symmetry to the following surgery.
patient, and I always explain that the immediate postoper-
ative appearance will change with time and that recurrent
ptosis is a likely outcome.
Ch04.qxd 11/28/05 1:39 AM Page 177
EXPLANTATION WITH AUTOGENOUS the plan to the patient and to precisely record this com-
TISSUE CONVERSION munication in the consultation notes. In addition, it is
important to document the risks and consequences of the
Removing a previously placed breast implant and substi- proposed operation in the preoperative consent for the
tuting in its place the patients own tissue is a treatment planned surgery.
option that is largely limited to the setting of breast recon-
struction. This is due to the incisions necessary to harvest
and transfer such tissue; potential additional attendant
donor-site morbidity; and the expense of such surgery,
which is rarely covered by medical insurance.
The most common donor area is the lower abdominal
region in the form of a transverse rectus abdominis muscle
(TRAM), deep inferior epigastric artery perforator (DIEP),
or superficial inferior epigastric artery (SIEA) flap.
Additional options are the gluteus maximus musculocuta-
neous flap, the superior gluteus artery perforator (SGAP)
flap, the Rubens flap, and flaps derived from the circum-
flex scapular artery system. For the breast reconstruction
patient with available donor tissue and a previously com-
prised implant, reconstruction autogenous conversion is
an excellent treatment option.
AUTOGENOUS CONVERSION
FOLLOWING PREVIOUS BREAST
AUGMENTATION
Autogenous conversion is a decidedly uncommon option

for the reasons enumerated earlier. However, I have
encountered three patients in whom we were able to obtain
insurance coverage for such surgery following a complica-
tion from breast augmentation. One of these was a 51-year-
old female who developed bilateral breast pain and a Baker
IV contracture secondary to severely calcified peripros-
thetic capsules around her implants (Fig. 4-52A,B). She
requested autogenous conversion, had excess tissue in her
lower abdomen, and would tolerate the scars and potential
morbidity of conversion to bilateral TRAM flaps (Fig. 4-53).
The flaps were elevated as superior pedicle flaps and trans-
ferred (Fig. 4-54).
The plan was accomplished without complications,
and the patient demonstrated a very satisfactory long-
term outcome. This is illustrated by the appearance of her
breasts and abdomen in this photograph 10 years follow-
ing surgery (Fig. 4-55).
The conversion of a cosmetic procedure into a recon-
structive one is a very big step for both the patient and the
surgeon. From the patients standpoint there are virtually
always additional scars and contour deformity that may be
construed as additional disfigurement. The patient must
be informed of and very clear about this before surgery. FIGURE 4-52. A-B, Patient 20 years following bilateral sub-
glandular breast augmentation with smooth silicone gel implants.
This is a big step for the surgeon, whether he or she She has extremely hard, uncomfortable, immobile implants
was the initial surgeon or a subsequent surgical consult- bilaterally (Baker IV). She desires removal and reaugmentation
ant. It is essential for the surgeon to clearly communicate with her own tissue.
Ch04.qxd 11/28/05 1:39 AM Page 178
FIGURE 4-53. The plan was to perform bilateral de-epithelial- FIGURE 4-54. The TRAM flaps are superiorly based. The right
ized TRAM flap augmentation of each breast following implant flap is shown de-epithelialized and the left flap has been trans-
removal. ferred.
Ch04.qxd 11/28/05 1:39 AM Page 179
FIGURE 4-55. The patient maintains excellent sym-

metry of her naturally soft breasts on 10-year follow-
up.
AUTOGENOUS TISSUE CONVERSION undergone a right subcutaneous mastectomy with

FOLLOWING SUBOPTIMAL IMPLANT- implant reconstruction following multiple biopsies of the
BASED BREAST RECONSTRUCTION right breast showing atypical changes. She presented
with a marked breast asymmetry 6 years later related to a
Autogenous tissue conversion is most common following ruptured right breast implant and left-sided macromastia
a compromised implant breast reconstruction, but it has (Fig. 4-56A,B). She was treated with the combination of a
not been all that common in my practice. It was employed total periprosthetic capsulectomy, implant removal, con-
mainly to treat problems of asymmetry due to capsular version to a TRAM flap for the right breast reconstruc-
contracture, implant rupture, quantitative and qualitative tion, and a contralateral left breast reduction. This
skin deficiencies, volume deficit, and combinations of bilateral breast surgery resulted in a markedly enhanced
these problems. breast symmetry that was stable at a 2-year follow-up
In my practice the pedicled TRAM flap has been the (Fig. 4-57A,B).
mainstay for this treatment strategy, although the pedicled Autogenous tissue conversion is a valuable treatment
latissimus dorsi flap (autogenous latissimus) and other option following explantation in the breast cancer patient
free flaps are also options for some patients (Chapter 6). who undergoes implant-based reconstruction. I predict
In my practice the pedicled TRAM flap has been the that autogenous conversion will become much more com-
workhouse for autogenous conversion. A typical case is mon with the expanded use of adjuvant radiation therapy
this 46-year-old female (Figs. 4-56 and 4-57), who had in the breast cancer patient population.
Ch04.qxd 11/28/05 1:39 AM Page 180
FIGURE 4-56. A significant breast asymmetry due to a rup-

tured right silicone gel implant used for right breast reconstruc-
tion following a subcutaneous mastectomy. A, AP view. B,
Lateral view.
Ch04.qxd 11/28/05 1:40 AM Page 181
FIGURE 4-57. The patient underwent autogenous conversion to

a TRAM flap on the right side and had a left mastopexy. Note the
markedly improved breast aesthetics. A, AP view. B, Lateral view.
Ch04.qxd 11/28/05 1:40 AM Page 182
REFERENCES 18. Handel N, Silverstein MJ, Gamagami P, et al. Factors affect-

ing mammographic visualization of the breast after augmen-
1. Larson DL, Anderson RC, Maksud D, et al. What influences tation mammaplasty. JAMA. October 14, 1992;268(14):
public perceptions of silicone breast implants? Plast Reconstr 19131917.
Surg. 1994 Aug;94(2): 318325; discussion 326327. 19. de Camara DL, Sheridan JM, Kammer BA. Rupture and
2. Kessler DA. The basis of the FDAs decision on breast aging of silicone gel breast implants. Plasr Reconstr Surg.
implants. N Engl J Med. June 18, 1992;326(25):17131715. April 1993;91(5):828834; discussion 835836.
3. Institute of Medicine. Safety of Silicone Breast Implants. 20. Shestak KC, Heil BV, Harris KM, et al. Accuracy of imaging
Washington, DC: National Academy Press; 1999. techniques to establish the diagnosis of implant rupture or
4. Independent Review Group. Silicone Gel Breast Implants: The integrity; and patient satisfaction with treatment options fol-
Report of the Independent Review Group. Norwich, UK: Her lowing explantation of silicone gel implants. Paper presented
Majestys Stationery Office; Crown copyright; 1998. at: 75th Annual Meeting of the American Association of
5. Gabriel SE, OFallon WM, Kurland LT, et al. Risk of connective- Plastic Surgeons; May 1996; Hilton Head, SC.
tissue diseases and other disorders after breast implantation. 21. Cheung KC, Greenfield ML, Walters M. Decision-analysis
N Engl J Med. June 16, 1994;330(24):16971702. methodology in the work-up of women with suspected sili-
6. Snchez-Guerrero J, Colditz GA, Karlson EW. Silicone cone breast implant rupture. Plast Reconstr Surg. September
breast implants and the risk of connective-tissue 1998; 102(3):689695.
diseases and symptoms. N Engl J Med. June 22, 22. Palcheff-Wiemer M, Concannon MJ, Conn VS, et al. The
1995;332(25):16661670. impact of the media on women with breast implants. Plast
7. Berkel H, Birdsell DC, Jenkins H. Breast augmentation: a risk Reconstr Surg. October 1993;92(5):779785.
factor for breast cancer? N Engl J Med. 1992;326:16491653. 23. Cunningham BL, Lokeh A, Gutowski KA. Saline-filled breast
8. Deapen DM, Bernstein L, Brody GS. Are breast implants anti- implant safety and efficacy: a multicenter retrospective
carcinogenic? A 14-year follow-up of the Los Angeles Study. review. Plast Reconstr Surg. May 2000;105(6):21432149; dis-
Plast Reconstr Surg. April 1997;99(5):13461353. cussion 21502151.
9. Rohrich RJ. Safety of silicone breast implants: scientific 24. Henriksen TF, Holmich LR, Friis S, et al. The Danish Registry
validation/vindication at last. Plast Reconstr Surg. Nov 1999; for Plastic Surgery of the Breast: establishment of a nation-
104(6):17861788. wide registry for prospective follow-up, quality assessment,
10. Eklund GW, Busby RC, Miller SH, et al. Improved imaging of and investigation of breast surgery. Plast Reconstr Surg. June
the augmented breast. AJR Am J Roentgenol. September 2003;111(7):21822189; discussion 21902191.
1988;151(3):469473. 25. Kjoller K, Holmich LR, Jacobsen PH, et al. Epidemiological
11. Shestak KC, Ganott MA, Harris KM, et al. Breast masses in investigation of local complications after cosmetic breast
the augmentation mammaplasty patient: the role of ultra- implant surgery in Denmark. Ann Plast Surg. March 2002;
sound. Plast Reconstr Surg. August 1993;92(2):209216. 48(3):229237.
12. Harris KM, Ganott MA, Shestak KC, et al. Silicone implant 26. Robinson OG Jr, Bradley EL, Wilson DS. Analysis of
rupture: detection with US. Radiology. June 1993;187(3): explanted silicone implants: a report of 300 patients. Ann
761768. Plast Surg. January 1995;34(1):16; discussion 67.
13. Ahn CY, Shaw WW, Narayanan K, et al. Definitive diagnosis 27. Rohrich RJ, Adams WP Jr, Beran SJ, et al. An analysis of sili-
of breast implant rupture using magnetic resonance imaging. cone gel-filled breast implants: diagnosis and failure rates.
Plast Reconstr Surg. September 1993;92(4):681691. Plast Reconstr Surg. December 1998;102(7):23042308; dis-
14. Ahn CY, DeBruhl ND, Gorczyca DP, et al. Comparative sili- cussion 2309.
cone breast implant evaluation using mammography, 28. Young VL. Guidelines and indications for breast implant cap-
sonography, and magnetic resonance imaging: experience sulectomy. Plast Reconstr Surg. September 1998;102(3):
with 59 implants. Plast Reconstr Surg. October 1994;94(5): 884891; discussion 892894.
620627. 29. Gabriel SE, Woods JE, OFallon WM, et al. Complications
15. Baker JL Jr. Classification of spherical contractures. Paper leading to surgery after breast implantation. N Engl J Med.
presented at: Aesthetic Breast Symposium; 1975; Scottsdale, March 6, 1997;336(10):677682.
Arizona. 30. Tebbetts JB. Patient evaluation, operative planning, and sur-
16. Leitch MA, Dodd GD , Costanza M, et al: American Cancer gical techniques to increase control and reduce morbidity
Society guidelines for early detection of breast cancer: and reoperations in breast augmentation. Clin Plast Surg.
Update 1997. CA Cancer J Clin. MayJune, 1997;47(3): July 2001;28(3):501521.
150153. 31. Lassus C. A 30-year experience with vertical mammaplasty.
17. Silverstein MJ, Handel N, Gamagami P, et al. Mammographic Plast Reconstr Surg. February 1996;97(2):373380.
measurements before and after augmentation mammaplasty. 32. Lejour M. Vertical mammaplasty: update and appraisal of
Plast Reconstr Surg. December 1990;86(6):11261130. late results. Plast Reconstr Surg. September 1999;104(3):
771781; discussion 782784.
Ch05.qxd 11/28/05 1:36 AM Page 183
C h a p t e r 5
Revision Surgery Following Breast

Reduction and Mastopexy
Anatomic Considerations 184 Scar Excision and Wound Reclosure 200
Preoperative Examination 184 Fat Necrosis 200
General Comments Regarding Reoperative Breast Asymmetry 202

Reduction 187
Complications of Breast Surgery 187 Volume Asymmetry 202
Hematoma 187 Nipple Areolar Complex Asymmetry 203
Skin Flap Ischemia and Skin Loss 189 Nipple Retraction 206
Seroma 192 Nipple Malposition 208
Wound Separation and Open Wound Inferior Nipple Malposition 213

Formation 192
Challenging Problems Following Breast
Cellulitis 195 Reduction 213
Nipple Loss 213
Recurrent Cellulitis 196 Massive Fat Necrosis 214
Subsequent Volume Loss with Loss of Breast
Nipple Areolar Ischemia 196 Fullness 220
Long-Term Complications 198 Redo Reduction 221
Dog Ears 198 Redo Mastopexy 221
Unattractive Scars Due to Hypertrophy or References 236

Spreading Hypertrophic Scars 199
Breast reduction and mastopexy are two commonly per- goal must be achieved in the context of removing breast
formed breast operations in which the surgeons goal is tissue (often in large amounts) to afford the patient relief
the same: to produce symmetric breasts that have a pleas- of her macromastia-related symptoms, whereas in
ing shape with round, sensate nipple areolar complexes mastopexy most often little or no breast tissue is removed,
(NACs) that are appropriately positioned. The surgeon and not uncommonly volume is added to the breast in the
attempts to produce breasts whose shape is preserved for form of an implant.
as long as possible and that have a minimum number of Achieving consistently good results in both the primary
well-positioned scars. surgical and reoperative setting entails a thorough analysis
Both procedures entail a superior shifting of the breast of the breast morphology and tissue condition, precisely
parenchyma with some degree of breast skin flap redrap- identifying the correct new nipple position and producing
ing. However, they differ in that in breast reduction the a well-designed and precisely executed operative plan.
183
Ch05.qxd 11/28/05 1:36 AM Page 184
These surgical operations are almost always a one-stage source(s) of blood supply to the NAC. Any surgical proce-
procedure in which the surgeon tries to obtain a perfect dure on the breast parenchyma not only alters its architec-
result with minimal consideration or mention of revisional ture but very often its blood supply as well. For example,
surgery. However, by their very nature, the results of both I believe that if a superior pedicle mammoplasty was per-
procedures are not permanent, and changes in the shape formed initially, then an attempt to base the blood supply to
and symmetry of the breasts occur over time. This is the NAC using an inferior pedicle design may result in vas-
related to changes in the relationship of the breast cular compromise of the NAC and possible nipple necrosis.
parenchymal volume and overlying skin envelope that are The sources of blood supply to the breast tissue emanate
most commonly due to significant fluctuations in weight, from various pedicle systems3 (Fig. 5-1): the internal and
pregnancy, and lactation, all of which alter the dynamics of external mammary systems, the thoracoacromial artery with
the breast volumeskin envelope relationship. However, perforators from the pectoralis major muscle (PMM), and the
additional important factors include the individual intercostal vessels. An inferior pedicle procedure diminishes
patients heredity, aging, and the inexorable influence of the circulation from the internal and external mammary sys-
gravity. Changes in breast shape following breast reduc- tems, and the surgeon must be aware of this. Because of this I
tion are common, as is the development of asymmetry, advocate performing revision surgery following both breast
even when a symmetric, well-shaped breast appearance is reduction and mastopexy by using the same pedicle that was
noted after the original surgery.1 employed during the first procedure. As mentioned in
Reoperative surgery following mastopexy or breast Chapter 2 (see Fig. 2-42) and Chapter 3 (see Fig. 3-10), the
reduction may be sought by the patient and undertaken to presence of an implant in the subglandular position reduces
address changes in the aesthetic appearance of the breast the blood supply from the PMM perforating vessels and some-
that occur with the passage of time or to treat complica- times also from both the internal mammary and lateral tho-
tions or problems resulting from the primary operation. racic systems. This must be borne in mind by the surgeon
Unusual types of reoperative surgery in this setting are considering a significant transposition of the NAC at the time
sometimes necessary to treat an unexpected intervening of revision of an augmentation mastopexy following a previ-
problem such as an occult malignancy discovered during ous subglandular breast augmentation.
initial procedure or to treat recurrent breast enlargement Another pertinent anatomic structure is the sensory
that can occur in the setting of virginal breast hypertrophy.2 nerves to the nipple. Nipple sensation is primarily derived
As with every type of reoperative surgical procedure, an from the fourth medial and lateral intercostal nerve, with
understanding of the problem and the timing of the surgical the anterolateral branch of the fourth intercostal nerve
intervention are crucial. Whether the surgeon is operating thought of as playing the key role in providing sensation to
to treat a problem in his or her own patient or in a patient the nipple.1,4 Recently my experience with vertical mammo-
previously operated on elsewhere, taking a careful history plasty using the medial dermoglandular pedicle has high-
and performing a physical examination are required. lighted the significant contribution from the medial
Particular attention is paid to the patients chief com- branches of the intercostal nerves in terms of their contribu-
plaint. I need to understand what she is most bothered by. tion to the sensation of the breast skin and NAC (Fig. 5-2).
I attempt to have her focus her complaint as much as pos- Any breast procedure that involves incising through
sible. Is the patient dissatisfied with the scars, changes in breast parenchyma or a significant resection of the breast
shape, contour problems, nipple malposition or frank tissue adjacent to the central pedicle poses risk to the sen-
asymmetry, fat necrosis, or pain in her breasts? Following sory nerves. Laterally the sensory nerves have their course
a previous breast reduction, has there been overreduction just on top of the serratus fascia after perforating through
or underreduction with the persistence of symptoms? Or, the serratus anterior muscle in the midaxillary line.3
after a mastopexy, has the patient experienced a recur- Therefore it is important to stay in a plane above the ser-
rence of her ptosis, or is she discontented with the loss of ratus anterior muscle fascia when dissecting in this infe-
upper pole fullness? A key element in successful revision rior lateral breast region. As the nerves head in a medial
surgery lies in understanding what the patient is most con- direction they run obliquely and take a superficial course
cerned with and what she would like you to do to help her. through the breast parenchyma as they proceed toward
the nipple. In general these nerves run with small arteries
and can be spared in many types of procedures.
ANATOMIC CONSIDERATIONS
Another key element is a precise understanding of the pre- PREOPERATIVE EXAMINATION

vious surgical procedure(s). This goes well beyond recog-
nizing the scar pattern and analyzing breast dimensions As previously discussed, the breasts must always be care-
and the relationship of the nipple to the breast tissue. It is fully and systematically evaluated in every patient. This
essential for the surgeon to understand the existing includes a detailed visual analysis and thorough palpation.
Ch05.qxd 11/28/05 1:36 AM Page 185
Chapter 5 Revision Surgery Following Breast Reduction and Mastopexy 185
FIGURE 5-1. Arterial blood supply to the breast. There are major contributions from the internal
mammary, the lateral thoracic, the intercostals, and the thoracoacromial system.
Nipple Areola Innervation The visual inspection is performed to evaluate the

shape, symmetry, contours, scar location, and skin quality,
intercostal nerve IV along with nipple areola shape and position relative to
both the inframammary (IM) fold and breast volume in
the upright position. Careful notes are made regarding
symmetry of contour, nipple areola position, presence of
striae, overall skin quality, and position of scars.
Additionally, the presence, size, and location of contour
deformities are recorded.
I take photographs cropped in a uniform way of all
anterlateral patients using the same background color and lighting
intercostal N. conditions. The views taken in each patient are the antero-
antermedial N.
posterior (AP), each lateral, and each oblique. If there are
specific areas of interest in the consultation that may be
better highlighted by other views, I will take a photograph
from above and perhaps a view from below with the
patient lying supine on the examination table.
In addition I record the surface measurements of
breast structures from key fixed anatomic points and
record these on a worksheet in the patients chart. These
include the suprasternal notch (SSN) to nipple distance,
the breast base width, and the distance of the nipple from
the IM fold and from the midline. I refer to both diagrams
FIGURE 5-2. The nerve supply to the NAC is derived from the and photographs when planning all surgical procedures
medial and lateral braches of the fourth intercostal nerves. on the breast.
Ch05.qxd 11/28/05 1:37 AM Page 186
A tactile examination of the breasts includes careful probably a good candidate for a vertical mastopexy. On
palpation of the skin, scars, and breast parenchyma. Of the other hand, if you are not able to produce this change
course careful palpation is done to examine for any in breast shape with the maneuver described, a mastopexy
masses, areas of thickening, tenderness, and scar adher- with both a vertical and horizontal skin excision should be
ence. In general, reoperative surgical procedures should undertaken. In addition, such a patient should be
not be undertaken until there is a return of mobility to the informed about an increased tendency for recurrent
breast tissue over the underlying chest wall structures, the mammary ptosis.
skin has reacquired its mobility over the breast Mammographic examinations of the breasts are
parenchyma, and the skin scars have begun to soften. ordered as necessary. If a patient seeking a reoperative
Breast palpation and tactile assessment also provide procedure has not had a mammogram and is near 35
additional insight into the elasticity of the skin, as well as years of age, I routinely order this study, even if the palpa-
the volume, distribution, position, and elasticity of the tion examination of the breasts is normal. This mammo-
parenchyma. In every patient being evaluated for primary gram will serve as the baseline study for future
and reoperative mastopexy I simulate the superior trans- mammograms, and it will provide insight into any mam-
position of the breast parenchyma by pinching the lower mographic alterations produced by the previous proce-
pole or lateral inferior pole of the breast mound. This dures. Surgery on the breast parenchyma produces a
maneuver (Fig. 5-3A,B) provides additional insight into change in the breast tissue from the standpoint of intra-
the parenchymal elasticity and helps me to select the parenchymal scars that are often discernible on the mam-
appropriate technique for the mastopexy. The ability to mogram. In addition, a patient with high adipose content
transpose the parenchyma to the upper pole of the breast in her breasts who has had previous surgery may also
indicates good tissue elasticity and that the patient is have calcifications in her breasts. These calcifications are
FIGURE 5-3. A, This 43-year-old patient will undergo a right vertical mastopexy at the time of an
immediate left breast reconstruction with a TRAM flap after a skin-sparing mastectomy done through a
vertical skin-sparing incision pattern. B, The pinch maneuver done in the lower pole evaluates the tis-
sue elasticity and ability to transpose the breast volume to the upper pole of the breast. She is a good
candidate for a vertical mastopexy procedure.
Ch05.qxd 11/28/05 1:37 AM Page 187
usually easily distinguishable from the worrisome calcifi- mastodynia, is multifactorial. I strongly believe that it is
cations that may be associated with mitotic processes in rarely possible to cure pain with a scalpel. I specifically
the breast (breast cancers). mention this to patients who present with pain as one of
their main complaints by telling them that in no way can I
guarantee pain relief with this surgical procedure and that,
GENERAL COMMENTS REGARDING in fact, there is a chance that the pain could be worse.
REOPERATIVE BREAST REDUCTION In my practice the reoperation rate following breast
reduction is very low. Nevertheless, revisional surgical pro-
It is often stated that breast reduction patients are per- cedures are done in the setting of a previous breast reduc-
haps the happiest patients in a plastic surgeons practice. tion for an aesthetic compromise in breast appearance or
In the vast majority of instances these procedures result to treat problems resulting from the previous surgery.
in smaller, shapelier breasts that have a more youthful Classification of the complications of breast reduction
appearance, albeit with scars on them. The tradeoff that and how I handle these complications follows.
the breast reduction patient makes is scars for shape. In
my experience these patients gladly make this trade
Complications of Breast Reduction
because the resulting smaller breast size allows them to
perform virtually all of their activities of daily living more See Table 5-1.
comfortably. In my experience, the overwhelming major-
ity (>95%) of patients demonstrate a relief of their macro-
mastia-related symptoms. This has been borne out in the HEMATOMA
plastic surgery literature by numerous outcome stud-
ies.5,6 It has been my experience that the vast majority of Hematoma can occur following any surgical procedure. The
breast reduction patients are happy with their surgical presenting symptoms are acute swelling; tenderness; asym-
outcome and they both accept and overlook the imperfec- metry; ecchymosis; and, most prominently, pain. Pain is the
tions resulting from the breast reduction procedure, symptom that predominates when a hematoma occurs any-
including asymmetries and associated scar deformities. where in the body.
I have found that, although there are numerous com- The incidence of hematoma following breast reduction
plications that can occur following breast reduction, it is is low (1% to 2%) despite the extensive infraparenchymal
rare for the surgeon to perform additional surgery to treat dissection. In our practice the importance of refraining
a complication in the acute or subacute phases of wound from aspirin products for at least 10 days before surgery is
healing. I often say to patients seen for an initial consulta- communicated to each patient. The patients ingesting
tion for macromastia symptoms that complications in even a single aspirin during the week before the procedure
breast reduction are not all that common, and when they will cause me to postpone the procedure.
do occur they usually heal without additional surgery. I Drains do not prevent hematoma and are not used in
still believe that this is true. However, breast reduction the majority of patients. However, I selectively use drains
remains a highly litigated procedure,7 and therefore it is in patients with large amounts of dense white parenchy-
important for the surgeon to review in detail the immedi- mal tissue that exhibits a tendency to ooze. When incised
ate and long-term potential risks of the procedure with this stromal tissue inhibits contraction of the small blood
each patient. I do this by discussing with the patient the vessels, which results in prolonged oozing. In addition,
risks that are enumerated on a preprinted consent form patients who undergo large resections (>1,000 g) after
(Fig. 5-4) that outlines the probable complications and which the parenchyma may not precisely fit the skin enve-
answering any questions the patient may have. lope often benefit from the use of a drain.
In the setting of reoperative surgery following a previ- Large hematomas recognized following surgery should
ous breast reduction, the initial consultation is longer in be drained. The most effective way of doing this is by
duration than it is for other procedures, and follow-up returning the patient to the operating room, opening the
consultations are far more common. I want the patient to incision, and placing a Jackson-Pratt drain (Ethicon, Inc.,
understand that the risk of complications is greater than it Somerville, NJ). I have found this to be the most reliable
is in the primary procedure. There may be increased risks method of managing this problem and the most effective
for sensory loss in the NAC, increased scar tissue within and reliable method of managing problems with
the breast, and more difficulty maintaining shape. Scars hematoma (and seroma as well, although with seroma I
cannot be erased, and skin healing can be less predictable place a Penrose rather than a Jackson-Pratt drain).
than it is with other procedures. Although improvement in Alternatively, smaller hematomas can be aspirated using
breast appearance is likely, no guarantees can be made. an 18-gauge needle following infiltration of the skin with
Finally, a brief mention must be made regarding pain fol- lidocaine (Xylocaine). This method is effective when such
lowing the previous surgery. The etiology of breast pain, or collections of blood are noted later in the postoperative
Ch05.qxd 11/28/05 1:37 AM Page 188
FIGURE 5-4. Sample consent form that I use for breast reduction.
Ch05.qxd 11/28/05 1:37 AM Page 189
TABLE 5-1 Complications of Breast Reduction

Acute Complications Subacute Complications Long-Term Complications
Hematoma, seroma Asymmetry Contour deformities

Skin loss Hypertrophic scars Recurrent ptosis
Wound separation Fat necrosis Scar deformities/unfavorable scars
Cellulitis Loss of shape
Nipple areola Nipple malposition
ischemia Underresection
Overresection
period (7 or more days following surgery) when the blood tion, and pedicle resection. Enough tissue must be
begins to liquefy. I used this technique in this patient, who resected from the pedicle such that the wounds are
had an inferior pedicle breast reduction for symptomatic approximated without excess tension in the line of
macromastia (Fig. 5-5A). She developed a localized collec- wound closure. When using the Wise pattern with its
tion of blood in the inferior medial aspect of her breast inverted T incisional closure, the point of maximal ten-
reduction wound that was aspirated on postoperative day sion is at the T junction. This pattern of flap closure
10 (Fig. 5-5B). Subsequently she healed uneventfully and involves the development of skin flaps and draping of
shows an excellent result at 1 year postoperative without these around a centrally positioned pedicle. For this
excess firmness or other problem with her right breast reason the sum of the measured lengths of the medial
(Fig. 5-5C). Aspiration of a hematoma was also used in this and lateral skin flaps is always longer than the length of
patient who had the diagnosis of hematoma made in the the IM incision.
lateral aspect of the wound following an inferior pedicle The lateral flap in an inverted T design tends to have a
breast reduction (Fig. 5-5D). She had very large breasts pre- longer length-to-width ratio, i.e., the blood supply is fur-
operatively with a wide chest. Patients with this body habi- ther from the distal edge than it is from the edge of the
tus invariably have a large fold of tissue extending down medial flap. For this reason, the lateral flap is more
from their axillary region that is not part of their breasts prone to ischemia at its margin (Fig. 5-6). Such relative
(Fig. 5-5E). I routinely tell such patients that I cannot skin flap ischemia can result in necrosis and full-thick-
remove this fullness without extending the incision consid- ness skin loss if these flaps are closed under excessive
erably posteriorly. Furthermore, to do so can put the lateral tension.
skin flap in jeopardy from the standpoint of its vascular By the very nature of this flap design (Wise pattern or
supply because additional vascularity is sacrificed and the inverted T) for breast reduction (and in fact for all
length-to-width ratio is increased. However, because this designs), the skin flaps are sutured with some tightness at
patient was particularly bothered by the fullness, a more the line of closure. However, I do not believe that the skin
aggressive surgical removal of tissue in this area with Mayo closure contributes significantly to breast shape. On the
scissors was carried out. No drain was placed. She devel- contrary, I feel that the key element in this regard is pedi-
oped a hematoma under the lateral chest flap that was aspi- cle configuration. I believe that part of the art of breast
rated on postoperative day 7 in the office (Fig. 5-5F). A reduction is that the remaining pedicle must precisely fit
second aspiration was needed 1 week later to successfully the wound created by the flap dissection (Fig. 5-7).
resolve this situation. Not uncommonly more than one Therefore, if there is excessive tension in the line of clo-
aspiration is required. I also have patients apply pressure to sure, resection of additional parenchymal tissue from the
such areas with an Ace bandage (Becton Dickinson, pedicle should be considered.
Franklin Lakes, NJ) that is applied and reapplied several Ischemia of the skin flap edges is usually noted early in
times during the course of the day. the postoperative period. It is rarely noted on the operat-
ing table. In my experience, ischemia of the skin flap
edges following breast reduction is much more common
SKIN FLAP ISCHEMIA AND SKIN LOSS in patients who smoke. This is also true for the complica-
tions of delayed wound healing and fat necrosis and
Breast reduction requires careful planning in terms of should be mentioned to all prospective patients who are
flap design, surgical precision in terms of flap eleva- smokers.
Ch05.qxd 11/28/05 1:37 AM Page 190
FIGURE 5-5. A, Patient with symptomatic bilateral macromastia who will undergo an inferior pedicle
breast reduction. B, On postoperative day 7 she has a localized hematoma in the inferior medial aspect
of her breast aspirated. C, She shows an excellent cosmetic result with no adverse sequelae from the
hematoma. D, Breast reduction planned in patient who is obese, with large body habitus and large
breasts. (continued)
Ch05.qxd 11/28/05 1:37 AM Page 191
FIGURE 5-5. (CONTINUED) E, Such patients almost invariably have a large roll of excess tissue pos-
terior to the breast along the lateral chest wall, which I do not attempt to resect in most cases. F, Here
such an attempt at aggressive scissor resection was made and it resulted in a hematoma that was aspi-
rated twice in the office with resolution.
FIGURE 5-7. The ideal breast reduction is when the dissected

pedicle precisely fits the skin flaps developed during the resec-
FIGURE 5-6. The typical appearance of skin loss on the distal tion of breast tissue. There is minimal tension at the site of
margin of the lateral Wise pattern breast reduction skin flap. wound closure.
Ch05.qxd 11/28/05 1:37 AM Page 192
SEROMA time to complete wound healing was 6 months, during

which she was seen frequently in the office so that we
In my experience seroma following breast reduction is could give her the appropriate psychologic support while
rare. It can present as a localized fluid collection that may we performed the necessary wound care. She was indeed
be apparent as an area of swelling. There may be a fluid a patient patient, and her eventual cosmetic result was
wave when the tissue is gently balloted. If such a collec- satisfactory (Fig. 5-8C,D).
tion is suspected, it can be aspirated using sterile tech- Another example of prolonged healing following skin
nique in a fashion similar to that used to treat hematoma. loss is seen in this 45-year-old patient (Fig. 5-9A) who will
I generally prefer to use an 18-gauge needle. Seromas may undergo a vertical breast reduction using a medial der-
require multiple aspirations in most locations of the body. moglandular pedicle (Fig. 5-9B). There was excessive ten-
As previously mentioned, an alternate strategy is to open sion on the inferior aspect of the vertical skin closure,
the previous incision and place a Penrose drain in the which resulted in skin necrosis and large open wounds
seroma cavity. that failed to show any progress toward healing over the
first 6 weeks postoperatively (Fig. 5-9C). There were
changes on the surface of the granulation tissue suggest-
WOUND SEPARATION AND OPEN ing a secondary wound infection, and cultures were con-
WOUND FORMATION sistent with a Staphylococcus sp. She was treated with
both mupirocin (Bactroban) topical ointment and oral
Some degree of wound separation is very common fol- dicloxacillin [500 mg by mouth (PO) four times daily
lowing breast reduction. Although I do not have precise (q.i.d.)] with rapid epithelialization and wound contrac-
data on its incidence, I believe it is in the range of 10% to tion that led to healing within 1 additional month. She
15% in patients undergoing inferior pedicle breast reduc- shows a very acceptable appearance of her breasts at 1
tions and is higher in patients who have vertical pattern year following surgery (Fig. 5-9D,E), and the wound is sta-
reductions. These numbers are much higher in smoking ble (Fig. 5-9F).
patients, and I inform them of this preoperatively. As pre- This patient is interesting from several perspectives.
viously noted, the most common site for ischemia of the During vertical mammoplasty the tension in the line of
flaps is at the T junction, and this is where open wounds closure should be on the parenchyma, not the skin edges.
are most commonly noted when the inverted T incisional It is a parenchymal reshaping procedure, and I made an
pattern is used for breast reduction. error in placing too much tension on the skin wound clo-
Open wounds following a breast reduction or sure.810 In addition, it is important to recognize when a
mastopexy will almost always heal in time. Delays in wound fails to show normal progress toward healing. The
wound healing are most often due to retained foreign most common etiologies are wound infection or the pres-
bodies in the wound (usually suture material) or to infec- ence of a foreign body, which in this setting is most often a
tion. When infection in such wounds is present it must contaminated suture.
be treated. Depending on presentation, this may require In general the wounds resulting from skin loss after a
a combination of systemic antibiotics, the topical appli- breast reduction progress relatively quickly toward com-
cation of antibiotic ointment, and wound dressing plete healing. It is almost never necessary for the surgeon
changes. to perform additional surgery to promote healing of such
These wounds heal by the process of epithelialization wounds. In the well over 1,000 breast reductions I have
and contraction. There can be considerable exudation performed, I have had to resort to a split-thickness skin
from their surface, making them messy for patients to graft only once. This was in a patient who was mentally
care for. I commonly ask patients to have patience during incapable of complying with the wound care regimen nec-
the process of wound healing. Simple wound care essary to achieve complete wound healing. Likewise,
includes washing the wound in the shower and applying wound excision and reclosure is almost never an option
bacitracin ointment topically. The moist environment and because the wound is usually indurated and will not hold
local bacteriostatic activity of this topical emollient will sutures well, especially if there is any tension at the site of
facilitate healing. The scars resulting from this secondary wound edge closure.
healing tend to be larger, usually hypopigmented, thinner The one exception to this may be an open wound sec-
in texture, and more depressed relative to the skin surface ondary to wound dehiscence that occurs at the time of
than the remainder of the scars. However, patients almost suture removal. In this situation immediate resuturing
never request additional treatment, even when scarring is after infection of a local anesthetic agent can prevent a
extensive as is seen in this patient (Fig. 5-8A), who under- more prolonged course of healing for this wound. I reop-
went an inferior pedicle breast reduction with the resec- erated on one patient who developed a prolapse of her
tion of 900 g of tissue from each breast. She developed inferior central breast area through an area of skin necro-
significant skin loss on each breast (Fig. 5-8B). The total sis at 1 year following surgery.
Ch05.qxd 11/28/05 1:38 AM Page 193
FIGURE 5-8. A, Preoperative AP view of patient who will undergo an inferior pedicle breast reduc-
tion. B, The procedure is complicated by skin loss involving the inferior medial aspect of the lateral skin
flap on both breasts. There is extensive skin loss on the left side C, The result after 5 months of dressing
changes shows complete healing of the wound and, D, the AP view reveals a very acceptable cosmetic
result.
Ch05.qxd 11/28/05 1:38 AM Page 194
FIGURE 5-9. A, Preoperative AP view of patient who will undergo a vertical reduction mammoplasty
using B, a superior medial dermoglandular pedicle. C, She developed skin loss in the lower aspect of the
vertical incision on both breasts. This was due to excessive tension on the incision line at the time of
wound closure. The wound showed no sign of healing during the first 6 weeks postoperatively. There
was a low-grade wound infection with a Staphylococcus sp. that was treated with topical mupirocin
(Bactroban) ointment, along with oral dicloxacillin. DF, This led to rapid epithelialization and con-
traction of the wound and an acceptable cosmetic appearance of her breasts. (continued)
Ch05.qxd 11/28/05 1:38 AM Page 195
CELLULITIS nosed early, oral antibiotics may be sufficient. I usually

begin with cephalexin [(Keflex) 500 mg PO q.i.d.]. If
Infection following breast reduction is very uncommon. patients are penicillin allergic I substitute ciprofloxacin
Most series will reflect an incidence of 1% to 2%. This is [750 mg PO two times daily (b.i.d.)]. If the process is
interesting given the length of time that wounds are open more advanced I usually begin parenteral antibiotic ther-
and the magnitude of the dissection carried out during apy using a second-generation cephalosporin [cefazolin
breast reduction. The breast is endowed with a robust (Ancef) 1 g intravenous (IV) q8h]. If the patient has a
blood supply, and there are probably other local immuno- penicillin allergy I prescribe ampicillin [(Unasyn) 3 g IV
logic mechanisms that are protective against and mini- q6h].
mize the incidence of infection. If an open wound is part of this picture a culture of the
When infections occur following a breast reduction wound is obtained by swabbing the surface or unroofing
they usually present as a cellulitis. In such cases there is an eschar. This specimen is processed for aerobic and
almost always an open wound that is the portal of entry. anaerobic organisms. At times obtaining such cultures
The most common causative microbial organisms are may help the clinician readjust the antibiotic treatment
Streptococcus sp. and Staphylococcus aureus. Typically the regimen.
patient presents with erythema; tenderness at the site of In every case it is important to monitor the result of
infection; and, if the process is significant enough, fever. the infection process. Toward this end the patient is
In cases of pronounced cellulitis the patient may present checked on a 24-hour basis and rechecked daily. An
with shaking chills. improvement in the cellulitis is expected within 48 hours
The treatment is prompt institution of appropriate of treatment. The average duration of therapy is between
antibiotic therapy. For small areas of involvement diag- 7 and 10 days.
Ch05.qxd 11/28/05 1:38 AM Page 196
RECURRENT CELLULITIS decrease in nipple blood supply due to excessive folding at

the time of closure.
A significant cellulitis that recurs may suggest a number In the setting of reoperative surgery this problem may
of potential etiologies, including a retained foreign body result from an incomplete or inaccurate understanding of
(usually suture material), a scar that has become embed- the previous pedicle orientation or blood supply used dur-
ded beneath the surface or a scar that is unstable and ing the initial surgery. I have previously alluded to the
prone to small cracks that may become portals of re-entry, importance of obtaining the most accurate information
an infected hematoma or occult abscess, and fat necrosis about the techniques used during previous procedures
with associated infection. Additional alternative diag- when reoperating on a patient who has had a previous
noses are hidradenitis suppurativa of the breast or an breast reduction or mastopexy. When the surgeon cannot
immunocompromised host. obtain such information and nipple relocation is planned,
Such clinical presentations may merit a workup with a it is best to maintain a broad central pedicle as the source
magnetic resonance imaging (MRI) scan to rule out a of blood supply to the NAC. Finally, cases of a previous
retained foreign body, retained fluid collection, fat necro- subglandular breast augmentation may pose a real prob-
sis, or a foreign body. Appropriate additional therapy is lem in maintaining blood supply to the nipple when a sig-
then undertaken as needed depending on the breast imag- nificant nipple transposition distance is planned.
ing findings and ancillary diagnoses. Nipple areolar necrosis is a small but real possibility in
Recurrent cellulitis of the breast often presents a chal- every mammoplasty procedure, including reoperative
lenge. It is important for the surgeon to make a diagnosis procedures. As such it must be a part of the informed con-
regarding the etiology and to refrain from surgical sent for the patient who is considering these operations.
overtreatment. Consultations with the infectious disease It is important for the surgeon to recognize nipple are-
service or other surgical colleagues with special training olar ischemia on the operating table. However, this is not
in the area of wound healing may be helpful. There is always easy to do, especially when operating on dark-
probably little indication for long-term suppressive skinned patients of African descent or others with dark
antibiotic therapy. areolar skin. If there is concern about the color changes in
the areola or about capillary refill following pressure
placed with a finger or surgical instrument, abrading the
NIPPLE AREOLAR ISCHEMIA edge of the incision with a gauze sponge and examining
the quality of the bleeding may be helpful. In some situa-
Ischemia of the NAC is a dreaded potential complication tions the administration of IV fluorescein (Chapter 8)
of every predicted breast reduction procedure. It is most might be of benefit.
often related to arterial insufficiency and it usually occurs If real concern about nipple ischemia exists during
in the setting of a large reduction where a long pedicle is wound closure, the wound should be opened and the pedi-
used to carry the circulation to the NAC. In such situa- cle checked for any evidence of folding or kinking. I prefer
tions the tissue resection compromises the arterial perfu- to place warm saline-soaked sponges on the pedicle to try
sion of the nipple and surrounding areola. In addition, to reverse any vasospasm that might be present. If there is
there may be a component of venous insufficiency in obvious ischemia of the nipple following these maneuvers
those cases where the pedicle is excessively folded during surgical treatment is undertaken. The nipple should be
wound closure. removed from its position on the pedicle by excising it as a
The latter situation presents with a hyperemic con- full-thickness skin graft (Fig. 5-10A). It is prepared by
gested appearance of the NAC, which shows dark deoxy- aggressively defatting the areola and resecting the tissue
genated blood emanating from its cut edges. In the on the undersurface to the level of the superficial dermis. I
former condition of arterial ischemia the nipple and areo- prefer to leave some of the nipple elements (the ductal tis-
lar tissue appears pale and dusky and there is little or no sue) in place so that when the nipple areolar graft heals,
blood entering its substance or noted at the cut edges of there will be some degree of nipple projection. The
the areola. ischemic portion (distal aspect) of the pedicle is usually
Nipple areolar necrosis in the setting of breast reduc- resected at this point to minimize the chance of fat necro-
tion is very uncommon, occurring with a frequency of 1% sis and to more easily accommodate breast skin flap
to 2%. It is probably much rarer following mastopexy. redraping. The free graft of the NAC is then placed on the
Predisposing factors at the time of the primary surgery de-epithelialized skin flaps if an inverted V pattern has
include a lengthy pedicle (in an inferior pedicle reduction a been used to develop the skin flaps (Fig. 5-10B), or on a
distance of greater than 15 cm from the nipple to the IM de-epithelialized portion of the original breast pedicle
fold), a nipple transposition distance exceeding 18 cm, and closer to the origin of its blood supply (Fig. 5-10C). If a
extremely large reductions (>2,000 g) done with pedicle Wise pattern design has been employed for the original
techniques where resection of the parenchyma can cause a skin incisions and the areolar cutout has been made, it is
Ch05.qxd 11/28/05 1:38 AM Page 197
closed with a purse string suture technique and the area If the problem does not become apparent until later in
where the nipple should be placed is de-epithelialized the postoperative course, some degree of nipple necrosis
(Fig. 5-10D). Alternatively, the previous areolar cutout can usually ensues. In this situation, and in countless others
be closed as a linear scar creating a T; however, the extent involving the management of acute complications, it is
of the horizontal incision should not fall outside of the important for the surgeon to be a doctor by supporting the
periphery of the nipple areolar graft. The graft is then patient through this difficult period from both a wound
secured by placing sutures at its periphery and finally by healing and a psychological standpoint. The surgeon must
constructing a tie over bolster-type dressing. In my experi- tell the patient that although it will take time for her tissues
ence this gives the frankly ischemic NAC noted at the time to heal, reliable techniques exist that will enable the surgeon
of the original surgery the best chance for survival. to construct a new nipple and NAC when the time is right.
Nipple graft placed closer to blood

supply of inferior pedicle
A B
resected ischemic
distal
pedicle
C D
FIGURE 5-10. A, The treatment of frank nipple ischemia recognized at surgery requires that the
nipple be removed as a full-thickness graft. B, It can then be transplanted to the area where it would
have been brought through if an inverted V design for the skin flaps had been used. The area of skin is
simply de-epithelialized. C, Alternatively, the nipple can be placed back on the pedicle closer to its base
where the blood supply is better, the distal (ischemic) area of the pedicle is resected, and the pedicle is
draped by the skin flaps. D, The preferred option for when a circular cutout of the breast skin has been
made at the start of the operation is illustrated on p.198. It entails a purse string closure of the circular
cutout and a subsequent de-epithelialization of this area to establish a recipient bed for a full-thickness
graft, which is the nipple areola complex. (continued)
Ch05.qxd 11/28/05 1:38 AM Page 198
FIGURE 5-10. (CONTINUED) E, If a Kehole pattern has been used and an areola cut-out created.
F, This circular opening in the skin can be closed with a purse-string suture. G, This area subsequently
deepithelialized to allow application of the nipple areola complex as a free graft.
In this setting, loss of the nipple and NAC is often often used to address these problems will now be
accompanied by necrosis of the underlying tissues. reviewed.
Treatment includes careful superficial wound care with
dressing changes performed several times a day, along
with conservative dbridement of the wound judiciously DOG EARS
performed as needed. Often careful wound management
and patience result in a better outcome than may have Dog ears occur because of either insufficient skin excision
been anticipated immediately following surgery. or improper skin redraping, or both. Following the
The most likely long-term sequelae of nipple areola inverted T incisional pattern they occur medially or later-
complex ischemia are asymmetries of nipple projection; ally in the IM incision or in both locations.
altered areolar shape; and, most commonly, problems with Dog ears are usually a result of the surgeons well-inten-
hypopigmentation. Management of these problems is best tioned effort to limit the length of the scar. When they
deferred until the later stages of wound healing. occur on the breast they are visible in either location and
can be particularly bothersome to the patient. Experience
with my own patients has taught me that it is most often
LONG-TERM COMPLICATIONS better to resect them at the time of the original surgery,
unless they are very small.
As previously stated, the complications following breast The IM scar in a breast reduction should be kept on or
reduction can be thought of as aesthetic imperfections or in the shadow of the breast contour when the patient is in
related to the operation per se. The most commonly the upright position. This usually can be accomplished by
encountered complications in the immediate postopera- careful planning done preoperatively. However, when a
tive period have just been described. The most commonly dog ear is noted at the conclusion of surgery and it is
noted aesthetic problems following breast reduction are greater than 1 cm in length, it is easily resected. The
dog ears, unattractive scars, breast asymmetries, nipple patient is placed in the sitting position on the operating
areolar problems, fat necrosis, loss of shape, underreduc- table as close as possible to 90 degrees.10 At this time an
tion, and overreduction. The secondary procedures most excision can be planned to direct the scar onto the breast
Ch05.qxd 11/28/05 1:38 AM Page 199
contour or in the shadow of the breast. That is to say, the

dog ear excision can be directed superiorly or inferiorly by
adjusting the position of the lines of excision. Altering the
direction of the scar is helpful, especially when placing it
on a structure with the three-dimensional convexity
exhibited by the breast. When performing an excision,
both the skin and the subcutaneous adipose tissue must
be resected, with more of the latter than the former.
Alternatively, if the dog ear is small (1 cm), it may be wise
to allow time for it to settle down. The patient should be
instructed to massage the dog ear on a consistent basis
and the surgeon should follow its progress periodically. If
a resection is indicated secondarily, this can be done in the
office under local anesthesia (Fig. 5-11). Using this strat-
egy the resulting scar is often shorter than it would have
been if an excision of a dog ear had been done at the origi-
nal surgery.
UNATTRACTIVE SCARS DUE TO

HYPERTROPHY OR SPREADING
HYPERTROPHIC SCARS
Unattractive scarring is probably the most commonly

noted adverse effect of breast reduction. The problem is
most commonly due to scar hypertrophy; however,
spreading of the scars following a breast reduction is also FIGURE 5-11. A dog ear noted on the most posterior lateral
not uncommon. aspect of the IM incision that will be resected. It is often best to
Scars demonstrate a thickened or hypertrophic appear- perform such resections at the primary surgery.
ance predominantly because of a tight skin closure. When
performing a breast reduction, the surgeon should avoid
the temptation of relying too heavily on the skin closure in to wait as long as possible (at least 1 year) before deciding
forming the new breast shape. As I have previously stated, to pursue scar excision.
in my opinion the parenchymal configuration largely The treatment of established hypertrophic scars entails
determines the shape of the breast, and I believe that it the application of pressure dressings, the intralesional
should precisely fit the wound resulting from the resec- injection of a depot steroid that acts at the site of injection
tion, with an almost passive redraping of the skin flaps. or excision, and reclosure of the wound. I find it difficult
This requires careful planning and consistent surgical to outfit patients with a device that will apply continuous
technique. The surgeon should avoid excising extra lateral pressure to the postreduction scars. I have had little expe-
skin as part of an exaggerated lazy S closure in an effort to rience with and have little enthusiasm for the topical
suspend or shape the breast. This leads to lateral scar application of silicone gel sheeting.
hypertrophy. The divergence of the medial limbs on a On the other hand, I know that the intralesional injec-
Wise pattern design should not be excessive. I find that tion of a locally acting steroid is effective in reducing scar
a pattern that permits minor adjustments of this medial thickness (the height that it projects above the skin) but
skin excision is helpful. The nipple areola should be cut not the width of a scar. It does this by inhibiting the activ-
with a larger diameter than the skin cut out at the site ity of a down regulator of collagenase, therefore allowing
where it is to be placed. Finally, I believe that using a two- this enzyme to tip the scales in favor of scar resorption in
layered wound closure is important, paying particular a wound. This has been effective in my hands for treating
attention to the deep dermal closure, which in my opinion hypertrophic scars of the breast. I use a 25-gauge needle
must be precise. I have just begun having my patients and a 5-cc syringe to inject triamcinolone in a concentra-
place paper tape on their wounds for 3 months postopera- tion of 10 mg per 5 cc. I re-evaluate the patient at a
tively. This may be helpful in decreasing the incidence of 3-month follow-up and perform an additional injection if
scar hypertrophy. requested. A final injection may be performed 6 months
In general all scars fade and soften with time. This is later if the patient is still not satisfied with the result of the
true of breast scars. For that reason I encourage patients treatment. The injections typically hurt, and applying ice
Ch05.qxd 11/28/05 1:38 AM Page 200
topically to the scar before the injections is helpful in deficit (Fig. 5-12B). She then requested a revision of her
blunting this. Steroid injections can alter scar color, i.e., wound closure that was done as outlined in Figure 5-12C.
producing not only hypopigmentation but also causing a Her postoperative breast appearance was improved
purplish discoloration or producing very apparent telang- (Fig. 5-12D) in terms of both scar quality and breast
iectases, and they can cause adipose tissue atrophy and shape.
even a sunken appearance of the scars. Any of these effects
can produce an unattractive appearance in the scar, which
may prompt the patient to seek scar excision and reclo- FAT NECROSIS
sure. Patients should be informed about these risks before
the injection of the steroid medication. Fat necrosis can occur following any surgical procedure
on the breast, including breast reduction. It most often is
the result of focal devascularization of an area of fat in the
SCAR EXCISION AND WOUND breast but it can also result from trauma, including sur-
RECLOSURE gery. It usually occurs in an area of decreased blood sup-
ply. The process usually presents as an area of induration
As stated earlier, I usually want patients to wait at least a or thickening, and not uncommonly it may be appreci-
year and most of the time longer (18 months) before ated in the most distal aspect of an inferior pedicle
proceeding with a scar excision and reclosure. The opti- employed in breast reduction, where a firmness may be
mal time to proceed is indicated when the scars exhibit palpated above the NAC in the central superior breast
signs of maturation, typically marked by lightening and (Fig. 5-13A). When it occurs, the condition often persists
softening. for 6 to 12 months. If the insult is severe enough to result
When scar excision is elected by the patient, I excise in pronounced ischemia, the area in question may
the scar tissue by incising through the entire dermis on become a hard lump that is noticeable to the patient and
both sides of the scar. I undermine the skin just below the easily appreciated by the examining physician. In my
dermis until the wound edges can be reapproximated experience, areas that present firm masses usually resolve
without tension. I perform a layered wound closure with with time (within 9 to 15 months) unless they are very
interrupted 4-0 coated polyglycolic acid sutures [PDS large. In contrast, areas that become hard do not resolve
(Ethicon, Inc., Somerville, NJ) or Maxon (Sherwood-Davis and never completely soften. Such areas may develop
& Geck, St. Louis, Mo)] with the knots buried. The skin microcalcifications as part of the saponification process
edges are then apposed using a removable subcuticular involved with the genesis of fat necrosis, and these micro-
nylon suture, also of 4-0 gauge. This suture is removed 1 calcifications may be visible on a mammogram (Fig.
week following surgery and the wound edges are splinted 5-13B). These microcalcifications have a characteristic
with Steri-Strips (3M Corp., St. Paul, Minn), which are appearance on mammography that is different and dis-
continuously reapplied for 2 months to eliminate tension tinct from the microcalcifications associated with certain
on the wound edges. I then have the patient place paper breast cancers.
tape over the wound for 3 months unless she has a sensi- If these firm or hard areas in the breast noted after a
tivity to the tape, which will become apparent as she uses breast reduction persist, they should be evaluated. The
it. The patient is instructed to massage the scar twice daily workup of such lesions includes a physical examination,
with vitamin E cream; this is continued for 2 years or until a mammographic imaging of the breast, and not uncom-
all of the hyperemic appearance of the wound has monly a needle aspiration performed in multiple sites of
resolved. the mass using an 18-gauge needle attached to a 10-cc
Following wound separation the scar typically is wide, syringe. The aspirated cells are plated and processed by a
thin, and depressed in its contour. The problem is almost trained cytology technician and then read by a
always located at the T junction or in the area of the verti- cytopathologist.
cal incision. I find that it is usually necessary to excise the In the vast majority of these cases the combination of
entire vertical scar in the middle of the lower pole of the the temporal relationship of the mass to the breast reduc-
breast, along with excising and recreating some length of tion procedure, its characteristic on physical examina-
both the IM and periareolar incision. This is necessary to tion, the typical x-ray appearance, and a benign needle
redrape the skin flaps in a way that will not distort the aspiration cytology report are sufficient to allay any anxi-
NAC. The technique is illustrated in this patient who sus- ety and fears of the patient.
tained skin loss on both breasts following an inferior Some patients are sufficiently bothered by the presence
pedicle breast reduction (Fig. 5-12A). The patient went on of the mass that they request an excision. If excision of the
to heal by secondary intention with epithelialization of mass is elected, it should be performed through the previ-
her wound. She developed a picture of prolapse of the ous incision on the breast. If such a lesion is of sufficient
parenchyma through the wound that produced a contour size, its excision may produce a contour abnormality in
Ch05.qxd 11/28/05 1:38 AM Page 201
FIGURE 5-12. A, Acute skin loss following an inferior pedicle breast reduction performed with a Wise
pattern. B, There is actual prolapse of breast tissue through the thin segment of scar tissue that has
resulted in a contour deformity of the breasts. C, This was treated by operative wound excision and
reclosure. D, The appearance of the breast contour and wounds 3 years following the reoperative surgi-
cal intervention.
Ch05.qxd 11/28/05 1:39 AM Page 202
FIGURE 5-13. A, The most common location of fat necrosis following an inferior pedicle breast
reduction that is superior to the NAC at the most distal aspect of the pedicle. B, The mammogram
shows a characteristic appearance of fat necrosis, which is easily differentiated from other processes.
the breast. If in the mind of the surgeon this sequela is a the breast from the foot of the table.10 If adjustments in vol-
likely result of such an excision, he or she must mention ume, contour, nipple position, or skin envelope draping are
this to the patient preoperatively. I believe that in this situ- necessary, I pursue them before completing the wound clo-
ation, most often it is preferable to perform a subtotal sure. This method produces a level of symmetry that is
excision of such a mass rather than produce a potentially acceptable to most patients. However, as I critically evalu-
major adverse cosmetic effect on the breast from the sur- ate the photographic images before and after breast reduc-
gical treatment of a benign process. It has been my experi- tion in my own patients, I am impressed by the fact that
ence that when it is presented in these terms, most some element of asymmetry is the rule rather than the
patients opt for a subtotal excision of the area of fat necro- exception.
sis. Long-term follow-up in terms of office visits and The overwhelming majority of asymmetries seen fol-
mammographic surveillance are part of the normal man- lowing breast reduction are readily accepted by the
agement of such a patient. patient. I believe that this is because they are so gratified
by the relief of symptoms that they have obtained from
the breast reduction procedure. However, some asymme-
ASYMMETRY tries are significant enough that they are objectionable to
patients. The most common asymmetries relate to vol-
Asymmetry following breast reduction is common. By this ume, contour, IM fold level, NAC appearance, and scar
I mean subtle differences in the size, shape, nipple appear- position. The following section discusses approaches for
ance, or position and contour of the breasts. In fact, I tell all achieving their correction.
patients to expect some degree of asymmetry. Because most
breast reduction patients have some element of asymmetry
before their surgery and they are so grateful for and grati- VOLUME ASYMMETRY
fied by the relief of their macromastia symptoms, they will
most often tolerate minor asymmetries. To obtain the best Discrepancies in breast volume following a breast reduc-
possible symmetry following each breast reduction, I have tion are common. Usually these are minor or subtle in
the anesthesiologist place the patient in the sitting position extent. Occasionally they are more obvious. If the discrep-
at 90 degrees on the operating table so that I can analyze ancy is bothersome to the patient, it can be addressed
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using either liposuction of the breast of by open excision mal incisions required for access, elimination of skin flap
of tissue. and pedicle dissection, the ease of adjusting contours and
It is most desirable to localize the area of breast tissue facilitating symmetry, and maximal preservation of nipple
excess with the patient in the sitting position in much the sensation and much less postoperative patient morbidity.
same way as adipose tissue excess is localized before a The potential drawbacks are the slight risk of nipple are-
body contouring procedure. My custom is to use a mark- ola retraction due to ductal injury and the other risks
ing pen to place marks on the skin over the areas of vol- associated with liposuction.
ume excess that will not be erased by the surgical prep. I When the asymmetry involves not only a volume differ-
employ the same analysis and marking procedure at the ence but a skin envelope disparity and or a discrepancy of
end of essentially every original breast reduction. After nipple position, the use of a standard open surgical
this marking, the surgeon can address the specific areas approach is indicated because it can be used to address all
with the patient in the supine position on the operating of these disparities. The plan in such cases almost always
table. calls for the use of the previous incisions. With this
If the asymmetry relates to volume excess only, i.e., approach the flaps are easily elevated, and most often they
without an accompanying skin envelope disparity or nip- are well vascularized because of what is analogous to a
ple areola asymmetry, then suction lipectomy alone can be previous delay from the original surgery. After flaps are
used for the correction, unless the breast tissue is elevated, the areas to be addressed by additional resection
extremely dense. I prefer to infiltrate the breast with a are directly visualized and correction is easily carried out.
wetting solution containing 12.5-mg % lidocaine If adjustments of the skin envelope are required, these can
(Xylocaine) and adrenaline in a concentration of be done using the tailor-tracking method, which is applied
1:1,000,000. This is made by placing 12.5 cc of 1% to the original incisional pattern (see Fig. 2-32A,B).
Xylocaine and 1 cc of adrenaline 1:1000 into 1 liter of nor- The open correction of asymmetry with surgical resec-
mal saline. I will inject the breast tissues using a 30-cc tion of parenchyma is most often the method of choice if
syringe and an 18-gauge spinal needle. After allowing 15 there is a skin flap asymmetry. The same pedicle should be
minutes for the hemostatic effect of the epinephrine to used as was used in the first procedure. After the previous
take hold, I will perform the liposuction using 3.0- and pedicle is recreated, the necessary tissue resection is car-
3.7-mm cannulae. ried out and peripheral to it in the appropriate areas of the
The following patient (Fig. 5-14A) underwent an infe- breast.
rior pedicle breast reduction for bilateral symptomatic
macromastia. She had the resection of 400 g of tissue
from the right breast and 425 g from the left breast. The NIPPLE AREOLAR COMPLEX
breasts were largely fat replaced. She was noted to have ASYMMETRY
an obvious asymmetry postoperatively (Fig. 5-14B). The
plan for correction of this asymmetry includes only suc- Following almost every type of breast procedure the
tion lipectomy of the right breast (Fig. 5-14C,D), mainly in appearance of the NAC (Fig. 5-16) contributes greatly to
its lateral aspect. The skin envelope symmetry is good, the symmetry of the breasts. If an asymmetry of this key
and I believe that a good correction of her asymmetry is structure is very apparent, it may represent a source of
possible with this minimally invasive approach. patient dissatisfaction. Such asymmetries may be related
This next patient noted a volume discrepancy in her to size, shape (Fig. 5-17), position, projection (Fig. 5-18),
breasts following a right breast reconstruction with an or pigmentation (Fig. 5-19). As outlined in Chapter 2,
implant and a vertical breast reduction on the left side to these are all important factors in breast aesthetics.
optimize symmetry (Fig. 5-15AC). The postoperative Following a breast reduction or mastopexy, it is not
result showed the left breast to be larger than the right, uncommon for the patient to exhibit mild asymmetries of
and this asymmetry was bothersome to her. This situation the NAC. The type of asymmetry depends on the surgical
was addressed using liposuction of the breast as outlined technique used because surgical techniques differ in their
in Figure 5-15D,E, which produced a good outcome from pattern of skin resection and wound closure. For example,
the standpoint of reducing the volume excess and the dis- an elongated or teardrop deformity of the NAC following a
crepancy in projection (Fig. 5-15F). Wise pattern skin reduction is not uncommon, whereas
Suffice it to say that liposuction is a valuable tool for perioareolar techniques often produce enlarged areolae
contour adjustment and volume reduction in the breast, with stellate scar irregularities around the periphery
just as it is elsewhere. It is becoming increasingly popular because of bunching of the skin and spreading of the NAC.
as the sole means of accomplishing primary breast reduc- Revision of any of these asymmetries should be deferred
tion. I predict it will have far greater application in the until the postoperative edema in the breasts has com-
area of breast reduction in the upcoming years. The pletely resolved. This usually means for a period of at least
advantages of this approach include the extremely mini- 6 months following surgery.
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FIGURE 5-14. A, Preoperative appearance of a 70-year-old patient requesting breast reduction. B,

She underwent a bilateral breast reduction using an inferior pedicle technique. There was slightly more
tissue resected on the left side than on the right side, and she shows an obvious asymmetry with the
right breast being larger than the left. CD, Correction is planned and will entail liposuction alone to
achieve better contour and volume symmetry between the breasts.
A typical asymmetry following the Wise pattern skin time the left NAC was reduced in size and elevated. This
resection with an inferior pedicle reduction is illustrated by prompted a reoperation, which was performed at 12
the patient in Figure 5-17, who underwent a 400-g resection months following surgery. The pre-operative plan begins
of tissue from each breast. She was bothered by the dis- with identifying the appropriate new level for the top of the
crepancy in the size, shape, and position of the NACs areola. This is marked from the fixed reference point of
(Fig. 5-17A). This prompted a reoperation, which was per- the supra-sternal notch (Fig. 5-17B). The desired size of the
formed 8 months following the original procedure. At that new areola is then marked. This is based on the size of the
Ch05.qxd 11/28/05 1:39 AM Page 205
FIGURE 5-15. A, A 55-year-old patient who has undergone a right mastectomy and immediate first
stage breast reconstruction with a short height tissue expander placement. B, The second stage plan is
for an implant reconstruction on the right and a vertical breast reduction on the left. C, The results of
that treatment show suboptimal symmetry with the left breast still too large. D, The plan for reopera-
tion includes liposuction of the left breast and a revision areola size of the nipple position. The mark-
ings for the revision are illustrated. E, The liposuction cannula attached to the syringe aspiration
system is being used to achieve correction. F, Markedly improved symmetry from the standpoint of vol-
ume and breast shape is demonstrated after the liposuction.
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FIGURE 5-16. Excellent postoperative nipple areola aesthetics are noted on frontal view in this
patient who has undergone a breast reduction.
opposite areola. The actul dimensions are marked on the requires at least 6 knots to avoid slippage. The knots must
areola to be repositioned (Fig. 5-17C). An area of areola and be buried in the subcutaneous tissue and the suture is
breast skin outside this is marked for resection as a periph- pulled through the skin outside the closure and cut flush
eral donut (Fig. 5-17C). This area is de-epithelialized at with the skin so that it can retract. This will minimize any
surgery. The superior border of the de-epithelialization is possibility of suture exposure. This method has produced
the intended level of the new areola (Fig. 5-17D). The open long-term stabilization of periareolar wound closure in this
wound around the areola is considerably larger than the setting (Fig. 5-17H) and that of peri-areola mastopexy and
areola size at this point. This skin opening must be reduced circum, vertical mastopexy.
and fixed with a peri-areola purse string suture to minimize
subsequent spreading of the areola post-operatively. To
accomplish this I use a permanent suture. In the past I used NIPPLE RETRACTION
a braided 3-0 suture such as Ethibond or Mersilene. Over
the past 3 years I have exclusively used a no. 2 Gortex Nipple retraction can be seen with any technique used for
suture that is swaged onto a straight Keith needle (Fig. 5- breast reduction. In the past it was most commonly noted
17E). This suture is placed into the deep dermis. Each pass with the Strombeck procedure. Nipple retraction results
is initially made deep in the dermis, but as a 1.0-cm bite is when the volume of breast tissue beneath the nipple is
taken, the needle moves closer to the skin and then comes insufficient to allow the nipple to maintain its position as
out again in the deep dermis. Passes are made across to the the most anteriorly projecting part of the breast gland. To
areola every 60 degrees, so a spoke wheel pattern is noted. avoid this deformity, a concerted effort must be made to
The suturing proceeds around the entire circumference of maintain breast parenchyma beneath the NAC. When per-
the peri-areola incision to be closed (Fig. 5-17F). Next the forming an inferior pedicle reduction, I create a pyrami-
ends of the suture are tightened so as to make the periph- dal pedicle by resecting the breast tissue away from the
eral skin slightly overlap the areola, making it slightly central portion of the pedicle. As mentioned previously in
smaller than the opposite side. This is checked by measur- this chapter, regardless of the pedicle used, sufficient tis-
ing the areola diameter on the opposite breast and setting sue must be maintained in the pedicle so that the skin
the areola size exactly where it needs to be to achieve a envelope is filled by the remaining breast tissue (see
slightly smaller opening (Fig. 5-17G). The Gortex suture Fig. 5-7).
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FIGURE 5-17. A, Postoperative asymmetry following inferior pedicle breast reduction. Note signifi-
cant difference in the size of the NACs. B, The plan entails equalizing the heights of the areolae. This is
done with the patient standing upright. C, The skin to be removed from the periphery of the new areola
is estimated by the pinch test. D, At surgery this skin is excised into the deep dermis. An incision is
made at the periphery of the opening, leaving 3 cm of dermis inside the skin excision. (continued)
Ch05.qxd 11/28/05 1:40 AM Page 208
FIGURE 5-17. (CONTINUED) E, The Gortex suture is passed. The position of the suture is in the der-
mis. The bites go from deep to superficial and then deep in the dermis. F, A complete circumference of
the peri-areola cut-out is encircled by the Gortex. G, The suture is used to bring the peripheral skin into
a dimension slightly smaller than the opposite areola and the suture is tied. H, The patient is shown 8
months following surgery with a stable correction and excellent areola symmetry.
When correction of this deformity is undertaken, it is NIPPLE MALPOSITION

usually necessary to tighten the skin envelope by advanc-
ing the medial and lateral flaps centrally, along with tight- Nipple malposition is often noted as being the most com-
ening the periareolar skin cutout. It may also be necessary mon long-term complication of breast reduction. Most
to increase the parenchymal support below the nipple by often the nipple is placed too superiorly on the breast. I
mobilizing and suturing breast tissue beneath the NAC, or believe that plastic surgeons are responsible for most of
perhaps by unfolding the de-epithelialized from the lower the nipple malposition that is seen. That is to say that we
breast or unfolding a de-epithelialized skin flap as illus- place our nipple too high in the first place.
trated for treatment of nipple malposition in the following Following a mammoplasty procedure, the nipple stays
section. where the surgeon puts it but the rest of the breast tissue
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FIGURE 5-19. Hypopigmentation of the areola after breast

reduction using the resection and nipple graft technique in this
black patient. Hypopigmentation of the areola is a definite poten-
tial problem in any case of nipple ischemia and is not uncommon
with full-thickness reapplication of a nipple and areola. This
hypopigmentation can be treated with intradermal tattoo.
FIGURE 5-18. Nipple loss following previous breast reduction
in patient seen for correction of this problem.
settles away from it. That is to say that the distance skin graft for closure of the previous nipple position. I
between the lower aspect of the areola and the IM fold have no experience with this method because it results in
increases following surgery, resulting in a decrease in a scar above the nipple. Another strategy is to place a tis-
breast projection and the appearance that the nipple is sue expander beneath the skin in the upper central part of
superiorly displaced.11 For this reason it is important to the breast and move the entire skin envelope inferiorly.
select the correct nipple position before surgery. As noted I have done this in the reconstruction of Poland
in Chapter 2 (see Fig. 2-11A,B), this is commonly done by syndrome, where I have first expanded the skin envelope
transposing the IM fold level anteriorly onto the breast and at a second stage done a latissimus dorsi muscle flap
using a finger behind the breast. For surgeons using this and subflap implant. The expansion of the skin envelope
landmark, I believe that the best method of accurately has lowered the nipple as much as 3.5 cm.
establishing the position of the IM fold is by placing a tape For superior nipple malposition following breast
measure directly in the fold (Fig. 5-20A). This allows the reduction or mastopexy, I prefer the method of shortening
nipple to be positioned appropriately in virtually every the distance from the nipple to the IM fold by excising the
case, and nipple position tends to remain in a more appro- skin excess that exists in that location. The technique is
priate aesthetic location, as seen in this patient on 4-year illustrated in Figure 5-22. This works in two ways: it
follow-up (Fig. 5-20B,C). directly decreases the skin excess that exists between the
Nevertheless, nipple malposition is the most common lower part of the areola and the IM fold, and folding tissue
problem following breast reduction and mastopexy. There inferiorly under the breast increases the fullness in the
is a range of superior nipple malposition in every plastic upper pole, providing the illusion that the nipple is better
surgeons breast reduction practice (Fig. 5-21AD), rang- centered behind the breast mound.
ing from mild to significant. Once again, many women The patient pictured in Figure 5-21D is one of the first
will tolerate most of the upward inclination of the nipple, women, on whom I performed a vertical breast reduction.
and some even find this appearance attractive. This breast reduction entailed the resection of 640 g of
Superior malposition of the NAC can be corrected by tissue on the right breast and 630 g of tissue on the left
moving the NAC inferiorly on a pedicle, usually with a (Fig. 5-23A). It was carried out with a superior pedicle
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FIGURE 5-20. A, The optimal way of precisely locating the

new nipple position in a breast reduction procedure is with a
tape measure placed in the IM fold. This provides the correct
position for nipple location at surgery, and the position is often
maintained as in these 4-year follow-up photographs. B, AP
view. C, Lateral view.
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FIGURE 5-21. AD, Various degrees of nipple malposition following breast reduction seen in four dif-
ferent patients.
Ch05.qxd 11/28/05 1:41 AM Page 212
B
A
De-epithelialized tissue
A B C turned under breast mound D
to increase projection
FIGURE 5-22. AD, My preferred technique for correcting superior nipple malposition secondary to
bottoming out following a previous breast reduction.
FIGURE 5-23. Superior nipple malposition following one of my early vertical breast reductions. A,
The nipples were placed at 21 cm from the SSN during the original procedure. B, Note the skin excess
between the lower areola and the IM fold on each side. The planned correction should include a cres-
centic excision of skin from the lower aspect of the areola (C) and a resection of skin in a horizontally
oriented ellipse from the lower pole of the breasts (D).
Ch05.qxd 11/28/05 1:41 AM Page 213
technique. She exhibited significant superior nipple areola ficult situation. As previously stated, conservatism with
malposition. I was more bothered by this than she was. active wound care, including the application of topical
The SSN to nipple distance was 21 cm (Fig. 5-23B); antibiotics and very judicious wound dbridement, often
however, there was a lengthy distance between the lower leads to a good outcome.
areola area and the IM fold on both breasts (Fig. 5-23C). Such a case is illustrated by this 22-year-old patient
My plan was to resect a large amount of skin on the lower requesting a bilateral breast reduction (Fig. 5-26A). She
pole of the breast only (Fig. 5-23D) and to turn under- requested a minimal scar reduction and we proceeded
neath the breast a large de-epithelialized flap of subcuta- with a superior pedicle vertical reduction despite that she
neous fat and breast tissue to increase the upper pole was a smoker. The procedure went well, but in a follow-up
fullness while revising the long lower pole distance as office visit on postoperative day 4 she was noted to have
illustrated in Figure 5-22. The patient relocated to ischemia of her right NAC (Fig. 5-26B). I did not feel that
another city before our planned surgery, but she is a good the application of nitrates had any role in her care at this
example of a patient with superior nipple areola malposi- point, and therefore we had her apply bacitracin ointment
tion who could have been helped with the strategy just 4 times daily. She was seen frequently, and we began very
outlined. judicious dbridement on postoperative day 16 when
there was evidence of demarcation (Fig. 5-26C) of her are-
olar and nipple tissues. Her appearance after dbriding
INFERIOR NIPPLE MALPOSITION the eschar is noted on postoperative day 23 (Fig. 5-26D).
She subsequently went on to a long course to healing over
When the NACs are asymmetric with one placed too low, 4 months (Fig. 5-26E,F). Eventually an intradermal tattoo
it is possible to produce a superior relocation of the provided a reasonably good appearance to the NAC
lower NAC. Small discrepancies (<2 cm) in the position (Fig. 5-23G).
of the upper portion of the areola can be addressed by This case represents the worst complication involving
directly excising a crescent of skin directly above the are- the NAC that I have had in a breast reduction. In retro-
ola (Fig. 5-24). This allows advancement of the areola spect, I probably should have selected another technique
and better symmetry. This technique should not be used for this smoking patient. I no longer perform vertical
when elevation greater than 2 cm is needed because it mammoplasty in smokers because I believe the complica-
will produce an elliptical or elongated appearance in the tions related to imperfect healing in the vertical incision
areola. are simply too great. Other lessons to be learned and rein-
For more significant elevations of the NAC I find that forced from this case are the need to be very conservative
the combination of a periareolar incision and a vertical V with dbridement in this type of a situation involving tis-
incision in the central part of the breast works very well sue necrosis of the NAC; to monitor the wound conditions
(Fig. 5-25). This technique moves the medial and lateral for healing and any evidence of infection very carefully;
edge (or pillar) of breast tissue in behind the nipple areola, and to support the patient through what is a difficult time
thereby creating support for holding it in place. In addi- for her (and the surgeon), maintaining optimism and tak-
tion, it has the added benefit of conifying the breast and ing every measure to provide the best possible outcome.
potentially improving its shape in that way. The circumstance of nipple areola ischemia does not
always end as favorably. Complete nipple loss following
reduction mammoplasty can be treated with a nipple
reconstruction procedure. In my opinion this can be best
CHALLENGING PROBLEMS
accomplished using a pull-out flap (modified star flap or
FOLLOWING BREAST REDUCTION
double opposing periareolar flap, both derivatives of the
skate flap design) and a subsequent intradermal tattoo.
Nipple Loss
The procedure can be done as an outpatient under local
Loss of the NAC is a potential complication of every anesthesia in an office setting. I usually recommend wait-
mammoplasty procedure. I mention this preoperatively ing at least 2 months between the completion of the nipple
to my patients. Fortunately it is very rare. We have reconstruction and the medical tattoo. With a well-done
already discussed the intraoperative maneuvers that can tattoo the results can be quite satisfactory.
be undertaken to address the problem of nipple ischemia Such a situation is illustrated by this 43-year-old
when it is recognized in the operating room. patient who was self-referred after sustaining a loss of her
In rare instances the problem will be noted for the first right nipple during an inferior pedicle breast reduction
time in the postoperative period. In these cases it is impor- (Fig. 5-27A). The nipple loss was accompanied by
tant for the surgeon to take a very conservative approach, hypopigmentation of the surrounding areolar complex tis-
maintain a positive outlook, and to be a doctor from the sue. There was reasonably good projection of the opposite
standpoint of supporting the patient through what is a dif- nipple (Fig. 5-27B), and the patient requested a procedure
Ch05.qxd 11/28/05 1:41 AM Page 214
excise crescent of tissue and the areolar tissue 3 months postoperatively. This restored
move nipple superiorly satisfactory symmetry between her nipple areola regions
(Fig. 5-27E).
Nipple areolar asymmetries produced by hypopig-
mentation of the areola (see Fig. 5-19) are not uncom-
mon, especially when the technique of breast
must not
} parenchymal resection and nipple transplantation is
exceed 2 cm
used in breast reduction. This is particularly a problem
in dark-skinned patients. The use of intradermal tattoo-
ing has allowed the plastic surgeon a straightforward
way to successfully manage such problems for patients
who experience it. Like all such tattoos, these often fade
with time and will need to be redone. When there is
dense scar tissue at the site of the areola, which is
exactly what happens in the setting of nipple areola loss,
tattooing is more difficult, and very often these tattoos
need to be repeated. As outlined in Chapter 10, the sur-
geon or medical tattoo artist should avoid the tempta-
tion to use a darker pigment than is present on the
opposite nipple. This can produce a color mismatch that
Elevating a nipple that is too low might require excision and full-thickness skin graft
placement as a means of correction.
FIGURE 5-24. The correction of mild inferior nipple malposi-
tion by the excision of a crescent of skin from the area above the
areola. Massive Fat Necrosis
Massive fat necrosis is a rare problem. It can result when
Vertical Incision Pattern the blood supply to the pedicle is significantly compro-
mised. Fat necrosis involving a large segment of tissue can
De-epithelialize present with erythema, fever, and pain. The acute inflam-
skin here
matory process must be given adequate time to settle
down. Antibiotics may be necessary only if there is accom-
panying infection.
resect skin
above and with If there is good skin coverage, a long period can elapse
parenchymal below before any surgical treatment is contemplated. The area
will most often organize itself into a firm mass that may
be hard and uncomfortable. If it produces discomfort or
visible distortion, surgical resection may be indicated.
Resection of the area can be undertaken. If the resection
involves a large area, a defect in the contour of the breast
may result. In this situation a rearrangement of the
remaining breast tissue in the form of flaps can minimize
such a contour abnormality.
Such a case is illustrated by this 68-year-old female
who had undergone a right lumpectomy and radiation
for breast cancer. This resulted in a significant breast
FIGURE 5-25. Correction of a more significant inferior nipple asymmetry that was treated 2 years later with a bilateral
malposition often requires a vertical incision to achieve stable inferior pedicle breast reduction. This latter operation
relocation of the NAC. produced a large area of fat necrosis in the upper central
aspect of the breast, with accompanying contour defor-
to restore a more symmetric appearance with the opposite mity (Fig. 5-28A). The area was exquisitely painful and
nipple. We used a modified star flap (Fig. 5-27C), which very hard on palpation. The patient had difficulty lying
was elevated in the appropriate location (Fig. 5-27C), on her right side, and there was pain in the chest region
overbuilding it slightly in anticipation of some loss of pro- at the extremes of shoulder motion. Breast imaging stud-
jection with healing (Fig. 5-27D).12 The patient healed ies did not suggest cancer recurrence. We allowed 9
without difficulty and underwent intradermal tattooing of months to elapse before proceeding with a surgical
Ch05.qxd 11/28/05 1:41 AM Page 215
FIGURE 5-26. A, Preoperative AP view of patient who will undergo a vertical breast reduction using
the superior pedicle technique. There were no abnormalities noted at surgery. B, Appearance on post-
operative day 4 in the office with obvious ischemia of the right nipple and areola. Treatment was begun
with the application of bacitracin ointment around the clock to keep the areola moist. C, An eschar is
noted at 16 days postoperative. D, It is dbrided at 23 days following surgery. (continued)
Ch05.qxd 11/28/05 1:42 AM Page 216
FIGURE 5-26. (CONTINUED) Appearance of the nipple areola

at 10 weeks (E) and at 4 months (F) without any additional
surgery. G, An intradermal tattoo solves what was a difficult
problem.
Ch05.qxd 11/28/05 1:42 AM Page 217
resection of the mass, which had not shown any ten- This situation was posed by this 55-year-old patient who
dency toward softening. For that reason we undertook a presented with bilateral nipple areola loss and significant
surgical exploration for resection of the mass after veri- fat necrosis in the central area of her breasts, allegedly
fying that an inferior pedicle was used for the breast after undergoing a breast reconstruction by a nonplastic
reduction (Fig. 5-28B). surgeon (Fig. 5-29A). She was seen frequently in the office
The mass was subtotally excised but all of the hard, cal- for judicious dbridement and maintained on a wet to dry
cified tissue (Fig. 5-28C) was resected. This specimen dressing regimen. This plan enabled her to obtain a healed
measured 9 6 8 cm (Fig. 5-28D) and the adjacent breast wound, and we subsequently sought to resect the necrotic
tissue was mobilized medially. The patient healed with a tissue in her central breast and reconstruct her breast form
small anticipated asymmetry, but her pain completely along with the NAC after the wounds had matured.
resolved (Fig. 5-28E). Unfortunately she was lost to follow-up before the planned
The other and more dreaded scenario involving fat second procedure.
necrosis is that which is accompanied by skin loss and Such a case could be treated after 6 months of complete
an open wound exposing the hypovascular breast and uninterrupted wound healing by the central transposition
fat tissue. This situation requires serial, conservative, of the remaining medial and lateral breast segments, which
judicious dbridement. The exposed tissue that is obvi- are elevated as full-thickness composites after the resection
ously necrotic must be dbrided. Wound care with of the central necrotic fat tissue in the form of an inverted
moist dressings and antibiotic ointments facilitates V. It is important to maximize the circulation to the
wound contraction and epithelialization. Secondary remaining breast tissue segments. My plan was to simulta-
surgery is timed such that the wound conditions are neously perform a nipple reconstruction with a superiorly
optimal. based wrap around a skin flap (see Fig. 8-10D).
FIGURE 5-27. Loss of the nipple and hypopigmentation of the NAC of the right breast following a pre-
vious breast reduction. A, AP view. B, Oblique view C, The reconstruction is done with a modified star
flap. D, The nipple is overbuilt in anticipation of some loss of projection with normal healing, which
will include some element of contraction of the nipple. E, An intradermal tattoo completes the recon-
struction of the areola and restores relatively normal breast and nipple symmetry. (continued)
Ch05.qxd 11/28/05 1:42 AM Page 218

Ch05.qxd 11/28/05 1:43 AM Page 219
FIGURE 5-28. A, Patient presents 8 months after a breast

reduction done on a right breast that had undergone a previous
lumpectomy with a painful, hard mass in the upper aspect of the
breast above the areola. B, The mass is outlined. The imaging
studies were all consistent with fat necrosis. C, Exploration of
the breast is undertaken through the incisions outlined. D,
Subtotal resection of this area of fat necrosis produces this spec-
imen. E, AP view 6 months postoperatively.
Ch05.qxd 11/28/05 1:43 AM Page 220
FIGURE 5-29. A, Massive bilateral fat necrosis and nipple loss in patient presenting to me for analysis
and proposed treatment options. B, Six months of judicious office dbridement and wound care by the
patient have produced healed wounds. She is now ready for excision of the necrotic areas, breast
reshaping, and nipple areola reconstruction.
Fat necrosis of this degree following breast reduction I encountered a form of this problem in a patient on
is decidedly rare in my experience. It may be more com- whom I performed a breast reduction at age 20. She was
mon in patients with an underlying vasculitis such as an athletic young woman who ran on the college track
lupus erythematosus or scleroderma. Surgery in the face team and whose full D cup breasts often impeded her
of previous whole breast radiation also probably puts the performance. We performed an inferior pedicle reduc-
patient at increased risk for its occurrence. As indicated, tion, reducing her to the full B cup size that she had
I prefer to perform subtotal resections of such areas to requested. Over the next 6 years she lost 20 lb and her
minimize the deformity. If the volume loss due to the breast volume further decreased and descended inferi-
excision of such a focus is too substantial, a breast recon- orly (Fig. 5-30A). This produced a significant lack of
struction can be performed either by placing a subpec- superior pole fullness, which was bothersome to her
toral breast implant or developing a musculocutaneous (Fig. 5-30B). We decided to pursue a breast augmenta-
flap in the form of a latissimus dorsi flap or a rectus tion to restore upper pole breast fullness (Fig. 5-30C).
abdominis flap. This was done with the retropectoral placement of high-
profile smooth-walled silicone gel implants (11.7 cm, 375
cc) using her existing IM incision. This patient had
Subsequent Volume Loss with Loss of
undergone the placement of a permanent defibrillating
Breast Fullness
device in the subcutaneous tissue layer of her upper left
A dreaded complication of breast reduction is overresec- chest region approximately 8 months earlier. In addition
tion of tissue, which leaves the patient with significantly to placing the silicone gel breast implants, we treated the
smaller breasts than anticipated. This can largely be slight settling away of her breast tissue from the implant
avoided with careful preoperative communication with a mastopexy, also done using her previous breast
between the surgeon and the patient and a precise surgi- incisional pattern (Fig. 5-30D). This produced a satisfac-
cal resection. tory result (Fig. 5-30E-G).
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The plastic surgeon performing breast reduction tightening can be used to achieve a redo breast reduc-
should do everything possible to avoid having to place an tion.
implant to treat volume overresection. This is almost
always possible to do with regard to the foreseeable post-
operative period. However, the passage of time, weight REDO MASTOPEXY
loss, and the settling of a patients breast parenchyma can
produce the clinical situation just described. In such Mastopexy is a procedure that reshapes and uplifts the
cases implant placement may be a good solution. breast parenchyma and repositions the NAC, placing it in
However, the key is to avoid getting into this situation a more aesthetically desirable location while tightening
whenever possible. the skin envelope and sometimes the parenchyma itself.
It is a procedure with a finite lifespan. The duration of the
benefit derived from the operation depends on a number
REDO REDUCTION of factors, including the degree of existing ptosis, the
elasticity of the skin and breast parenchyma, and the
Another uncommon scenario in my practice is recurrent patients heredity and overall health.
breast hypertrophy, which prompts the patient to seek a The challenge that all plastic surgeons face when per-
redo reduction. However, weight gain, which is so com- forming a mastopexy is to reposition the existing breast
monly seen as the patient moves into her second, third, tissue in a more favorable (almost always superior) posi-
and fourth decades of life, can be reflected in a recrudes- tion and keep it there using parenchymal suspension or,
cence of large breasts in a patient who has had a previous more commonly, skin support. Often it is difficult or
reduction. impossible to move the breast tissue substantially cepha-
Such patients may be candidates for a breast reduction lad; however, the vertical mastopexy technique is a power-
done by liposuction alone if the recurrent enlargement is ful breast shaping tool in this regard. This is illustrated by
due to adipose tissue content and there is not significant this 48-year-old patient with grade III ptosis who desires a
accompanying breast ptosis. This technique is being per- breast uplift (Fig. 5-32A,B). The vertical technique using a
formed more widely, and it can be quite effective for superior pedicle produces a dramatic change in the breast
reducing breast volume without redo flap elevation and shape on the operating table (Fig. 5-32C). The patient is
parenchymal dissection. However, many patients who shown 2 years postoperatively with maintenance of an
have noted a weight gain also report and show a change in excellent appearance of her breasts (Fig. 5-32D,E). The
shape that requires a re-elevation of the skin flaps and a vertical technique is a parenchymal reshaping procedure
formal redo reduction. where the medial and lateral breast tissue segments or pil-
Alternatively, a patient may seek not only another vol- lars are closed in behind the central segment that moves
ume reduction but an enhancement of breast shape. In up, thereby providing an intrinsic means of support to
this situation a formal redo breast reduction can pro- keep this central segment in its new position.
vide not only a smaller breast but an enhancement in With time an inevitable degree of tissue relaxation and
projection, settling occurs. This settling is aided by the factors noted
An example is seen in this next patient who had earlier and also by the constant force of gravity acting on all
undergone an inferior pedicle breast reduction in her of our body parts, including the breasts. Therefore, the real-
late teenage years with a good outcome. I saw her 10 ity of the situation is that the most common complication
years later with recurrence of her breast enlargement or unwanted side effect of every mastopexy is that of recur-
(Fig. 5-31A) as an accompanying feature of a 50-lb rent ptosis. All patients must be informed about this before
weight gain. The plan was to perform a redo breast surgery. They must understand that while the scars that are
reduction, again using an inferior pedicle (Fig. 5-31B,C), necessary for the completion of the mastopexy procedure
and abdominal liposuction. We used the tailor-tacking are permanent, the result will in all likelihood not be.
method of guiding skin excision (Fig. 5-31D). She The most common reasons for reoperation following
achieved smaller, more symmetric appearing breasts previous mastopexy are dissatisfaction with breast shape
(Fig. 5-31E,F) with this redo breast reduction and was due to recurrent ptosis, suboptimal scarring, inadequate
pleased with the outcome. breast fullness, and nipple malposition. In those cases
Redo breast reduction is a rare plastic surgery proce- where a patient has undergone a previous augmentation
dure. If it is undertaken, I believe it is important to use mastopexy, there may be problems related to the implant
the same pedicle orientation that was used in the such as capsular contracture, implant malposition, or set-
primary operation. In addition, it is also most common tling of the breast tissue away from the implant. My per-
to use the same skin incisions. If the skin envelope is rel- sonal reoperation experience includes patients who have
atively normal with an expectation of skin contraction, undergone previous mastopexy alone, and patients who
the liposuction alone with or without minimal skin have undergone previous augmentation mastopexy. I have
(continued on p. 227)
Ch05.qxd 11/28/05 1:43 AM Page 222
FIGURE 5-30. AB, AP and lateral views of patient who underwent breast reduction by me 8 years
earlier. With a 20-lb interval weight loss she has lost the superior pole fullness in the breasts. CD, The
plan is for a silicone gel submuscular breast augmentation. (continued)
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FIGURE 5-30. (CONTINUED) EG, The 4-month postoperative

views demonstrate a nice restoration of breast fullness.
Ch05.qxd 11/28/05 1:44 AM Page 224
FIGURE 5-31. AB, Preoperative photographs of a patient who had undergone a breast reduction 10 years ear-
lier. There has been an interval weight gain of 50 lb. C, The plan is for redo breast reduction. D, The skin excision is
guided by a tailor-tacking maneuver. (continued)
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FIGURE 5-31. (CONTINUED) EF, The postoperative appear- FIGURE 5-32. A, AP view of the breasts in a patient with grade
ance at 8 months shows a satisfactory appearance of the breast III ptosis. There is decreased skin and parenchymal elasticity.
reduction. B, The vertical mastopexy is a powerful breast reshaping tool,
as is demonstrated by this photograph after performing the
superior pedicle vertically on the right side only. (continued)
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FIGURE 5-32. (CONTINUED) C, AP view of the breasts at

2 years following surgery. D, Preoperative lateral view.
E, Postoperative lateral view at 2 years following surgery.
Ch05.qxd 11/28/05 1:45 AM Page 227
seen many patients who have had a previous augmenta- soft tissue laxity a breast augmentation alone would have
tion and whose tissue over time has settled away from the produced fuller but matronly appearing breasts, a look
implant. All of these patients may be candidates for a redo that she was definitely not interested in. After two con-
mastopexy procedure. sultations we settled on the procedure of augmentation
As with the reoperative procedures following breast mastopexy.
reduction, it is important for the surgeon to know what The plan was to perform a vertical augmentation
pedicle was used to carry the NAC. For those patients who mastopexy (Fig. 5-34C) with the partial subpectoral place-
are seen in consultation for consideration of a secondary ment of smooth-walled saline implants (11.9 cm, 320 cc)
procedure, the most reliable way to know this is by read- with a nipple transposition distance of 3.5 cm, using the
ing the previous surgeons operative report. Most often the tailor-tacking method for skin adjustment (Fig. 5-34D). At
same incisional pattern or a portion of it will be used. If a 4-month follow-up office visit she showed excellent
the patient has undergone a previous augmentation upper pole breast fullness and a good appearance of the
mastopexy, important information for the surgeon to have breasts on lateral view (Fig. 5-34E,F). At 16 months post-
includes the type of implant used and the implant posi- operatively there was settling of her implants with loss of
tion, as well as the most recent imaging data of the breast, upper pole fullness (Fig. 5-34G,H). The patient requested
which may provide information as to the status of the another operation to try to regain the upper breast full-
implant, i.e., whether it is intact or possibly ruptured. ness. The plan was to repeat the vertical mastopexy, tight-
Once again, it is important to realize that the presence of a ening the parenchyma and excising additional skin, and to
subglandular implant does reduce the blood supply to the exchange the saline implants (Fig. 5-34I) for larger ones
breast parenchyma. This must be taken into account if (12.3 cm, 390 cc). At a 7-month postoperative follow-up
part of the plan is to move the NAC a long distance on the visit the patient has regained her upper pole breast full-
glandular pedicle. ness and the contour of the breasts is improved in every
Patients with advanced ptosis that occurs at an early respect (Fig. 5-34JL).
age are especially prone to relapse after a mastopexy pro- The final patient was presented with dissatisfaction
cedure. Such a situation is illustrated by this case of a 36- related to her breast appearance. She had undergone a
year-old nulliparous athletic female who presented with bilateral subglandular breast augmentation with smooth-
dissatisfaction related to her breast shape (Fig. 5-33A,B). walled silicone gel implants 18 years earlier. Approximately
There was markedly decreased elasticity of both the skin 10 years after that she had a second procedure to address
and the parenchymal tissue as evidenced by striae on the bilateral capsular contracture with the placement of
skin and the shape of the breasts. The plan was for a verti- polyurethane implants. She noted that the implants
cal mastopexy using a superior pedicle (Fig. 5-33C). There seemed high and that her breast tissue had begun to settle
was nipple transposition of 8 cm on the right and 7 cm on away from her implants. For this reason 4 years before
the left. No breast tissue was resected. The procedure was these photographs (Fig. 5-35) were taken she had an
complicated by skin loss involving the vertical incision inverted T mastopexy with a superior pedicle. She pre-
bilaterally and ischemia at the periphery of the right are- sented with excess superior fullness (Fig. 5-35A) and a pic-
ola (Fig. 5-33D). She developed widening of the scars and ture of her breast tissue settling away from her implants
some loss of the correction we had achieved (Fig. (Fig. 5-35B). She wanted softer breasts with better nipple
5-33EG). Fourteen months after the original operation position. The plan was for an explantation of her
we reoperated to revise the previous mastopexy. This polyurethane implants through the vertical limb of her pre-
entailed the excision of additional periareolar skin and vious incisions, through which we accessed (Fig. 5-35C)
recreation of the pillars with resuspension of the gland and removed the polyurethane implant by performing a
(Fig. 5-33H). The appearance at the completion of that total periprosthetic capsulectomy (Fig. 5-35D). We sutured
revision procedure is illustrated in Fig. 5-33I. The 8- the subglandular space closed (Fig. 5-35E) and inserted
month postoperative view (Fig. 5-33J,K) reveals satisfac- shaped textured saline implants [McGhan style 363, base
tory appearance of the breasts with an improvement in width 12.2 cm, height 10.2 cm, 315 cc (McGhan Medical
the shape, symmetry, and scar condition of both breasts. Corp., Santa Barbara, Calif)] into the subpectoral space.
This case illustrates the rather rapid relapse of some These implants were selected to give a maximum of lower
of this patients ptosis. The early reoperation was precipi- pole projection with a minimum of superior pole fullness
tated by the suboptimal scar appearance and the subopti- as desired by the patient. On the operating table she shows
mal breast form. an improved breast appearance (Fig. 5-35F). On her 3-year
This next patient highlights some of the same issues. postoperative follow-up examination she has maintained
She too is a 36-year-old nulliparous female who pre- an excellent result on both the AP (Fig. 5-35G) and lateral
sented to my office for a breast augmentation. Her views (Fig. 5-35H).
breasts had a settled appearance and her tissue exhibited These three patients illustrate the type of breast tissues
a generalized looseness. I felt that given her anatomy and that are especially prone to reoperation following
Ch05.qxd 11/28/05 1:45 AM Page 228
FIGURE 5-33. AB, Marked ptosis in this 36-year-old fit and athletic nulliparous female. C, The initial
mastopexy will be done with the superior pedicle vertical technique. D, Postoperatively there is
ischemia of the skin of the lateral pillar flap and the periphery of the areola on the right. (continued)
Ch05.qxd 11/28/05 1:45 AM Page 229
FIGURE 5-33. (CONTINUED) The appearance at 10 months following surgery shows some loss of
correction (EF) and suboptimal scarring (G). H, The plan for redo mastopexy includes resection of
skin and remaking the pillars. (continued)
Ch05.qxd 11/28/05 1:45 AM Page 230
FIGURE 5-33. (CONTINUED) I, The appearance of the breasts

on the operating table at the end of the second procedure. JK, An
improvement in the overall breast appearance is seen 8 months
following the second surgery.
mastopexy. The guiding principles for reoperative surgery Augmentation mastopexy is an operation whose degree
are to establish the appropriate aesthetic or correct nipple of difficulty and potential hazards is greater than the sum
position; communicate with the patient about her breast of its parts. However, I strongly feel that it can be learned
volume and decide whether an implant is needed to achieve and that it is possible to do well on a consistent basis. The
the desired superior breast fullness; and use the previous key to success is communicating with your patient to
incisions, or a portion of them, to perform the procedure. make sure she is informed of the risks, complications,
I firmly believe that mastopexy is a challenging but fun and realities of the procedure. Perhaps the most common
operation. My impression is that when well done it car- reality of mastopexy and augmentation mastopexy is that
ries with it a high degree of patient satisfaction. of reoperation.
Ch05.qxd 11/28/05 1:46 AM Page 231
FIGURE 5-34. This is a 36-year-old nulliparous patient with grade II ptosis requesting breast rejuve-
nation. A, AP view. B, Lateral view. Note the extreme laxity of the tissues. C, The plan is for a vertical
pattern augmentation/mastopexy. D, The tailor-tack method guides the skin excision on the table.
(continued)
Ch05.qxd 11/28/05 1:46 AM Page 232
FIGURE 5-34. (CONTINUED) EF, She shows a nice appearance of the breasts at 4 months following
surgery. GH, One year later (16 months postoperatively) she demonstrates loss of upper pole breast
fullness.
Ch05.qxd 11/28/05 1:46 AM Page 233
FIGURE 5-34. (CONTINUED) I, The redo augmentation/mastopexy requires redoing the vertical
mastopexy and placing a larger implant. JL, This results in a much improved breast appearance at 7
months following the second operation.
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FIGURE 5-35. AB, AP and lateral views of a patient who has undergone two previous breast sub-
glandular silicone gel implant breast augmentations. The first was performed 18 years ago and the
second one 10 years later. Note that the breast tissue has settled away from the implants. CD,
A total periprosthetic capsulectomy completely removes the implant. (continued)
Ch05.qxd 11/28/05 1:47 AM Page 235
FIGURE 5-35. (CONTINUED) E, The subglandular space is closed with sutures. F, There is no nipple
transposition and new shaped textured saline implants are placed and the lower pole tissue is tightened.
Note improved contour lower pole of breast parenchyma and skin when compared with preoperative
stage (A, B). GH, At a 3-year follow-up the patient shows excellent maintenance of her breast
correction and good relationship between the breast implants and the soft tissue envelope of the
breasts.
Ch05.qxd 11/28/05 1:47 AM Page 236
REFERENCES symptoms of macromastia. Plast Reconstr Surg. 2002;109(5):

15561566.
1. Hoffman S. Recurrent deformities following reduction mam- 6. Gorney M. Personal communication.
moplasty and correction of breast asymmetry. Plast Reconstr 7. Lejour M. Vertical mammoplasty: early complications after
Surg. 1986;77:5560. 250 personal consecutive cases. Plast Reconstr Surg. 1999;104
2. Ryan RF, Pernoll ML. Virginal hypertrophy. Plast Reconstr (3):764770.
Surg. 1985;75:737742. 8. Lassus C. Update on vertical mammaplasty. Plast Reconstr
Bostwick J III. Plastic and Reconstructive Surgery of the Surg. 1999;104(7):22892298; discussion 22992304.
Breast. St. Louis: Quality Medical Publishers; 1990. 9. Hall-Findlay EJ. Pedicles in vertical breast reduction and
3. Courtiss EH, Goldwyn RM. Breast sensation before and mastopexy. Clin Plast Surg. 2002;29(3):379391.
after plastic surgery. Plast Reconstr Surg. 1976;58(1):113. 10. Reus WF, Mathes SJ. Preservation of projection after reduc-
4. Gonzalez F, Walton RL, Shafer B, et al. Reduction tion mammoplasty: long-term follow-up of the inferior pedi-
mammaplasty improves symptoms of macromastia. Plast cle technique. Plast Reconstr Surg. 1988;82(4):644652.
Reconstr Surg. 1993;91(7):12701276. 11. Shestak KC, Gabriel A, Landecker A, et al. Assessment of long-
5. Collins ED, Kerrigan CL, Kim M, et al. The effectiveness term nipple projection: a comparison of three techniques.
of surgical and nonsurgical interventions in relieving the Plast Reconstr Surg. September 1, 2002;110(3):780786.
Ch06.qxd 11/28/05 5:21 AM Page 237
C h a p t e r 6
Revision of Implant Breast

Reconstruction
Preoperative Evaluation 238 Expander or Implant Too Low 272
Selecting the Right Device 242 Raising the Inframammary FoldCapsular Suture
Technique 272
Begin with the End in Mind 243
Raising the Inframammary FoldFocal Capsule
Preoperative Patient Assessment 243 Excision and Direct Capsular Suture Technique
(Raw Edge to Raw Edge of Capsule) 273
Difficult Patients for Implant-Based Breast
Reconstruction 246 Establishing Better Definition of the
Inframammary Fold 277
First-Stage Breast Reconstruction with Tissue
Expansion Using Short-Height Tissue Superior Implant MalpositionCorrection in the
Expanders 248 Obese Patient with a Thick Lower Thoracic
Adipose Tissue Layer 280
Technique of Tissue Expander Placement
Immediate Reconstruction 250 Lateral Implant Malposition 280
Surgical TechniqueDelayed Breast Medial Implant Malposition 282

Reconstruction with Tissue Expander
Placement 255 Increasing Projection of an Implant Breast
Reconstruction 284
Acute Complications Following Tissue Expander
and Implant Placement 256 Folds 287
Hematoma 256
Seroma 256 Folds Following Implant Reconstruction
Infection 259 Periprosthetic Capsular SpaceImplant
Skin Loss 259 Disproportion 289
Expander Malposition 264
Implant Deflation 291
Reinsertion of Another Tissue Expander to Revise
an Inadequate Implant Reconstruction Implant Rupture Following Breast Reconstruction
Revision of the Periprosthetic Capsular Space with a Silicone Gel Implant 291
with Change in Device Dimension 269
Combination Breast DeformityImplant
Revision at the Second Stage, or Adjustments at Malposition, Advanced Capsular Contracture,
the Time of Implant Exchange 271 Implant Immobility, and Qualitative Tissue
DeficiencyTreatment by Autogenous
Superior Malpositions of Expander or Conversion 291
Implant 271
237
Ch06.qxd 11/28/05 5:21 AM Page 238
Capsular Contracture, a Vexing Unsolved Advanced Capsular Contracture Treated with

ProblemThoughts and Possible Therapeutic Autogenous ConversionImplant Removal,
Approaches 294 Capsulectomy, and TRAM Flap Breast
Reconstruction 297
Radiation-Induced Capsular Contracture
Treatment with Autogenous Tissue Finishing Touches 298
Supplementation Using the Latissimus Dorsi
Muscle Flap 294 References 301
Breast reconstruction with implants remains very popular. (volume or base width), implant or expander malposition,
It represents the majority of breast reconstructions per- inframammary (IM) fold asymmetries, skin rippling with
formed in the United States.1 Since the introduction of tis- the appearance of ripples or folds, compromised local
sue expansion for breast reconstruction,2 the most common covering soft tissue, saline implant deflation, and silicone
method of implant-based breast reconstruction is a two- gel implant rupture.4 In addition, there may be breast
stage process of tissue expansion followed by the insertion asymmetries that are most often derived from a combina-
of either a silicone gel or saline-filled breast implant. tion of all of the above, or are related to the patients oppo-
The essential goals of breast reconstruction remain site breast, which may not be inherently well matched by
creating a breast mound, maximizing symmetry between the placement of an implant.
the reconstructed mound and the contralateral breast, This chapter focuses on the most commonly encoun-
and reconstructing a nipple in the appropriate position to tered problems seen in patients who are in the implant-
transform the mound into a true breast facsimile. A final based breast reconstruction continuum, with the exception
finishing touch is providing skin pigmentation to the nip- of implant rupture, which is covered in the chapter on
ple and areola area to produce the best possible color explantation (Chapter 4). These challenges are often com-
patch symmetry between the reconstructed nipple and the plex, but if handled appropriately the outcome can be very
nipple areola complex (NAC) of the opposite breast. This satisfying for the patient and rewarding for the surgeon.
process occurs in stages, and in fact breast reconstruction
in every patient occurs as a continuum. This must be
stressed to each patient who is seen in consultation for PREOPERATIVE EVALUATION
breast reconstruction. This is especially true for implant-
based breast reconstruction, which as stated is almost When evaluating a patient who has a problem during or
always a two-stage process consisting of the placement of after any of the stages of implant breast reconstruction, it
a tissue expander followed by the placement of an is essential to obtain a careful history and to perform a
implant. systematic and compulsive physical examination. If the
Although prosthetic breast reconstruction is a simpler patient has been previously operated on by a different sur-
procedure for the patient, I find it much harder to obtain geon(s), I find it helpful to obtain the previous operative
consistently good results with implant-based breast recon- reports so that I have precise information about implant
structions than with autologous tissue methods. It must be type, position, and volumes. Only with this information is
borne in mind by the surgeon that by their very nature it possible to accurately assess the factors that may be
such procedures are much more likely to require surgical contributing to the specific problematic situation with a
revision, especially with the passage of time.3 This fact given breast reconstruction.
must be explained to every patient preoperatively. There are four issues for the surgeon to consider in
There are many challenging problems and situations evaluating each particular patient. First, it is important
that may present themselves in the course of implant- for the treating surgeon to determine whether an implant-
based breast reconstruction, either between the position- based reconstruction is or was a reasonable or even feasi-
ing of the tissue expander and the planned implant ble operation in the first place for a given patient. In many
exchange, or after the second stage when a saline-filled or patients it is the default option. By this I mean that this
silicone gelfilled implant has been placed. This chapter method is chosen because there is no other good option.
will discuss my approach to treating problems encoun- The typical scenario is a patient with significant skin defi-
tered at either stage in this process. ciency (>6 cm in the vertical or horizontal dimension
Most often these problems include capsular contrac- a situation where the addition of flap tissue is highly
ture around the previously positioned implant, asymme- preferable but declined by the patient) who is recon-
tries relating to improper expander or implant size structed with an implant, or a patient with extremely thin
Ch06.qxd 11/28/05 5:21 AM Page 239
Chapter 6 Revision of Implant Breast Reconstruction 239
local tissues who exhibits a poor result because of inade- Third, if the patients problem is asymmetry, the surgeon
quate covering tissues. The surgeon must understand must determine whether opposite breast modification in
what local conditions may have existed that would most the form of breast augmentation, mastopexy, augmentation
likely have predisposed a suboptimal outcome such as sig- mastopexy, or reduction, all of which may sometimes be
nificant scars at the site of breast reconstruction, previous necessary to optimize symmetry, was discussed before sur-
infection, and most importantly antecedent radiation gery. In my experience, it is most often difficult, if not
therapy. It is also important to know if there was a history impossible, to achieve really good symmetry by placing an
of failure of a previous breast reconstruction. implant beneath tissues remaining after a mastectomy
A second issue relates to the implant that was used. It is without placing an implant on the opposite side as either a
important for the surgeon to decide if the appropriate breast augmentation or augmentation mastopexy. Said
implant or tissue expander was used for the initial stage(s) another way, I believe that patients in whom it is possible to
of the reconstruction, i.e., whether the device had suffi- achieve truly excellent symmetry with an implant on one
cient surface dimensions in the form of base width, side and no surgery on the opposite breast are indeed very
height, and volume to appropriately contour the local soft rare. In these rare individuals the opposite breast almost
tissues to best match the opposite breast. looks like an implant, with a round appearance (Fig. 6-1).
FIGURE 6-1. Preoperative (AB) and postoperative (CD) AP and oblique views of patient treated for
cystosarcoma of the left breast with staged left breast reconstruction with tissue expansion followed by
the placement of a round moderate-profile textured silicone gel implant. Excellent symmetry is noted
because of the shape of the patients unoperated right breast.
Ch06.qxd 11/28/05 5:21 AM Page 240
Finally, the surgeon must ask whether there has been when an implant is placed. In the latter situation the
any intervening condition that has changed the appear- amount of tissue that is hidden from the mammogra-
ance of the previous implant reconstruction. The most pher depends on the size of the breast, the size and posi-
common condition in this context is radiation therapy. In tion of the implant, and the presence and degree of
my experience, radiation administered at any stage of the capsular contracture.6 For this reason, in the setting of a
process of implant-based breast reconstruction usually previous contralateral breast cancer, I place virtually all
produces an accelerated form of capsular contracture, implants in the submuscular position. In this location
which often results in a profound change in the visual the risk of capsular contracture is reduced and the inter-
and tactile characteristics of the reconstructed breast ference with mammography is minimized. I have per-
(Fig. 6-2). Such a situation is most often an indication for formed opposite breast modification with increasing
the addition of flap tissue to address the firmness in the frequency over the past decade, to the point where a sig-
existing tissues.5 nificant majority (>60%) of my patients have the oppo-
I have found that in the setting of an implant recon- site breast adjusted when an implant reconstruction is
struction, modification of the opposite breast is a common performed.
consideration (Fig. 6-3A). This can be discussed in a sim-
ple and straightforward manner with the patient. I find
that having the patient view photographs of other patients
who have undergone the combination of implant recon-
struction on the side of mastectomy and the placement of
an implant with or without mastopexy (Fig. 6-3B) on the
opposite breast is very helpful and educational for her. It is
also important to show the patient photographs of out-
comes in other patients who have not undergone this com-
bination (Fig. 6-4). The patient can then decide whether to
have the opposite breast modified. I have a book contain-
ing photographs of each procedure I perform available in
the office for patients to review before their surgery.
The treating surgeon must explain the risks and bene-
fits of opposite breast modification. The risks include
scars on the breast, loss of nipple sensation and decreased
sensation in the skin of the breast, alteration of breast
parenchyma, and decreased sensitivity to mammography
FIGURE 6-3. Preoperative (A) and postoperative (B) AP views

of patient who underwent delayed reconstruction of the left
FIGURE 6-2. Appearance of right breast following completion breast with low-height tissue expander and implant. Symmetry
of radiation therapy in patient with tissue expander in place. in this patient (and in many cases) is optimized by contralateral
Skin changes are those of subacute and chronic radiation injury. vertical mastopexy at the time of nipple reconstruction.
Ch06.qxd 11/28/05 5:22 AM Page 241
As noted, options for surgery on the opposite breast ance in the contralateral breast (Fig. 6-3). However, the
include augmentation, augmentation with mastopexy, best results usually entail implant placement on the
mastopexy alone, and even breast reduction. It has been opposite side, which gives the contralateral breast a
my experience that a vertical mastopexy technique7 can rounded look that best matches an implant reconstruc-
often produce a more round and implant-like appear- tion (Fig.6-5).
FIGURE 6-4. Preoperative (A) and postoperative (B) AP views of a 51-year-old patient who has under-
gone a unilateral implant reconstruction without opposite breast modification. Note characteristic
asymmetry with upper breast pole fullness and round look seen on the side of the implant reconstruc-
tion with no fullness of upper pole in opposite breast.
FIGURE 6-5. Preoperative (A) and postoperative (B) views of patient who will undergo left mastectomy
and implant reconstruction with subsequent vertical mastopexy of right breast (C). (C shown on p. 242)
(continued)
Ch06.qxd 11/28/05 5:22 AM Page 242
FIGURE 6-5. (CONTINUED) This vertical mastopexy tech-

nique produces an almost implantlike fullness in upper pole that
markedly enhances breast symmetry (DE). Patient is shown 11
months following surgery.
SELECTING THE RIGHT DEVICE tion. As noted in Chapters 2 and 3, the implant selected
should have the appropriate base width, volume, and ver-
Begin with the end in mind. tical dimension to produce the desired contour and shape
As outlined in Chapter 2 and Chapter 3, Fig. 3-1A, there are in the reconstructed breast. The analysis of the curves,
many implant options for the surgeon to choose from. shape, and relationship of the opposite breast to the chest
Good results in a given patient can be obtained from using wall is reviewed in Chapter 2.
any number of implants. Surgeons tend to use implants Following a thorough discussion with the particular
(and tissue expanders) they are experienced and comfort- patient about her goals and a careful examination of the
able with from the standpoint of predictably producing breasts, the surgeon must be able to envision what he or she
good results in their hands. Different implants may be is trying to create and then select the appropriate implant(s)
used in different situations. Variability in patient for that situation. Presently in my practice implant recon-
anatomy, including chest wall configuration, skin condi- struction is almost always (>98% of the time) done in stages,
tions, and tissue deficits, may encourage the surgeon to with the placement of a tissue expander as the first stage,
select a certain implant over another in a given situation. followed some time later by the placement of an implant.
There are very few ironclad rules or stipulations Therefore it is important for me to select the appropriate tis-
regarding the choice of an implant for breast reconstruc- sue expander, as well as the appropriate implant.
Ch06.qxd 11/28/05 5:22 AM Page 243
BEGIN WITH THE END IN MIND For implant breast reconstruction (and breast augmenta-
tion to a great degree), device selection is governed by
Selection of the tissue expander for a given patient starts dimensional concepts8 (Chapters 2 and 3). This is espe-
with selection of the implant(s). The choice of implant for cially true when using saline-filled implants. The volume
breast reconstruction is largely determined by the base contained in these breast implants can vary depending on
width of the breast, by the desired breast volume, to some projection or profile of the device, i.e., a high-profile
degree by the vertical height of the breast, and by whether implant contains a greater volume of filler for a given base
the patient chooses to have a contralateral breast augmen- dimension (diameter) of the implant.
tation. After the evaluation is complete, I find that it is The implant selection for a given patient is determined
helpful to refer to the implant charts compiled by each of by the factors previously reviewed, the most important of
the implant manufacturers (see Fig. 3-5) for the final which is the base dimension of the opposite breast. The
implant selection. The surgeon must pick a tissue fill volume and projection are also important. Different
expander that will accommodate the base width of the volumes are contained within a given base diameter of an
implant that will be used. Therefore, I try to always select implant depending on its projection specifications. These
the implant I will use before I place the expander. specifications are listed on the charts issued by the
In most cases the choice comes down to either of two implant manufacturers (see Fig. 3-5). Selection of the tis-
expanders, with one having a slightly larger base width sue expander is then made to create a periprosthetic cap-
than the other (e.g., a 12-cm versus a 13-cm expander). In sular space that will accommodate this implant.
most cases I choose the larger device for a variety of rea-
sons. A larger space will allow better movement of the
implant within the periprosthetic capsular space because PREOPERATIVE PATIENT ASSESSMENT
my preference is to use a smooth-walled implant.
Additionally, if the periprosthetic space is of slightly larger I now believe that for breast reconstruction, tissue expan-
dimension than the selected implant, it can be reduced in sion is more of a tissue-molding process than it is a
volume and altered in its dimension or changed in its process of tissue expansion or skin stretching per se. That
position (e.g., to a lower level) in a fairly precise way by a is to say, I believe that the results of the tissue expansion
suture capsulorrhaphy or direct excision of the capsule process in many ways represent more of a loan than a div-
with surgical repair. This is especially common if the idend. For that reason, I believe that when the measured
patient elects to undergo contralateral breast augmenta- or anticipated skin tissue deficiency in a given patient is
tion because the larger expander will accommodate the more than 4 cm, this is an indication for a flap reconstruc-
larger implant needed on the side of the reconstruction to tion rather than a tissue expander insertion. That said, the
produce volume symmetry with the augmented opposite majority of breast reconstructions in my practice are done
breast. in stages by first creating a periprosthetic capsular space
I have found that the best appearance of the recon- by shaping and molding the tissues in the lower pole of
structed breast is achieved when there is little or no the new breast, then placing the implant.
manipulation of the lower portion of the periprosthetic As noted several times earlier in this chapter, when tis-
capsule because this is the area that accounts for the sue expansion is chosen, the surgeon must select a tissue
smooth appearance of the IM fold and lower pole of the expander with the appropriate base width for a given
reconstructed breast. However, in most cases the volume patient. This dimension is determined by measuring the
and internal dimensions of the periprosthetic capsular base width of the patients opposite breast from the
space can be increased by performing appropriately parasternal area to the anterior axillary line in the frontal
positioned capsulotomies. In this way progressively plane [anteroposterior (AP) view; Fig. 6-6]. This can be
larger implants can be accommodated in a given done using a caliper or tape measure.
periprosthetic capsular space that has been created by The height or superior extent of the opposite breast is
the tissue expander. This is commonly done at the time also noted. It is the most important dimension for select-
of exchange of the tissue expander for the implant that ing the implant that will be used to complete the second
will be used for the breast reconstruction. Similarly, the stage of the reconstruction. This dimension is most accu-
volume of the periprosthetic space can be decreased by rately determined by gently displacing the opposite breast
performing the necessary capsulorrhaphy(ies) before posteriorly against the chest wall with the ulnar side of the
implant placement. examiners hand (Fig. 6-7) and noting the superior extent
In summary, when performing implant-based breast of the breast fullness. I usually outline the dimensions
reconstruction, choose the implant first. This entails with dots placed on the skin (Fig. 6-7). This vertical
selecting a device of sufficient base width, height, and vol- dimension from the dots to the lower contour of the
ume to produce the appearance of visual symmetry with breast is recorded in the chart for each patient because it
the opposite breast when viewed in the frontal position. serves as a guide for the selection of the implant.
Ch06.qxd 11/28/05 5:22 AM Page 244
This vertical dimension is not nearly as important for

selecting a tissue expander as it is for selecting the implant.
I now almost exclusively use a low-height tissue expander
(Fig. 6-8). However, I record the breast height in the
patients chart and refer to it before I select the implant.
Suffice it to say that the key dimension in selecting a tissue
expander is the base width of the contralateral breast (see
Fig. 2-3). Initial tissue expander positioning is important
in that a very accurate placement of a tissue expander sets
the stage for the best possible result in terms of permanent
implant position and breast appearance.
Currently available tissue expanders for breast recon-
struction include single-chamber saline devices (Figs.
6-8A,B and 6-9), dual-chamber saline devices (PMT), and
combination salinesilicone devices [e.g., Becker (Mentor
Corp., Santa Barbara, Calif)]. For breast reconstruction
procedures, virtually all expanders are textured devices.
Most have integrated ports, but some, such as the Becker
expander/implant and the Spectrum (Mentor Corp., Santa
Barbara, Calif) (Fig. 6-10), have remote fill ports.
As stated, when planning a breast reconstruction I always
begin with the end in mind from the standpoint of
selecting an implant. In the United States both manufac-
turers (Mentor Corp. and INAMED Medical, Santa
Barbara, Calif) offer a wide variety of implant shapes, pro-
FIGURE 6-6. Measurement of base dimension of opposite
breast serves as guide to selection of appropriate implant and,
jection profiles, and surface characteristics, along with
before that, correct tissue expander for breast reconstruction. brochures and charts I refer to constantly when dimen-
sionally planning an implant reconstruction (see Fig. 3-5).
Both silicone gel and saline-filled implants are used in my
practice, but the distinct majority of my breast recon-
struction patients request the silicone gelfilled breast
implant. The cohesive gel implant is gaining wide popu-
larity in Europe and South America. My early experience
with that device has been a very positive one from the
standpoint of breast shape.
As stated, each surgeon has his or her own prefer-
ences in terms of implants for breast reconstruction. I
feel that I am currently achieving the most consistently
good results with the use of a high-profile smooth-walled
silicone gel implant placed after the first-stage tissue
expansion is completed with a low-height tissue
expander. As noted in Chapter 3, I am big believer in
implant displacement exercises as a means of promoting
implant (and breast) softness. Therefore I have all
patients who receive smooth implants for breast recon-
struction (as well as for breast augmentation) perform
implant displacement exercises twice a dayforever. I
believe this is helpful following the placement of a
smooth-walled high-profile gel implant, and it seems to
promote better mobility of the implant in the peripros-
thetic capsular space.
FIGURE 6-7. Superior extent of upper pole of patients breast I have extensive experience with textured shaped
tissue is noted following gentle displacement of breast posteri-
orly against the chest wall. This is outlined by dots placed on the implants of both the saline-filled and silicone gelfilled
skin. This maneuver will help guide selection of an implant with types. Patients with long torsos and who require upper
appropriate dimensions for breast reconstruction. pole fullness are well served by tall implants such as the
Ch06.qxd 11/28/05 5:22 AM Page 245
FIGURE 6-9. Tissue expanders come in various dimensions in

terms of base width and height.
FIGURE 6-8. Breast tissue expanders with textured surface

and integrated filler valves. Photographs of low-height tissue
expanders. A, Mentor style 6200. B, On face view of INAMED
(McGhan) style 133 LV. C, Lateral view with fluid in device.
FIGURE 6-10. Becker expander/implant (Mentor Corp.) with
inner chamber of saline and outer rim of silicone gel with sepa-
rate filling port, and Spectrum saline expander/implant (Mentor
Corp.), which is a pure saline device with remote filling port.
INAMED Style 468 saline implant or the INAMED Style are obtained with the use of a smooth-walled high-profile
410 textured shaped cohesive silicone gel device. My best silicone gelfilled implant following preliminary tissue
results with saline implants with a wide variety of patient expansion with the short height tissue expander. I inform
body types have come from the use of a shorter vertical each patient before surgery that a breast reconstructed
dimension implant, namely the INAMED Style 363LF and with an implant will not fill the anterior (front part) of her
the Contour Profile shaped textured saline device devel- bra cup like her normal breast does. Furthermore, I tell
oped and marketed by Mentor Corp. patients preparing to undergo implant breast reconstruc-
With experience, good results can be obtained using tion that breasts that are reconstructed with implants will
almost any implant. At present my most consistent results not look like, move like, or feel like their normal breasts.
Ch06.qxd 11/28/05 5:22 AM Page 246
DIFFICULT PATIENTS FOR IMPLANT- optimal implant reconstruction candidates (Fig. 6-11E).
BASED BREAST RECONSTRUCTION The radiated tissue does not expand easily (Fig. 6-11F),
and in my experience there is a high rate of capsular
Synthetic implant-based reconstruction is often the contracture with the placement of any type of implant that
default option for a patient who has insufficient donor tis- often results in an unsatisfactory breast reconstruction
sue for an autogenous reconstruction. These patients are (Fig. 6-11G). Finally, patients with a wide chest dimension,
commonly of asthenic habitus and their chest wall tissues husky build, and heavy tissue in the chest region are also
are very often thin (Fig. 6-11A). This situation often sets suboptimal candidates for implant reconstruction because
the stage for a suboptimal outcome following the tissue they seem to swallow up the implants (Fig. 6-11H,I) and
expansion process because the expansion itself further the tissue drape over the implants often fails to adequately
thins or attenuates the covering tissue (Fig. 6-11B). This replicate the opposite breast silhouette.
scenario permits any implant irregularities to show In summary, an essential aspect of achieving good
through the skin (Fig. 6-11C,D). This type of patient must aesthetic outcomes from implant-based breast recon-
be informed before surgery of the limitations imposed by struction is patient selection. All too often implants are
suboptimal qualitative and quantitative covering tissue at the default option. In such cases there are definite limita-
the site of implant breast reconstruction. Patients who tions imposed by the tissue conditions, and this reality
have undergone previous lumpectomy and radiation or must be communicated to the patient, preferably before
radiation of the skin following a mastectomy are also sub- surgery.
FIGURE 6-11. A, Preoperative AP view of very thin patient

requiring bilateral mastectomy who is interested in immediate
breast reconstruction. B, Appearance following completion of
expansion with full-height tissue expander device. C, AP view
following saline implant placement shows folds in superior
medial breast. (continued)
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FIGURE 6-11. (CONTINUED) D, Oblique view. Note folds in superior medial aspect of right breast
and superior aspect of left breast. These may have been minimized by use of a low-height tissue
expander, which minimizes attenuation of upper pole breast tissues. E, Postlumpectomy deformity in
diabetic patient with recurrent breast cancer who requests reconstruction with an implant. F, Low-
height issue expander is in place but radiated tissue envelope does not expand easily over 9 months. G,
Placement of saline implant produces smaller, immobile breast form that shows advanced degree of
capsular contracture. (continued)
Ch06.qxd 11/28/05 5:23 AM Page 248
FIGURE 6-11. (CONTINUED) H, Preoperative AP view of patient requiring left mastectomy who
requests an implant-based immediate left breast reconstruction. Tissue expansion precedes placement
of large saline implant (14 cm, 650 cc). I, Final result is a breast that is a poor match for the large oppo-
site breast in this patient with a very wide chest dimension and thick covering tissues.
FIRST-STAGE BREAST
RECONSTRUCTION WITH TISSUE
EXPANSION USING SHORT-HEIGHT
TISSUE EXPANDERS
For a long time I have believed that perhaps the main prob-
lem with tissue expansion for breast reconstruction is that
too much stretching (and harmful tissue thinning) occurs
where you do not need it or want it, namely in the tissues of
the upper pole of the new breast. For that reason most
recently I have used tissue expanders that predominantly
[Contour Profile (Mentor Corp.); see Fig. 6-8A] or exclu-
sively [LV low-height crescent expander (McGhan Medical
Corp., Santa Barbara, Calif); see Fig. 6-8B] expand the
lower pole tissues. These devices provide expansion where
it is needed, i.e., predominantly in the lower pole. The tis-
sue expander produces the appearance of a shelf or a ledge
in the upper pole of the breast that is being created (Fig. 6-
12). There is an additional benefit of not stretching the
upper pole: a better breast shape at the second stage when
the expander is removed and the implant is inserted,
regardless of which implant is used. This is because the
pectoralis major muscle (PMM) has not been stretched,
and following the additional subpectoral dissection at the
second stage the muscle compresses the implant, produc-
ing a straighter contour or tapered shape in the lateral view.
When I use a short-height tissue expander, I employ
underexpansion. Specifically, I fill the expander to within
80% to 85% of the desired implant volume. This is
because approximately the upper 30% of the new breast
FIGURE 6-12. Typical appearance of a patient at completion
form is not generated as part of the expansion process, of tissue expansion process when a low-height tissue expander is
and the implant selected will generally have a volume that used. Note shelflike appearance at superior aspect of expander.
is 20% to 30% greater than that contained in the expander A, AP view. B, Lateral view.
Ch06.qxd 11/28/05 5:23 AM Page 249
at the completion of the filling process. I then give the tis- the desired fullness and shape of the upper pole by employ-
sues time to accommodate to their degree of stretch or ing modifications of the surgical dissection in conjunction
expansion by allowing 8 to 12 weeks to elapse between the with the implant diameter, volume, and projection. If cor-
last expansion and the date of the implant exchange. rections of the IM fold or medial or lateral contours (Fig. 6-
At the time of tissue expander removal, a superior cap- 14) are needed after the expansion, these are done while
sulotomy (Fig. 6-13A) is always needed if a short-height tis- performing the superior capsule release or capsulotomy.
sue expander has been used. This capsulotomy allows the In a very real sense this type of tissue expander permits
surgeon to open and precisely develop the submuscular the surgeon to control the upper pole shape of the newly
plane in the upper breast area, which has not undergone reconstructed breast in a way not possible with other tis-
expansion (Fig. 6-13B). This allows the surgeon to create sue expander designs. This is why it has been my
FIGURE 6-13. A, Outline for superior capsulotomies that will

be performed at the time of low-height tissue expander removal
and implant placement. B, Development of subpectoral plane in
upper breast area performed to precisely accommodate place-
ment of selected implant. C, Appearance of breast 6 months fol-
lowing placement of smooth-walled high-profile silicone gel
implants.
Ch06.qxd 11/28/05 5:23 AM Page 250
priate base dimension establishes the correct horizontal

dimension of the periprosthetic capsular space and hence
the correct horizontal silhouette of the new breast form.
In this way the expansion process can shape and mold the
surrounding soft tissue. Accurate device placement allows
the tissue expansion process to generate a custom-made
periprosthetic capsular space. This allows the preopera-
tively selected implant to be positioned in such a way to
achieve the optimal breast shape.
The accuracy of the initial expander placement (at the
first stage of the reconstruction) greatly facilitates a satis-
factory outcome for most tissue expander/implant breast
reconstructions. For that reason I will now describe my
approach to the placement of a tissue expander in the set-
ting of immediate breast reconstruction and also in the
setting of a delayed breast reconstruction.
TECHNIQUE OF TISSUE EXPANDER

PLACEMENTIMMEDIATE
RECONSTRUCTION
One of the most important factors in obtaining consistently

good results with tissue expander breast reconstruction is
maximizing the soft tissue coverage for the device. For me,
this means the upper part of the expander (below the inci-
FIGURE 6-14. Additional modifications of capsule are out- sion) is covered by the PMM and the lateral portion of the
lined before surgery in two different patients. Such capsular expander is covered by the serratus anterior muscle slips.
modifications are very common and are completed at the time of
expander removal, along with superior capsulotomy (Fig. 6-13B) The lower part of the device sits below the deep layer of the
and subpectoral dissection (Fig. 6-13C). adipose tissue beneath an incision in the rectus abdominis
muscle fascia medially and in the lateral two thirds of the
IM fold just deep to the divided external oblique muscle
(Fig. 6-15). This positioning is achieved in most cases of
immediate breast reconstruction in the following way.
preferred method of tissue expansion for the vast majority The marking for tissue expander insertion is straight-
of patients undergoing tissue expander breast reconstruc- forward. A skin-sparing mastectomy is preferred and per-
tions over the past 3 years. In my opinion it has increased formed in virtually every case. At our center the marks for
the artistry and made this type of reconstruction more fun the skin resection are designed by the plastic surgeon, but
and fulfilling for both the patient and the surgeon. they are confirmed as oncologically sound by the surgeon
I find it helpful to have sample tissue expanders and performing the mastectomy. The most important land-
implants in the office for patients to examine. I also have mark is the IM fold (Fig. 6-16). The lower limit of the dis-
schematic diagrams available so that patients can gain an section is either to the existing fold or to some level
insight into how the implant is to be positioned while they beneath it if the existing fold is too high relative to the
examine the integrated filler value and understand how it opposite breast. The medial extent of the dissection is to
is filled. In addition, I find that it is helpful to show the parasternal perforating vessels arising from the inter-
patients several samples of the type of implant that is nal mammary artery. Laterally the dissection conducted
most likely to be placed following the completion of the in a plane below the serratus anterior muscle is usually
expansion process. performed to a site just posterior to the anterior axillary
I believe that the technique used to place the tissue line. It can be extended as far posteriorly as the midaxil-
expander is very important. The device should be placed lary line, however, if this is needed to accommodate the
such that the lower pole accurately simulates the IM fold chosen expander. The plane above the ribs and beneath
level of the opposite breast, and it should be placed in the serratus muscle over the lateral chest is quite distinct
such a way that maximum skin recruitment and stretch- and easy to develop under direct vision. The necessary
ing (as opposed to muscle stretching) in the lower pole pocket dissection is dependent on the dimensions of the
routinely occurs. Selecting an expander with the appro- opposite breast when measured from the parasternal area
Ch06.qxd 11/28/05 5:23 AM Page 251
Splitting fibers
in pectoralis muse
down to rectus fascia
proposed
thin
inframammary
fascial
fold
confluence
FIGURE 6-16. Marking patient for tissue expander insertion.

FIGURE 6-15. Frontal (A) and sagittal (B) views of tissue The most important mark is the level of the IM fold. This patient
expander position, which is covered by the PMM superiorly and will undergo a skin-sparing mastectomy.
the slips of serratus muscle laterally and lies beneath the ante-
rior rectus abdominis fascia inferiorly with its lower pole above
the fascia but beneath the deep adipose layer.
to the anterior axillary line, and it is developed to accom- origin with 3-0 PDS suture (Ethicon, Inc., Somerville, NJ).
modate the selected tissue expander. The dissected space If it cannot be sutured to its origin, it is often possible to
should be slightly larger than the height and width dimen- suture it to the undersurface of the skin flap with 3-0 PDS
sions of the selected tissue expander. suture, thereby providing muscle coverage for the tissue
This dissection is done with the electrocautery device expander beneath the skin closure. Other surgeons have
using the coagulation mode under illumination with a used 3-0 Prolene suture (Ethicon, Inc., Somerville, NJ) tied
headlight or lighted retractor. The dissection proceeds over a bolster to achieve the same goal of attaching the
inferiorly below the rectus abdominis muscle fascia. In divided origin of the PMM to the inferior skin flap.8
immediate reconstruction it is imperative for the plastic The subpectoral plane is accessed and developed by
surgeon to convey to the general surgeon performing the splitting the PMM in line with its fibers 3 cm medial to its
mastectomy the importance of not violating the pectoralis lateral edge (Fig. 6-17A). The loose areolar layer beneath
fascia in the lower aspect of the mastectomy dissection the PMM is readily visualized and the dissection proceeds
near its confluence with rectus fascia. In addition, the tis- medially, laterally, and superiorly. With the short-height
sue between the PMM fascia and the rectus fascia, which I expander, it is generally not necessary to dissect the sub-
call the fascia intermedialis (see Fig. 6-15), should not be pectoral space beyond the third intercostal space.
violated. If it is injured, it is very difficult to raise the rectus During the initial dissection I find it easiest to identify
fascia confluent with the PMM fascia. If the PMM muscle the plane beneath the rectus fascia by extending the
is inadvertently injured or detached at its inferior origin, it muscle-splitting incision in the PMM inferiorly over
most often can be repaired and placed back to its point of and through the rectus fascia (Fig. 6-17B) by simply
Ch06.qxd 11/28/05 5:23 AM Page 252
continuing it inferior-medially over and through the rec-

tus fascia. When developing the plane deep to the PMM
inferiorly, the medial PMM is elevated with the medial
rectus muscle fascia. The lateral PMM is elevated in con-
tinuity with the lateral rectus fascia and accompanying
external oblique muscle. The subfascial plane above the
rectus muscle is developed in conjunction with the
subexternal oblique plane as the dissection is carried lat-
erally. Near the IM fold the plastic surgeon must gain
access to the plane of the deep adipose layer above the
rectus fascia by incising the fascia on its deep surface. At
the desired level for the new IM fold (marked on the skin
preoperatively) the dissection is brought more superfi-
cial, i.e., toward the skin. An incision is made with the
electrocautery directed superficially through the deep
surface of both the rectus fascia and external oblique
muscles until the yellow adipose tissue at the deep sur-
face of the deep layer of adipose tissue is seen (Fig. 6-18).
This enables the tissue expansion process to generate the
new IM fold in the most ideal position. Under direct
vision the rectus fascia and external oblique muscle is
incised on its deep surface in the shape of an arc that
outlines the desired shape of the IM fold. Along this
entire incision the surgeon will note a yellow layer of adi-
pose tissue, and he or she should stop the dissection
when this level is reached.
When this is completed, in addition to a line of yellow
adipose tissue, the surgeon will note markedly increased
distensibility of the entire inferior musclefascia envelope
in the area of the lower pole under the inferior skin flap as
the deep subcutaneous space is entered. It is in this plane
that the lower pole of the tissue expander is positioned. If
done properly there is complete coverage of the expander
by the muscle layer above and the lower skin flap, includ-
ing the rectus fascia and the external oblique muscle
below.
The only patients in whom I do not make a concerted
effort to release the rectus fascia and the external oblique
muscle in this way are patients with exceedingly thin tis-
sues, i.e., those patients with extremely little or virtually
no subcutaneous adipose tissue. In such patients the
external oblique muscle and rectus fascia are usually also
thin, but they may provide a little bit of extra covering tis-
sue or tissue padding, which may help camouflage the
inferior edge of the implant. For that reason I may not
extend the dissection superficially at the IM fold level in
these patients.
A barrier drape of OpSite (Smith & Nephew, Largo,
Fla; Chapter 3) is placed on the skin of the breast area and
an opening is cut in it to permit the passage of the selected
FIGURE 6-17. A, Subpectoral plane is developed by splitting the expander into the wound. In this way the tissue expander
PMM in the direction of its fibers 3 cm medial to lateral edge of does not make contact with the skin. The expander is
PMM. B, Dissection is brought inferiorly to the level of the prox-
imal aspect of the anterior rectus fascia, which is seen as the placed into position after the removal of the factory-
white layer in the inferior aspect of the wound just above the instilled air and without any fluid inside of it. As previ-
retractor. ously outlined, accurate positioning of the expander is
Ch06.qxd 11/28/05 5:23 AM Page 253
FIGURE 6-18. A, As the surgeon is looking toward the patients foot and the retractors are spreading
the lateral and medial rectus muscle segments. An incision has been made in the rectus fascia directed
superficially toward the skin. Note yellow fat that has come into view. This is the deep surface of the
deep subcutaneous adipose tissue. B, The incision is continued laterally, dividing the external oblique
muscle, exposing the adipose tissue laterally, and establishing the position of the lower pole of the tissue
expander and of the IM fold.
essential to facilitate symmetry. When it is in this flat-as-a- reiterate an important point, the release of external
pancake (see Fig. 6-8) state, I believe that the most accu- oblique and rectus fascia places the lower pole of the tis-
rate positioning of the device is achieved. Next, sterile sue expander in the deep subcutaneous adipose space
saline is introduced through a closed filling system. and this allows the expander to stretch and recruit skin
The head of the operating table is then brought as close rather than muscle. In my opinion this makes the
to 90 degrees as possible so that the symmetry of the IM process of tissue expansion for breast reconstruction
folds can be checked with the patient in the sitting posi- quicker and less painful. In addition, placing the
tion. The levels of the IM folds must be as symmetric as expander in the deep layer of adipose tissue allows the
possible to facilitate overall breast symmetry. If such sym- creation of a well-defined, natural-appearing lower
metry is not achieved, device repositioning or additional breast pole.
dissection or a combination of these maneuvers is done to Finally and most importantly, the use of short-height
achieve symmetric IM fold levels. As much fluid as possi- expanders has led to focusing the expansion process
ble is then placed into the expander while still permitting where it is neededin the lower pole. In my experience
a tension-free closure of the skin wound. Closure of the the combination of using the described technique of tis-
PMM fibers ensures total deep tissue coverage of the sue expander placement and the new short-height devices
device beneath the level of the skin incision. has resulted in implant-based breast reconstructions with
This method is used for tissue expander placement in a consistently better shape, marked by excellent lower
both immediate and delayed breast reconstruction. To pole aesthetics and a tapered upper pole (Fig. 6-19).
Ch06.qxd 11/28/05 5:23 AM Page 254
FIGURE 6-19. Preoperative appearance of breasts on AP (A) and lateral (B) views before a bilateral
mastectomy and immediate breast reconstruction with low-height tissue expanders. Two-year postop-
erative appearance on AP (C) and oblique (D) views following placement of shaped textured silicone gel
implants with base width of 14 cm and gel volume of 540 cc.
Ch06.qxd 11/28/05 5:23 AM Page 255
SURGICAL TECHNIQUEDELAYED space (immediately superficial to the rectus fascia) is

BREAST RECONSTRUCTION WITH accessed. The dissection in the setting of a previous mas-
TISSUE EXPANDER PLACEMENT tectomy is easier and generally proceeds more quickly
than the same dissection done at the time of a mastectomy.
Preoperative patient marking is performed in every case This is because the scar tissue and healing following the
exactly as described earlier. As in immediate reconstruc- mastectomy makes injury to or avulsion of the PMM
tion, the opposite breast serves as a template for the surgi- exceedingly rare. In the case illustrated earlier (see Fig. 6-
cally absent breast in terms of IM fold level and base width 7) the plan was for a silicone gel implant reconstruction of
(see Fig. 6-7). Most often only the central 60% of the mas- the left postmastectomy defect with a partial subpectoral
tectomy scar is incised and removed to permit exposure of silicone gel breast augmentation of the contralateral right
the underlying PMM. However, if the scar shows hypertro- breast. A 12-cm base width tissue expander was used
phy, evidence of step-off, or other irregularity, it is entirely because it would accommodate a 12-cm 375-cc silicone gel
excised. Skin flaps are raised inferiorly and superiorly for a implant on the left. (In addition, the plan called for a 160-
distance of 3 cm to expose the PMM fibers. The dissection cc silicone gel implant on the right [Fig. 6-20A,B].) Those
of the subpectoral, subserratus space is then performed as implants were placed with the result displaying excellent
described earlier and inferiorly the deep subcutaneous shape and symmetry of the breasts (Fig. 6-20C,D).
FIGURE 6-20. A, Delayed left breast reconstruction with an implant-based strategy. B, Low-height
tissue expander appearance at the end of tissue expansion process. The base width is adequate to
accommodate previously selected implants as depicted in the preoperative plan outlined on skin.
Postoperative result at 9 months in AP (C) and oblique (D) views.
Ch06.qxd 11/28/05 5:23 AM Page 256
ACUTE COMPLICATIONS FOLLOWING in the skin flap that often occurs in this setting limits the
TISSUE EXPANDER AND IMPLANT optimal drape of the skin flap over the implant, thereby
PLACEMENT limiting the aesthetic outcome. Therefore, it is my custom
to evacuate any significant collection that occurs.
The postoperative complications occurring in the acute
phase following tissue expander placement and implant
Seroma
placement are bleeding, hematoma, seroma, infection,
skin loss, implant exposure, and loss of the device. In gen- Seromas are not uncommon, especially following immedi-
eral each of these should be managed aggressively to ate breast reconstruction with tissue expander placement. It
prevent loss of the expander. is most likely due to the extensive dissection of the subcuta-
neous space during elevation of the mastectomy flaps or dur-
ing axillary dissection. Although a drain is placed into this
Hematoma
space in virtually all cases and some element of tamponade
A collection of blood may occur in the submuscular or sub- is provided by the saline fill of the expander, seromas still
cutaneous space. The surgeon routinely obtains meticulous occur. They are usually managed by sterile needle aspiration
hemostasis at the time of expander insertion. Despite this, of the subcutaneous space with the needle being placed over
hematomas can occur. This condition is either the result of a the area of the filler port of the expander but not being
clot that comes off a blood vessel previously controlled at advanced to the point where it penetrates the port (Fig. 6-
surgery or from a diffuse oozing that may be seen after the 22A). The fluid can be compressed or moved to the area
use of aspirin products. The former situation is more com- immediately over the filler port by an assistants hand (Fig. 6-
mon and may occur following a cough or Valsalva maneuver. 22B). Following aspiration of the seroma fluid, saline is
The most likely source is a small arterial branch of the inter- installed into the expander to obliterate the space into which
nal mammary, lateral thoracic, or intercostal system. The it might reaccumulate. It may be necessary to perform this
patient usually presents with swelling, ecchymosis, and ten- sequence several times before the problem is resolved.
derness in the affected breast. I believe that returning the Seroma fluid sequestered laterally over the chest wall
patient to the operating room to evacuate the hematoma is or lateral aspect of the expander may represent a lymph
the best course. Most often a distinct bleeding point is not fistula. Such fluid accumulations are carefully aspirated
found. Nevertheless, the blood should be evacuated and a after protecting the expander or implant. Occasionally it
drain placed. This is the best chance of achieving a good may be necessary to return the patient to surgery to con-
reconstruction with the lowest probability of capsular trol a lymphatic vessel or to place a drain.
contracture. A seroma may co-exist with an area of skin flap
In addition, when a hematoma occurs in the subcuta- ischemia or incipient wound separation. In such cases it is
neous space, it almost always imparts stiffness to the skin best to return the patient to the operating room to drain
flap due to the fibrosis that results in response to the pres- the seroma, resect the skin in question and perhaps
ence and the biologic resorption process of the blood col- decrease the fluid amount in the expander, and then
lection in this space. Therefore in cases with significant reclose the wound over a suction drain.
hematomas (Fig. 6-21) I believe in the conservative treat- This situation is illustrated by the following case (Fig. 6-
ment to reoperate to evacuate the blood and to place a 23A), where the patient was noted to have clear fluid
drain (Fig. 6-21B). In this way the surgeon creates the best drainage from her left breast reconstruction incision follow-
possible softness and draping potential of the skin flap ing the placement of a tissue expander. There were no local
over the implant placed at the second stage. or systemic signs of infection. She was returned to the oper-
Such a case is illustrated by this patient who presented ating room within 24 hours, where the fluid was drained,
with swelling and ecchymosis of the left breast 1 week fol- the cavity was dbrided with a uterine curette, and a drain
lowing an immediate tissue expansion reconstruction of was introduced through a remote lateral incision (Fig. 6-
the left breast (Fig. 6-21A). She underwent operative 23B). Muscle coverage over the expander was re-established
exploration and removal of blood from the subcutaneous and the edges of the skin wound were excised and reapprox-
space (Fig. 6-21B). The tissue expander in the submuscu- imated. Her tissue expansion was completed (Fig. 6-23C),
lar position had been completely covered by the PMM and and a satisfactory appearance of her breast reconstruction
was preserved. She underwent successful bilateral tissue resulted from the placement of an implant with a contralat-
expansion, and subsequent implant placement produced a eral vertical augmentation mastopexy (Fig. 6-23D). This
good outcome for her in terms of her bilateral breast case illustrates that when serous fluid is persistently drain-
reconstruction (Fig. 6-21C). I believe blood around an ing through the wound following an implant breast recon-
implant probably increases the risk of capsular contrac- struction, exploration is indicated to minimize the chance
ture in the setting of both breast reconstruction and of implant loss. Excision of a seroma cavity and closure over
breast augmentation. As also noted, the additional fibrosis a drain can often prevent the loss of the implant.
Ch06.qxd 11/28/05 5:23 AM Page 257
FIGURE 6-21. A, Hematoma following immediate left breast

reconstruction noted on postoperative day 5. B, Patient was
returned to operating room for drainage of this collection of
blood, which was located in the subcutaneous space. C, Patient
demonstrates a very satisfactory breast reconstruction seen
2 years following nipple areolar tattoo.
FIGURE 6-22. The safe method for aspirating a fluid collection (serosanguineous) anterior to the
muscle coverage over tissue expander used for breast reconstruction. A, Sterile needle is introduced
over filler port but not placed through it. B, Assistant can milk or compress tissue to move a lateral
seroma over site of port, where it can be safely aspirated.
Ch06.qxd 11/28/05 5:24 AM Page 258
FIGURE 6-23. A, A 46-year-old patient shown preoperatively for immediate left breast reconstruction
with tissue expander placement. She developed serous drainage through the wound on postoperative
day 4 without signs of infection. B, She was immediately returned to operating room for exploration of
the wound. Seroma was drained and subcutaneous space was curetted and closed again over drains. C,
Tissue expander was salvaged. D, Placement of silicone gel implant produced very satisfactory recon-
struction of left breast.
Ch06.qxd 11/28/05 5:24 AM Page 259
changes that mimic cellulitis. They are treated for the

Infection
presumptive cellulitis, usually with a very slow or little
Infections that occur in the setting of prosthetic implanta- response. A more cautious move to reoperation is in
tion must be treated aggressively. If they are diagnosed order when treating skin changes in this subgroup of
early, involve only the superficial soft tissue, and are patients.
treated aggressively, it is often possible to salvage the tis-
sue expander or implant (Fig. 6-24).
Skin Loss
If they involve the prosthetic device itself, this repre-
sents a much more difficult situation in that I believe that In the acute setting following immediate breast recon-
it is very hard to sterilize an infected prosthetic implant struction with a tissue expander, skin loss usually
(Fig. 6-25A). This implant infection required removal of occurs at the distal margin of the skin flap. The manage-
the device (Fig. 6-25B). A period of 6 months was allowed ment of this problem depends on several factors. The
to elapse to realize wound equilibrium. Because of the vol- most important factors in dictating treatment include
ume requirement and both quantitative and qualitative the extent of the problem, whether total muscle cover-
tissue deficiencies, the reconstruction was carried out age of the expander was achieved at the surgery to place
with a bipedicled transverse rectus abdominis myocuta- the expanders, and the anticipated need for chemother-
neous (TRAM) flap (Fig. 6-25C), which resulted in a very apy. If this area is small and occurs in a setting where
satisfactory outcome shown 8 months following surgery total muscle coverage was achieved over the expander
(Fig. 6-25D). and chemotherapy will not be administered, then non-
In either situation, the patient should be treated operative management with the application of oint-
aggressively with broad spectrum antibiotic coverage. The ments and dressing changes with as minimal an office
organism in question is most likely a gram-positive coc- dbridement regimen as required will usually lead to
cus, either Streptococcus sp. or Staphylococcus aureus. healing.
I prefer to use a combination of a semisynthetic penicillin, A more aggressive approach to wound management is
aminoglycoside, and clindamycin. Alternatively, a drug warranted if total muscle coverage was not achieved
such as ampicillin (Unasyn) can be used. (Fig. 6-26) or the area is somewhat large, or if adjuvant
The usual presenting signs and symptoms are ery- chemotherapy might be delayed by a wound complica-
thema, tenderness, and/or fever. An elevated white blood tion. In such a setting a return to the operating room for
cell count (WBC) and erythrocyte sedimentation rate excision of the threatened skin (Fig. 6-26B,C) and wound
(ESR) may or may not be present. Following the institu- reclosure is usually successful in achieving healing and
tion of antibiotic therapy there should be a clinical preventing wound separation and possible loss of the tis-
response within 72 hours. If there is no significant sue expander. In these situations, it may be necessary to
response within this time frame a return to the operating remove some or all of the fluid that had been placed in
room should be considered. The bacteriology of pros- the expander to permit wound reclosure without tension.
thetic implant infections has been extensively reviewed in Such a maneuver often facilitates advancement of the
Chapter 3, and the reader is encouraged to refer to the ref- skin flaps and results in wound closure without tension
erences in that chapter for details regarding possible etio- (Fig. 6-26). This strategy was successfully employed to
logic organisms and their treatment. salvage the tissue expander in this case. In these situa-
If the patient shows a clinical response to the intra- tions the aggressive approach is really the conservative
venous antibiotic therapy, the therapy should be contin- approach.
ued for 10 to 14 days at home. Additional antibiotics can The following case illustrates an example of signifi-
be given for 1 to 2 weeks thereafter. I most consult an cant skin loss in a patient who had a previous lumpec-
infectious disease specialist to help select the most tomy and radiation therapy of the left breast. She
appropriate antibiotic and to determine the duration required a mastectomy for local recurrence and
of therapy. requested a bilateral mastectomy. She refused the place-
One caveat about skin color changes and implants is ment of additional scars elsewhere; therefore she under-
in order. Usually it is very obvious to a clinician when a went placement of a submuscular tissue expander
breast implant infection is present. The one situation (Fig. 6-27A). She developed a large area of ischemia on
that may be confusing is erythema occurring in the skin the inferior skin flap of the left breast. The area became
of a previously radiated patient. It is not common to per- demarcated and thus early excision was undertaken
form an implant-based breast reconstruction following (Fig. 6-27B). Primary wound closure was successful and
radiation, but with the rapidly increasing numbers of the tissue expander was salvaged (Fig. 6-27C). She
patients requiring mastectomy for local recurrence after underwent tissue expansion and had the successful com-
a previous lumpectomy, more and more implants are pletion of her breast reconstructions with the subse-
being used in this setting. Such patients can develop skin quent placement of saline implants (Fig. 6-27D).
Ch06.qxd 11/28/05 5:24 AM Page 260
FIGURE 6-24. AB, Infection at site of immediate left breast reconstruction noted 2 weeks following
surgery. Treated with aggressive antibiotic therapy, including 3 weeks of home IV antibiotics in con-
junction with the infectious disease consultant. CD, There was resolution of infection and successful
completion of reconstruction.
Ch06.qxd 11/28/05 5:24 AM Page 261
FIGURE 6-25. A, Infection of left breast implant used for reconstruction noted 6 weeks after place-
ment of smooth-walled saline implant. There was drainage from the wound and involvement of the
implant with the infectious process. B, Treatment required removal of implant and delayed primary clo-
sure. C, Reconstruction was delayed 6 months to achieve wound equilibrium and was accomplished
with bipedicled TRAM flap. D, AP view demonstrating satisfactory outcome of breast reconstruction 8
Ch06.qxd 11/28/05 5:24 AM Page 262
FIGURE 6-26. A, Ischemic skin necrosis noted at margin of

superior and inferior skin flaps overlying a tissue expander used
for an immediate left breast reconstruction. There was incom-
plete muscle coverage of expander at the time of its insertion. B,
Patient is immediately returned to the operating room for exci-
sion of the ischemic skin. C, Fluid is removed from expander to
allow a tension-free skin reapproximation. D, Expander is sal-
vaged. E, Patient subsequently has placement of silicone gel
implant, which results in a satisfactory breast reconstruction.
Ch06.qxd 11/28/05 5:24 AM Page 263
FIGURE 6-27. A, Larger area of ischemic necrosis of inferior skin flap of left breast in patient who
underwent bilateral immediate breast reconstruction. Total muscle coverage was achieved on each side.
B, Because of the size of the area, I elected to excise the nonviable skin and perform wound reclosure in
the operating room. C, Removing fluid from expander permitted a tension-free closure of wound. D,
Subsequent implant placement achieved satisfactory bilateral breast reconstruction. The reoperation
provided several advantages to the patient. Expansion was initiated earlier and completed earlier than
it would have been without the excision, and appearance of skin overlying breast was superior to what it
would have been had an excision of this area not been undertaken.
Ch06.qxd 11/28/05 5:24 AM Page 264
Perhaps the most common form of malposition

Expander Malposition
relates to the lower pole of the tissue expander. It is not
As noted previously, during a staged breast reconstruction uncommon for it to be either too high or too low. It is
with a tissue expander and subsequent implant placement, I more predictable to correct the expander that is too low.
focus a good deal of attention on correctly placing the tissue This is because it is easier to raise the level of the
expander at the first stage. Despite this, malpositions of the implant (the lower pole contour and the IM fold level)
expander do occur. These are the result of either inaccurate and achieve greater predictability in maintaining this
placement of the device initially, or shifting of the expander position than it is to lower the IM fold, which may result
early in the postoperative course as a result of the develop- in a tendency for the implant to continue to descend
ment of a biofilm or seroma that prevents tissue in growth with time. This is particularly true when the use of a
into the device. This lubrication effect at the devicetissue large implant (>450 cc) is planned because there is real
interface allows the tissue expander to move or rotate as potential for bottoming out in this situation if the infe-
noted in the left breast of the patient pictured in Figure 6-28 rior periprosthetic capsule tissue is entirely released
or to shift position in multiple directions (Fig. 6-29). In my to establish the correct level for the lower pole of
experience this problem appears to be more common fol- the implant (the new IM fold). This is especially seen
lowing immediate breast reconstruction. It can be seen in when a smooth-surfaced saline implant is used for the
both unilateral and bilateral breast reconstructions. reconstruction (Fig. 6-30).
FIGURE 6-29. Actual shift in position of both tissue expanders

FIGURE 6-28. Counterclockwise rotation of left short-height in patient who underwent immediate bilateral breast recon-
tissue expander placed at the time of mastectomy in patient struction. Note extreme lateral malposition of the right side
undergoing immediate bilateral implant-based breast recon- device and marked asymmetry of position, including IM fold
struction. level.
Ch06.qxd 11/28/05 5:24 AM Page 265
Most of these asymmetries are minor, or of the degree Early intervention to correct expander malposition is
that they can be addressed at the time of implant illustrated by the following patient who underwent a bilat-
exchange by adjusting the periprosthetic capsular space at eral mastectomy for an intraductal right breast cancer and
the time of implant placement (Fig. 6-30). On the other a multifocal ductal carcinoma in situ (DCIS) of the left
hand, if there is a major shift of the device or if a marked breast (Fig. 6-32A). Preoperatively she was noted to have A
asymmetry of IM fold position of the breasts is noted, cor- cup breasts with a base width of 12 cm. Note the lateral
rection of the expander position should be undertaken inclination of her breast and the curvature of her chest
before placing the implants (Fig. 6-30). This is especially wall on both sides (she may have had a forme fruste of pec-
true for expanders that are superiorly malpositioned. In tus carinatum). She desired much more breast fullness
this setting I believe that it is important to reposition the postoperatively. For this reason she underwent the place-
expander for several reasons. Continued expansion in this ment of low-height tissue expanders with a base width of
setting does not result in tissue expansion where it is 13 cm to accommodate an implant that would allow us to
needed, namely in the lower pole, and merely results in increase her breast size substantially. There was significant
thinning of the upper pole tissues. In addition, to achieve malposition of both expanders with marked superior lat-
symmetry of the breast levels, a complete inferior capsulo- eral displacement of the right tissue expander and a lateral
tomy with dissection into the lower thoracic subcuta- malposition of the left-sided device, along with an obvious
neous adipose tissue will be needed. This may result in an asymmetry of the IM folds (Fig. 6-32B). This required an
inferior malposition of an implant or bottoming out when unplanned revision to reposition the expanders (Fig. 6-
the use of a large implant (>450 cc) is planned. 32C). This improved their position, but they were not in
If the surgeon elects to use a smooth-walled implant optimal position because they were displaced away from
after a total release of the inferior capsule implant, sizes the parasternal area (Fig. 6-32D). At the time of implant
with a volume greater than 450 cc (approximately 1 lb) placement a significant medial capsulotomy was necessary
should be used only very cautiously. These large implants on both periprosthetic capsules (Fig. 6-32E). We used a
can settle inferiorly because the weight of the implant is high-profile silicone gel implant with a base width of 14
supported only by the subcutaneous tissue in the lower cm and a volume of 600 cc to complete the reconstruction.
aspect of the reconstructed breast. Inferior malposition in These implants produced a very satisfactory appearance
this setting may pose a significant problem, especially in and excellent symmetry of the breasts (Fig. 6-32F).
the patient with thin tissues. A textured implant may pro- The plan from the start was to use a large-volume
vide some additional protection against inferior malposi- breast implant based on the patients desire for eventual
tion due to tissue ingrowth prompted by the textured breast size. For this reason I believe that it is important to
surface. have the periprosthetic scar tissue as a supporting struc-
At the first stage of expander positioning, the goal is to ture for such a large implant. Completely releasing and
match the level of the opposite IM fold. Many times an removing the potential support of the implant by this scar
asymmetry of the folds becomes apparent during the tissue in the inferior aspect of the breast at the time of
expansion process. If the fold is too high, this can be recti- exchanging the expander for the implant often produces
fied by lowering it at the time of implant exchange by per- a significant chance of the implant bottoming out.
forming a capsulotomy with incremental lowering of the Therefore we performed a correction of expander posi-
fold to the correct level, which is marked preoperatively tion by relocating it to the appropriate level (Fig. 6-32D)
(Fig. 6-30B). This is done using electrocautery dissection before placing the implant selected for her breast recon-
illuminated with a headlight or lighted retractor (Fig. 6-31) struction. Also of note in cases like this is that continuing
to release the inferior capsular tissues. Following this to expand the upper chest soft tissues when an expander
adjustment, the selected implant is placed, it is inflated if it is malpositioned superiorly will cause thinning of these
is a saline implant, and a temporary wound closure is per- tissues as well as an inadequate molding of the inferior
formed with the patient placed in the sitting position at 90 tissue envelope where it is most needed. In such cases
degrees. When symmetry of the IM fold with that of the I believe early intervention for correction of the expander
contralateral breast is verified, a standard three-layer clo- malposition contributes to a better long-term outcome
sure of the capsule, deep dermis, and skin is performed. (Fig. 6-32F).
Ch06.qxd 11/28/05 5:25 AM Page 266
FIGURE 6-30. A, Discrepancy in level of IM folds created by

tissue expander placement in the form of a delayed breast recon-
struction. B, Outline for a release of lateral two thirds of inferior
periprosthetic capsule tissue to achieve IM fold symmetry. C,
Note excellent symmetry of IM folds following second stage of
reconstruction with silicone gel implant placement.
Ch06.qxd 11/28/05 5:25 AM Page 267
FIGURE 6-31. Correction of malposition most often requires a

capsulotomy. Inferior capsulotomy incision is marked and
release of the scar tissue is best done using the electrocautery
device under direct vision with illumination of surgical field.
FIGURE 6-32. A, Preoperative AP view of patient who will undergo bilateral mastectomy and desires
immediate breast reconstruction with an implant-based reconstruction strategy. She desires much
larger breasts. Note curvature of chest wall and lateral position and inclination of her breasts. B, She is
noted to have an extreme degree of bilateral tissue expander malposition. (continued)
Ch06.qxd 11/28/05 5:25 AM Page 268
FIGURE 6-32. (CONTINUED) C, This malposition required an interval procedure to reposition

expanders. D, Expander position is still not optimal as the medial aspects of the expanders are wide
apart. E, The planning before insertion of high-profile silicone gel implants (14 cm, 600 cc) includes sig-
nificant bilateral medial and superomedial capsulectomies (outlined in green) to enhance cleavage.
Excellent breast shape and symmetry are seen on AP (F) view at 3 months following placement of
implants.
Ch06.qxd 11/28/05 5:25 AM Page 269
REINSERTION OF ANOTHER TISSUE tioning of the IM fold to match the other breast (Fig. 6-
EXPANDER TO REVISE AN 33C). This was done with the placement of another tissue
INADEQUATE IMPLANT expander with a base dimension to match the opposite
RECONSTRUCTIONREVISION OF THE breast. She subsequently underwent the placement of a
PERIPROSTHETIC CAPSULAR SPACE shaped textured silicone gel implant with a base width of
WITH CHANGE IN DEVICE DIMENSION 14 cm and a volume of 540 cc, which produced satisfac-
tory symmetry with the opposite breast and the outcome
Patients often present with breast asymmetry related to that the patient sought with the reoperative procedure
the positioning of an implant or tissue expander and the (Fig. 6-33D,E). The tissue expander used in this case
device itself. The implant may have an inadequate volume established the pocket necessary for the aesthetically
or base dimension to match the opposite breast or the correct breast dimension, and the scar tissue from the
tissue expander dimensions may be inadequate to create capsule provided support for the larger implant that
the periprosthetic space dimension necessary for breast was used.
symmetry at the second stage. In these cases both the If the decision is made to lower the IM fold level by
abnormal device position and the device itself (the releasing the periprosthetic capsular tissue inferiorly,
implant or the tissue expander) must be changed. Such a I find it helpful to place multiple sutures (3-0 Prolene)
situation is illustrated by the following patient. She pre- between the superficial fascia (Scarpa layer) and the chest
sented to the office with a marked asymmetry of the wall fascia (Fig. 6-34). This suture can provide additional
breasts after a left breast reconstruction with a silicone gel tissue support and may act as a barrier to limit inferior
implant (Fig. 6-33A,B). The reoperative plan entailed the implant malposition. This is especially helpful if a single-
removal of her implant and a significant inferior reposi- staged correction is planned.
FIGURE 6-33. Severe breast asymmetry following left breast reconstruction done with implant seen
on AP (A) and oblique (B) views. (continued)
Ch06.qxd 11/28/05 5:25 AM Page 270
FIGURE 6-33. (CONTINUED) C, The plan for revision is to

retreat and place a new tissue expander with an adequate base
width in the appropriate position to create symmetry with the IM
fold of the opposite breast, following placement of shaped tex-
tured silicone gel implant with base width of 14 cm and 540 cc of
gel, patient demonstrates a very satisfactory outcome from this
revision sequence on AP (D) and oblique (E) views.
Ch06.qxd 11/28/05 5:25 AM Page 271
any sutures on the deep surface of the presternal or

parasternal breast tissue can easily produce dimpling.
Therefore simple suture capsulorrhaphies here tend to
be unsuccessful, and often the elevation of capsular flaps
is necessary to permit the best chance for long-term
correction.
SUPERIOR MALPOSITIONS OF
EXPANDER OR IMPLANT
Superior malpositions of the expander can most often

be corrected at the time of implant exchange by inferior
capsulorrhaphy and incremental inferior dissection.
The implant position is checked on the operating table
by positioning the patient in a sitting position at 90
degrees on the table and assessing the lower pole sym-
metry. I often suture the superior capsular space to close
it down in an attempt to limit the possibility of recurrent
superior implant malposition. Care must be taken not to
dimple the skin or cause abnormal contours if this
is done.
FIGURE 6-34. Sagittal section illustrating placement of 3-0 As discussed previously, an additional important caveat
Prolene sutures between SFS and fascia of chest wall. These may is to be careful with complete inferior capsular releases in
help limit the possibility of additional implant migration inferiorly.
the setting of placing a large-volume implant, especially if
the implant is a smooth-walled saline with a volume of
450 cc or greater. Such a situation may lead to inferior
implant migration or bottoming out, in essence producing
the reverse deformity of what was previously corrected. To
help prevent or minimize this potential problem, 3-0
REVISION AT THE SECOND STAGE, OR Prolene sutures can be placed in the superficial fascia and
ADJUSTMENTS AT THE TIME OF attached to the fascia of the chest wall. This is illustrated
IMPLANT EXCHANGE in Fig. 6-34 in sagittal section. The sutures placed joining
the SFS to the chest wall confer an extra barrier to limit
It is true that most adjustments of the expanded soft tissue inferior implant migration.
envelope in staged tissue expanderimplant reconstruc- In general, superior malposition is the easiest problem
tions are in fact made at the time of implant exchange. to correct while exchanging the expander for an implant.
These adjustments are most often made to correct asym- The surgeon marks the correction before surgery with the
metries produced by malposition of the expander, alter or patient in the standing position (Fig. 6-35A). After remov-
define the IM fold, or increase the projection or alter the ing the tissue expander, an inferior capsulotomy is per-
shape of the reconstructed breast. formed and inferior dissection proceeds incrementally
The expander position can be too high, too low, too under headlight assistance (see Fig. 6-31) with the elec-
lateral, or too medial. Most of these problems can be trocautery device. The selected implant is positioned and
addressed with manipulations of the periprosthetic cap- the patient is placed in the sitting position at 90 degrees
sular tissue in the form of capsulotomies, focal capsular on the operating table. The capsule and other tissues in
excisions, or capsular scoring and internal suture capsu- the wound are closed and a careful assessment for ade-
lorrhaphies. In these situations the periprosthetic scan quacy of the correction is made. When IM fold symmetry
tissue capsule is often the surgeons ally. Manipulations of and the desired appearance of the implant reconstruction
the capsule can substantially improve the appearance are achieved, permanent closure of the wound is carried
of an implant breast reconstruction. By far the most diffi- out in three layers. I often place on the repair as an exter-
cult problem to successfully address is the expanded space nal bolster a thick piece of foam rubber that is cut to con-
that is too medial and produces medial implant malposi- form to the contour of the IM fold or of the lower breast
tion. If it is bilateral, symmastia or pseudosymmastia can pole (see Fig. 8-14E). The result achieved is fairly pre-
be produced. This is because there is so little tissue near dictable, and in this case the correction is shown in
the chest wall medially that can hold sutures. In addition, Figure 6-35B.
Ch06.qxd 11/28/05 5:25 AM Page 272
FIGURE 6-35. A, Asymmetric position of lower contours of breasts at completion of tissue expansion.
Inferior-medial capsulotomies outlined for correction. B, Two years following reconstruction with
shaped textured silicone gel implants, patient developed Baker III capsular contracture of right breast.
EXPANDER OR IMPLANT TOO LOW monofilament suture (Fig. 6-37), and I commonly use a
3-0 Prolene suture. The best approach is to place two
If the lower level of the expander is too low at the conclu- rows, the first interrupted and the second a running layer
sion of the expansion process, or if a previously placed to close the capsular tissue over the knots from the inter-
breast implant is too low, then the lowest portion of the rupted row of sutures. It is my experience that this type of
periprosthetic capsular space must be superiorly reposi- repair provides sufficient strength to maintain the correc-
tioned. If the IM fold is also low, it too can be superiorly tion when implants with a volume less than 450 cc are
repositioned or reconstructed at a higher position if indi- used.
cated. This alteration in the capsule most often can be
done internally with a capsulorrhaphy. The internal
approach most often involves either a suture plication of RAISING THE INFRAMAMMARY FOLD
the capsule (most often done with a strong permanent CAPSULAR SUTURE TECHNIQUE
monofilament suture, e.g., 3-0 Prolene) or a focal or strip
resection of the capsule tissue combined with a suture Superior repositioning of the IM fold begins preopera-
repair, sewing raw edge of capsule to raw edge of capsule, tively by analyzing the discrepancy between the IM folds
again using a permanent monofilament suture. If the IM when the patient is completely upright, preferably in the
fold requires reconstruction, this too can be accom- standing position (Fig. 6-38A). This patient (Fig. 6-38A)
plished using either an internal approach with sutures or is noted to have an asymmetry of her IM folds at the
an external incision and a flap of skin that is de-epithelial- completion of her tissue expansion process. The
ized. This external approach entails anchoring the lead exchange procedure entails the placement of 450-cc
edge of the dermal flap to the chest wall as described by smooth round silicone gel implants. The technique of
Ryan.9 I prefer the internal approach,10 which in my opin- periprosthetic capsule suture plication will be used
ion consistently achieves good results and avoids an (Fig. 6-37). The necessary repositioning of the IM fold
external scar. Such a maneuver virtually always raises the and capsular suture placement was outlined on the
level of the IM fold. patients skin preoperatively (Fig. 6-38B). She was cor-
If the level of the lower pole of a previously placed rected with the technique outlined (Fig. 6-37B). The
implant or expander is too low, it is best addressed by patient is shown 4 months following surgery, before her
placing capsular sutures to raise the implant level by pli- nipple reconstruction, with excellent symmetry of the IM
cating the capsule (Fig. 6-36). I prefer to use a permanent folds (Fig. 6-38C).
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RAISING THE INFRAMAMMARY FOLD

FOCAL CAPSULE EXCISION AND
DIRECT CAPSULAR SUTURE
TECHNIQUE (RAW EDGE TO RAW EDGE
OF CAPSULE)
Focal capsule excision and direct capsular suture tech-

nique is my preferred method for correction of implant
malposition when a large implant has been used (>450 cc)
or in situations where a previous suture capsulorrhaphy
has been unsuccessful. It is also particularly helpful in
cases of lateral implant malposition where the implant
constantly stresses the repair with the patient in the
supine position due to the effect of gravity. This technique
was used for correction of an inferior implant in the fol-
lowing patient.
This 45-year-old patient experienced progressive infe-
rior migration of a 550-cc smooth-walled saline implant
following left breast reconstruction with a latissimus dorsi
flap (Fig. 6-38D). As in all of these cases, the correction was
planned perioperatively by placing fingers against the skin
of the lower pole of the breast, simulating the correct posi-
tion of the IM fold (Fig. 6-38E). I tend to place circles with
an in the center on the areas under my fingers (Fig. 6-
38F) and use these marks as a guide to the eventual suture
line for raw edge of capsule to raw edge of capsule apposi-
tion when working inside the capsule. At surgery the cor-
rection involves opening the anterior capsule and
removing the indwelling tissue expander or implant. Next,
FIGURE 6-36. Diagram illustrating suture plication of with the assistance of a headlight or a lighted retractor, a
periprosthetic capsule to alter dimensions of the space and the resection of a strip of capsule in the inferior recess is car-
position of space relative to surface landmarks (i.e., either IM ried out after the area to be excised is outlined on the cap-
fold or lateral extent of implant position). sular tissue (Fig. 6-38G). A strip of capsular tissue is
resected from the inferior recess below the desired new
level of the IM fold (Fig. 6-38H), and the incised raw edges
of the capsule are sutured with a row of internally placed
3-0 Prolene sutures that correspond to the skin markings
(Fig. 6-38I). Every other suture is tied and the implant is
replaced with an accompanying closure of the skin wound.
With the patient placed in the sitting position as close to 90
degrees as possible on the operating table, an assessment
of the correction is made (Fig. 6-38J). If the folds are sym-
metric, the remainder of the sutures are tied and closure of
the wound in three layers proceeds in a normal fashion.
The correction achieved with this 45-year-old patient is
noted at 1 year postoperatively (Fig. 6-38K).
If the correction is incomplete, which is indicated when
the IM fold is still positioned too low, then additional
sutures are placed in a second, more superiorly positioned
row to further raise the IM fold. Another segment of the
capsule can be excised above the previous capsular exci-
sion. Conversely, if the fold was initially overcorrected, then
the sutures are removed and more inferiorly positioned
FIGURE 6-37. Technique of suture placement in periprosthetic sutures are placed. As symmetry is achieved, the wound
capsule. closure is performed in standard three-layer fashion.
Ch06.qxd 11/28/05 5:26 AM Page 274
FIGURE 6-38. A, Moderate asymmetry of IM folds noted before exchange of tissue expanders for high-
profile silicone gel implants. B, Correction of inferior fold malposition outlined on left breast. C, Four-
month postoperative appearance reveals symmetric IM folds. D, Marked inferior malposition of a 550-cc
smooth-walled saline implant placed beneath latissimus dorsi musculocutaneous flap for left breast
reconstruction 6 months previously. Patient cannot wear clothing with this degree of asymmetry. E,
Correction of IM fold is simulated by digital pressure against skin of lower pole of implant. F, Correction,
which includes the capsule tissue to be resected and the position of suture placement, is outlined. G,
Markings are made with methylene blue to illustrate position and dimension of capsule tissue to be
resected. H, Capsule is resected. (continued)
Ch06.qxd 11/28/05 5:26 AM Page 275

Ch06.qxd 11/28/05 5:26 AM Page 276
FIGURE 6-38. (CONTINUED) I, Cut edges of capsule are

sutured together with 3-0 Prolene sutures. J, Patient is posi-
tioned at 90 degrees on operating table, correction is evaluated,
and symmetry of IM folds is checked. K, Pre-operative asymme-
try due to implant malposition and corrected breast shape is
seen 1 year following surgery.
The plication sutures change the internal volume implant but also to affect the way the implant fills
dimensions of the periprosthetic capsular space (see out the soft tissue envelope. I have found that tight-
Fig. 6-36). This can have a very powerful effect on the ening the periprosthetic capsule is a helpful adjunct in
shape an implant produces in the overlying skin. treating the problem of rippling, as well as for
The focal capsule excision and direct capsular suture defining the IM fold. We will also discuss this more com-
technique can be used not only to change the level of an pletely.
Ch06.qxd 11/28/05 5:26 AM Page 277
An IM crease in a patient who has undergone implant fold generated by the expander was ill defined and differ-
reconstruction is often not as well defined as that seen on ent from the opposite IM fold (Fig. 6-39A,B).
the opposite breast. This is most frequently noted in The patient required a large implant for symmetry.
patients with heavy tissues and a thick deep adipose Because the opposite IM fold was very well defined, I felt
layer in the lower thoracic area. Increased definition of that part of her reconstruction required redefinition of her
the crease can be accomplished by focally defatting the IM fold (see Fig. 6-34). This was accomplished by making
deeps adipose layer and intermittently suturing the super- segmental incisions in the periprosthetic capsule along
ficial fascial system (SFS or Scarps fascia) to segmental the length of the fold (Fig. 6-39D). We dissected toward
openings in the lower aspect of the peri-prosthetic cap- the skin to obtain exposure of the SFS in order to place
sule. sutures from the SFS to the posterior aspect of the
The intended level of the fold is outlined on the patients periprosthetic capsule (Fig. 6-39C) as outlined on the skin
skin and it is usually not necessary to change it. The preoperatively. Additional sutures were then placed in the
implant is removed and the peri-prosthetic capsule is inter- capsule to enforce the repair and to make the fold smooth
mittently incised with the electrocautery in 2 cm segments, externally. Not releasing the capsule in its entirety pro-
exposing the deep layer of adipose tissue. The dissection is vides an additional margin of safety for preventing signifi-
brought superficially until the SFS or Scarpas fascia is cant inferior implant malposition when a large implant is
identical beneath the intended level of the IM fold. A small selected.
amount of deep fat is excised. Sutures are placed between The technique is as follows. The level of the new crease
the SFS superficially and the posterior edge of the divided is outlined on the skin of the breast by digital pressure as
peri-prosthetic capsule below. Leaving 1 cm segments of outlined previously. Marks are then placed on the skin
intervening capsule provides some insurance against infe- (Fig. 6-39C). During surgery, after the tissue expander is
rior migration of the implant, especially if a large implant is removed, discontinuous incisions are made in 3-cm long
being used. segments (Fig. 6-39D). Dissection proceeds superficially
An example of this technique is illustrated by the toward the skin until the SFS is reached. A small amount
patient shown in Figure 6-39A-C. of the adipose tissue in the deep subcutaneous fat layer is
excised in the shape of a narrow trough exactly in the line
of the desired fold to permit accurate suture placement
ESTABLISHING BETTER DEFINITION OF and the development of crease in the skin. A 3-0 Prolene
THE INFRAMAMMARY FOLD suture is placed in the posterior capsule and also in the
SFS. Additional sutures are placed in the SFS along the
In general, patients with a husky build and corresponding IM fold through additional focal capsulotomy incisions.
thick layers of adipose tissue are not good candidates for The intervening periprosthetic capsular tissue is main-
implant reconstruction. The implants needed in such tained (Fig. 6-39E), and 3-0 Prolene sutures are placed in
patients tend to be very large because this type of this capsular tissue. An example of such a fold created
physique tends to swallow up the implant. using this method is illustrated by this patient (Fig. 6-39 F,
Such patients often manifest another problem, namely G), who is seen before exchange of her expander for an
poor definition of the IM fold that is created with an implant. There is poor definition of the IM fold created by
implant breast reconstruction. This can be aesthetically the tissue expander. Internal suture redefinition of the
undesirable, especially if there is relatively good definition fold was performed exactly as described, and 6 months
of the opposite IM fold. In these cases a redefining of the following the revision procedure, a definite crease is seen
IM fold is necessary to achieve symmetry with the oppo- that better approximates the appearance of the contralat-
site IM fold, as illustrated by the following case. eral IM fold (Fig. 6-39F, G). This is best illustrated by com-
This patient (Fig. 6-39) required a left mastectomy for paring the inferior-medial fold definition preoperatively
treatment of her breast cancer and wished to undergo an (Fig. 6-39A) with that noted following correction (Fig. 6-
immediate left breast reconstruction. She preferred an 39F, G).
implant-based reconstruction. She had significant breast I have found the focal capsule excision and direct
ptosis and the mastectomy was performed using a Wise capsular technique of suturing the SFS layer (see
pattern skin excision. She also requested a contralateral Fig. 6-34) to the posterior capsule to be an anatomically
mastopexy. In addition, she had undergone a lower sound and reliable method of creating a defined IM
abdominal midline incision for a hysterectomy. This was fold. In the patient with a very thick subscarpal adipose
done in stages, with tissue expander placement and layer, it is often beneficial to resect a good portion of
mastopexy as the first stage. The patient had a thick adi- this deep fat along the intended IM fold to enhance the
pose tissue layer in the lower thoracic area, and the IM correction.
Ch06.qxd 11/28/05 5:26 AM Page 278
FIGURE 6-39. Somewhat obese patient requires left mastec-

tomy for breast cancer and requests implant-based breast recon-
struction. She has significant bilateral breast ptosis, and the plan
is for a right mastopexy along with immediate placement of tis-
sue expander on the left, both done with a Wise pattern. A,
Appearance of tissue expander before exchange. B, Note ill-
defined IM fold on side of expander. C, Sagittal section depicting
layers of superficial fascia and posterior capsule to be altered to
produce IM fold. (continued)
Ch06.qxd 11/28/05 5:26 AM Page 279
FIGURE 6-39. (CONTINUED) D, Focal incisions in capsule

are made and dissection proceeds superficially toward skin to
access superficial fascia (different patient). EF, Purchase on
fascia is obtained with 3-0 Prolene sutures along course of
desired fold. Remainder of capsule is left intact to support
weight of large implant to be placed.
Ch06.qxd 11/28/05 5:26 AM Page 280
SUPERIOR IMPLANT MALPOSITION related to the size, shape, and position of her recon-
CORRECTION IN THE OBESE PATIENT structed right breast (Fig. 6-40A). The plan for revision
WITH A THICK LOWER THORACIC involved the placement of a tissue expander with the cor-
ADIPOSE TISSUE LAYER rection of inadequate breast dimension (base width and
height) along with the creation of a new, more well-
As previously mentioned, obese patents and those with defined IM fold positioned at the appropriate level to
thick adipose layers in the lower thoracic region are usu- match that of the opposite breast (Fig. 6-40B). Because
ally suboptimal candidates for implant breast reconstruc- the opposite breast had good definition of the IM fold, it
tion. In general they require very large implants, and often was important to place the lower pole of the tissue
even large implants do not produce the desired shape in expander in a deep portion of the superficial adipose layer.
the reconstructed breast. This may be due to large torso This was done, the expansion was completed, and she was
dimensions, but more often it is related to the fact that reconstructed with a textured shaped saline implant
implants are obscured by the thickness of the subcuta- (Fig. 6-40C,D). The patient demonstrates a highly satisfac-
neous adipose layer in patients with a heavy body habitus. tory breast appearance from the standpoint of shape,
For this reason I tend to encourage the use of autologous dimension (more adequate base width), and symmetry of
methods in patients of this body build. At times these the breast as a result of this reoperative procedure. The
options are unavailable due to patient preference, previ- definition and contour of the newly created fold highlight
ous surgery, or other anatomic factors. the improvement in breast appearance.
When an implant-based breast reconstruction is per-
formed in a heavy patient, there are often requests for
improved shape as part of the reoperative breast surgery LATERAL IMPLANT MALPOSITION
procedure. This is perhaps most commonly noted in the
lower pole, where definition of the IM fold may be subop- In its natural state the breast exhibits medial fullness and
timal or not apparent at all. extends from the parasternal area laterally to, but not
In patients with a thick layer of adipose tissue in the beyond, the anterior axillary line. However, many implant
lower thoracic area who require revision of a previously breast reconstructions extend too far laterally, reducing or
placed implant that is superiorly malpositioned, I have eliminating the superior fullness and creating a situation
had the most consistent success by removing the implant wherein the patient will bump the lateral aspect of the
and placing a tissue expander whose lower aspect is posi- breast implant with her upper inner arm. This lateral mal-
tioned superficially, i.e., above the superficial fascia. This position is due to either excessive lateral dissection; an
method of retreating has been helpful in that it allows implant that accidentally prolapses into the space of a pre-
relatively precise positioning of the new IM fold at the vious axillary dissection; or simply the stretching of the
proper level. The dissection to achieve correction is as lateral chest wall tissues under the influence of gravity,
described earlier for tissue expander placement (see Fig. which primarily exerts its effects when the patient is lying
6-18AC). It is necessary in obese patients with thick adi- in the supine position.
pose layers such as the one illustrated in Figure 6-40 to Lateral implant malposition can be treated by suture
position the lower pole of the expander in the deep capsulorrhaphy of the lateral capsular space. If a large
aspect of the superficial adipose layer above the superfi- implant has been used, I achieve the correction by clos-
cial fascial system. The expansion process can be done ing down this lateral capsular recess with a focal exci-
slowly, allowing the generation a supporting layer of sion of lateral capsule and direct suture of the raw edges
periprosthetic capsule tissue and the development of a as outlined earlier, or by correcting this with capsular
natural-appearing IM fold. Attempting to do this in one flaps (see Fig. 3-75) as previously discussed for correc-
stage with a capsulotomy and implant repositioning tion of implant malposition following breast augmenta-
risks inferior implant malposition because there is mini- tion. I like this method because it allows an extra
mal tissue support garnered from the superficial adipose thickness of capsular tissue to be sewn to itself with raw
layer. I have found that this extra procedure adds a mar- tissue being sutured to raw capsule edge tissue. Two or
gin of safety and increases the predictability of revisions three rows of nonabsorbable suture (I prefer a 3-0
done in this setting. The following case illustrates this Prolene) are most often used to provide sufficient
strategy. strength to the repair so that it will permit long-term
This 42-year-old somewhat obese patient had under- maintenance of the correction.
gone a right modified radical mastectomy and subse- The planning is similar to that done to correct inferior
quently had a staged breast reconstruction with a tissue malposition of the implant. The surgeon uses his or her
expander and the secondary placement of a saline examining fingers to manually displace the implant to
implant. She presented for correction of a significant the desired position of correction with the patient in the
postsurgical breast asymmetry with dissatisfaction standing position. The surgeon then places marks on
Ch06.qxd 11/28/05 5:27 AM Page 281
FIGURE 6-40. A, Significant breast asymmetry in the patient with a thick adipose layer who has under-
gone previous delayed reconstruction of right mastectomy defect with tissue expansion and subsequent
placement of saline implant. B, The plan for revision is outlined to address these issues and involves plac-
ing tissue expander of appropriate dimension more superficially (above superficial fascia) and more inferi-
orly at correct position for new IM fold. CD, Six-month postoperative view following placement of
textured shaped saline implant shows marked improvement in breast symmetry and appearance on AP (C)
and oblique (D) views.
Ch06.qxd 11/28/05 5:27 AM Page 282
the skin with a marking pen to outline the capsular tissue closure is completed, I splint the repair by placing a care-
to be resected and guide the placement of sutures when fully fitted piece of thick foam rubber sponge in the
internal capsule suture correction is carried out. intermammary sulcus or cleavage area (see Fig. 8-14E).
As in the correction of the other types of malposition, This can be made using straight Mayo scissors to cut a
the previous skin incision is opened and a short skin flap sterile piece of foam rubber. I secure it with either ben-
of about 2 cm is raised. The capsule is thus entered at a zoin or by using the sticky surface of the foam against
different position from the skin incision so that if there the skin and have the patient wear this for 2 weeks. I
is a dehiscence of either the capsule closure or the skin limit medial mobilization of the implant for an entire
closure, the chance of implant exposure is minimized. month following surgery. I have found that this regimen
The implant is removed and the sutures are placed. A produces the best chance for a long-term correction of
decision about whether to use a flap of capsular tissue medial implant malposition (or symmastia if it is bilat-
depends on the thickness and quality of the peripros- eral) following breast implant placement.
thetic capsule. After the correction is performed, the Such a case is illustrated by the following patient, who
implant is replaced and the position of the implant and underwent an immediate left breast reconstruction by the
shape of the breast is checked both with the patient sit- placement of a tissue expander following a modified skin-
ting up on the operating table at 90 degrees and with the sparing mastectomy (Fig. 6-41). The original dissection to
patient in the supine position. I perform a temporary position this device extended too far medially, and a pic-
stapled skin closure before inspecting the contour of the ture of medial implant malposition was apparent during
breast reconstruction with the patient in the supine the tissue expansion process (Fig. 6-41A). The second
position. stage of her reconstruction involved removal of the
expander and placement of a silicone gel implant on the
left side, along with a right breast augmentation with a
MEDIAL IMPLANT MALPOSITION smooth round silicone implant placed in the retropec-
toral position of her right breast. An attempt to correct
Medial implant malposition is the most difficult implant the medial malposition of the left breast shape with a
malposition to correct. Very often a number of maneuvers suture capsulorrhaphy was only partially successful
are required to address it, including a lateral capsular (Fig. 6-41B). Because of this, the combined implant
release, a change of implant, and carefully placed capsular reconstruction and breast augmentation produced the
sutures that are oriented parallel to the lateral border of appearance of symmastia.
the sternum. Almost always a capsulotomy with develop- The patient was disturbed by the symmastia (Fig.
ment of the anterior flaps of the capsule raised on both the 6-41B). In addition to an obvious lack of cleavage, the
anterior and posterior surfaces of the periprosthetic cap- patient exhibited lateral rib show (Chapter 2) from the
sular space is used (see Fig. 3-75). The position of the cap- frontal view with a deficiency of inferolateral breast full-
sule incision is again determined by digitally compressing ness and contour, along with a volume asymmetry
the implant laterally and marking the skin when a satis- between the augmented right breast (which was larger)
factory appearance of the correction has been simulated and the left breast reconstruction.
over the lateral border of the sternum, similar to what is The goals of the reoperative breast surgery in this
illustrated for correction of inferior implant malposition case were to restore a relatively normal cleavage space,
(see Fig. 6-38E). recreate a lateral breast contour to match the opposite
Suturing freshly incised edges of the capsule permits breast by concealing the anterolateral ribs, and increase
the deposition of collagen at the site of correction and the overall volume of the implant breast reconstruction
medially in the parasternal area. I believe this con- (Fig. 6-41C). These goals were accomplished by per-
tributes to the maintenance of the correction. I place forming a lateral capsulotomy to allow the new implant
permanent sutures of 3-0 Prolene in an interrupted fash- to extend into a more appropriate lateral position,
ion using figure-of-8 suture technique. The concomitant repairing the symmastia with a double capsular flap
lateral capsulotomy allows the effect of gravity to work technique (see Fig. 3-75) done in the medial capsular
on the implant to help protect the medial capsular region using multiple permanent (3-0 Prolene) sutures,
repair. Following the placement of the implant, a tempo- and increasing the volume and dimension of the
rary closure is performed and the breast position is smooth-walled silicone gel implant used for her recon-
checked with the patient sitting up at 90 degrees on the struction. These maneuvers produced a pleasing correc-
operating table. If the correction is appropriate, closure tion of her breast appearance (Fig. 6-41D). A subsequent
of the wound proceeds as explained previously. If addi- nipple reconstruction done with inferiorly based modi-
tional sutures are required or if one needs to be removed fied fishtail flaps (Fig. 6-41E) and an intradermal tattoo
due to dimpling of the skin, this maneuver is carried out for areolar pigmentation (Fig. 6-41F) completed her
before completing the wound closure. After the final skin breast reconstruction.
Ch06.qxd 11/28/05 5:27 AM Page 283
FIGURE 6-41. Correction of medial malposition of breast implant used for breast reconstruction. A,
This 41-year-old patient requires left mastectomy and elects to undergo staged reconstruction of breast
with tissue expander, followed by implant with plan for contralateral breast augmentation with silicone
gel implants. Note medial malposition of tissue expander. B, Second stage produced suboptimal breast
reconstruction with medial malposition of implant, which had too narrow a base width for the patients
chest dimension. C, This required a revision to correct medial malposition using double capsular flap
technique (see Fig. 3-75)(and not the suture capsulorrhaphy technique as noted on skin). D, Breast
implant with greater base width and volume was chosen, which improved breast silhouette and shape.
(continued)
Ch06.qxd 11/28/05 5:27 AM Page 284
INCREASING PROJECTION OF AN
IMPLANT BREAST RECONSTRUCTION
The task of increasing the projection of an implant

breast reconstruction generally involves two maneuvers.
The first is to release any constraint imposed on the pro-
jection by the periprosthetic capsule anterior to the
implant. This is done by methodically incising the cap-
sular tissue using parallel radial incisions in the capsule
or crisscrossed incisions (Fig. 6-42D) oriented at right
angles to each other (creating a tic-tac-toe board appear-
ance within the capsular tissue), or by performing a
focal or subtotal capsulectomy (see Fig. 3-98). I prefer
to perform a focal capsulectomy, which in my experi-
ence produces maximum distensibility of the tissues
overlying the implant. Caution must be exercised in
patients with very thin covering tissue because remov-
ing the capsule theoretically can impair the blood
supply to a thin overlying skin flap. This is perhaps a
consideration only in patients who have undergone
either previous subcutaneous mastectomy or multiple
revision procedures for revision of implant breast
reconstruction where the overlying skin flaps may be
scarred and very thin. Otherwise, performing this
maneuver with the electrocautery device using the
coagulation mode set on a low setting (3 to 4) has
proven successful and safe in my hands.
In addition, it is almost always necessary to change the
implant to one with greater projection. When reoperating
on a patient with a saline implant in place, the surgeon
should avoid the temptation to simply overfill the saline
implant in an attempt to increase the projection. This
maneuver will most often produce excessive upper pole
fullness as well as scalloping of the edges, which may be
seen as ripples through the skin.
The following case illustrates the use of multiple focal
capsulectomies combined with a change in implant to one
with more projection to improve the shape of an implant
reconstruction with inadequate lower pole projection
(Fig. 6-42). The patient had undergone bilateral staged
immediate implant-based breast reconstruction and had a
shaped textured implant with a base width of 13.9 cm and
gel volume of 540 cc (Fig. 6-42A,B). She was dissatisfied
with the shape and projection of the lower poles of her
breasts. This was addressed by performing vertically ori-
FIGURE 6-41. (CONTINUED) E, The plan for nipple recon-
struction illustrates symmetry achieved by this reoperative pro-
ented focal capsular excisions in the lower pole (Fig. 6-
cedure. F, Intradermal tattoo completes aesthetic revision, 42C,E), along with changing to a round high-profile
transforming breast mound into lifelike breast facsimile. silicone gel implant with a base diameter of 13.8 cm, a gel
volume of 600 cc, and almost 1 cm greater projection. The
improved projection is evident on the operating table
(Fig. 6-42G), and a 6-month postoperative analysis of the
breasts shows much improved contour and shape of the
lower poles (Fig. 6-42HI).
Each implant manufacturer includes with its implant
offerings specifications of dimensions that detail the
Ch06.qxd 11/28/05 5:27 AM Page 285
expected projection. As alluded to several times earlier in Smooth round implants, whether saline-filled or sili-
this chapter and in Chapter 3, I believe that the surgeon cone gel, are available in low-profile, normal-profile, and
should refer to these charts or pamphlets in the selection of high-profile shapes. High-profile implants provide the
breast implants in virtually every case. The most valuable maximum anterior projection for a given base diameter. I
information in this regard is the base width and vertical find them very useful in breast reconstruction performed
height of the implant; however, information regarding pro- with implants and very helpful in revision surgery where
jection is also helpful, especially when increasing the projec- increased projection of the reconstructed breast is the pri-
tion of a previous breast reconstruction is the primary goal. mary goal.
FIGURE 6-42. A, This 45-year-old patient had undergone bilat-

eral immediate breast reconstruction done with tissue expan-
sion and shaped textured silicone gel implants. B, Patient was
bothered by shape of breasts, which lacked projection in lower
poles. C, Projection can be increased by modifying the capsule.
The plan was to perform multiple parallel focal capsulectomies
in capsular tissue of lower pole. (continued)
Ch06.qxd 11/28/05 5:27 AM Page 286
FIGURE 6-42. (CONTINUED) D, Alternatively, a crisscross incision pattern in capsule may be used.
Regardless of technique used, it is important to maintain a segment of capsule intact along edge of inci-
sion to ensure secure closure of capsule. E, Location and pattern for capsulectomies outlined on capsu-
lar tissue surface with electrocautery. F, Each area of scar is excised. G, Smooth-walled high-profile
silicone gel implant is substituted for shaped implant, and immediately on operating table a better
shape and projection of lower pole of breast is noted. (continued)
Ch06.qxd 11/28/05 5:27 AM Page 287
FOLDS
Folds that are seen through the skin are a definite detrac-
tion from the aesthetic result of implant-breast recon-
struction (Fig. 6-43A,B). Unfortunately, the presence of
folds is not rare. The etiology of folds is multifactorial, but
the primary factors are underfilling of the implant and
inadequate tissue padding. The other factors responsible
for folds in the skin following implant reconstruction are
listed in Table 6-1.
I have had fewer problems with folds since I switched
to the use of a low-height tissue expander and a smooth-
walled silicone gel implant in most of my patients under-
going implant-based breast reconstruction. This is
because there is no stretching (and thinning) of the upper
breast tissues, and the problems associated with underfill-
ing and traction rippling are largely eliminated.
Folds in the skin following breast reconstruction (and
also after breast augmentation) are difficult to completely
correct. This is one of the situations where I underpromise
and try to overdeliver. I inform the patient preoperatively
that it may not be possible to completely correct the folds
and that if we are able to achieve correction right after sur-
gery, the folds may recur in time as her tissues stretch again.
Underfilling of the upper pole of a breast implant is the
common denominator in the genesis of folds seen in
breast reconstruction with a synthetic implant. Relative
underfilling of the upper pole of an implant is very com-
mon when a saline device is used. This applies to both tex-
tured shaped implants and smooth round implants.
Because of this I mention the importance of never under-
filling a saline implant several times throughout this book.
This practice predisposes the patient to an increased like-
lihood of folds in the breast. Paradoxically, significantly
overfilling a round implant (filling a saline implant more
than 50% over the recommended fill volume) can cause
scalloping of the edge. Such overfilling may cause visible
wrinkles in the skin, especially in a patient with thin cov-
ering tissues.
Although it is more commonly seen with saline
implants, the phenomenon is also observed with silicone
gel implants. A glaring example of this is the Inamed
Corp. Style 153 textured shaped silicone gel 13.1cm BW
and 450 cc gel (Dow Corning Corp., Midland, Mich),
which were underfilled and were associated with a sub-
stantial rate of skin wrinkling. Textured silicone gel
implants were used following tissue expansion in the
patient illustrated in Figure 6-43.
Inadequate tissue padding or thin covering tissue is
another very common motif in patients who display wrin-
FIGURE 6-42. (CONTINUED) HI, At 6-month follow-up,
there is definite improvement (compared with preoperative
kles or ripples after a breast reconstruction. Rippling that
appearance in A and B). Patient is pleased with outcome of revi- results from thin covering tissue is difficult to correct
sion procedure in terms of increase in projection of breasts. without supplementing the inadequate covering soft tis-
sue envelope with the addition of a flap. In such cases
transposing a latissimus muscle flap to wrap the implant
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TABLE 6-1 Etiology of Skin Folds with Implant

Breast Reconstruction
Underfilled upper pole of implant
Thin covering or padding tissue
Textured implant with traction rippling
Implantpocket disproportion
may be helpful. If this is done, I find that it is helpful to

tack the latissimus muscle to the periphery of the implant
pocket with sutures and place the implant beneath it.
I have had little experience with synthetic tissue sub-
strates such as allogenic dermal grafts11,12 when used for
this purpose, but they may hold promise. In a recent arti-
cle, Baxter11 outlines the use of AlloDerm acellular dermal
grafts (LifeCell Corp., Branchburg, NJ) as an inlay graft to
the superior and inferior aspect of the periprosthetic cap-
sule to improve rippling following a saline implant breast
reconstruction. The series is small, but the results are
encouraging. I suspect that this substrate will have more
widespread use for problems encountered following
implant breast surgery in the future.
At present I believe that adding vascularized tissue to
the periprosthetic capsular space is a far more reliable
way of increasing the tissue padding and decreasing the
possibility of folds in selected cases. Of course such a tech-
nique means an additional major operation, most often
with an additional donor scar, which may also be an aes-
thetic detraction. Because of this, suggesting this option
to an aesthetic patient (i.e., a previous breast augmenta-
tion patient) is almost never done. However, in the
extremely rare instance when it might be an option, it can
be offered with reservation, but the surgeon must explain
thoroughly the additional incisions and possible donor
deformity and obtain the appropriate informed consent.
The use of a TRAM flap to treat recalcitrant capsular con-
tracture in a breast augmentation patient is illustrated in
Chapter 4.
Breast reconstruction patients are more likely to be
accepting of such an intervention, but they too must be
informed of the additional incisions that will result in per-
manent scars that can be unattractive, along with the
other potential risks of such a procedure, including partial
or complete flap loss.
FIGURE 6-43. A, Fold seen in upper pole of both breasts fol- Smooth implants in general show less rippling than
lowing bilateral breast reconstruction with full-height tissue textured implants, and silicone implants show less rip-
expanders and shaped textured silicone gel implants (13.1 cm, pling than saline implants. I often convert a patient from a
450 cc). B. Folds are accentuated in different postures, and espe- textured device to a smooth device of greater dimensions
cially when bending forward. and volume when performing a reoperative procedure to
address rippling following a previous implant breast
reconstruction. I believe there is significantly less chance
that a smooth silicone device will cause rippling because
of the better fill volume and the more avid capsule that is
generally laid down around the device as part of the
Ch06.qxd 11/28/05 5:27 AM Page 289
patients natural biologic incorporation of the smooth- Fig. 6-36; sutures placed in the middle or equator of the
surfaced implant. I often alter the dimensions of the capsule). This maneuver most often decreases the volume
periprosthetic capsular space with plication sutures as of the periprosthetic capsular space without altering
part of this procedure (see Fig. 6-36). external contour or projection of the implanted breast, as
Many times I have been successful in decreasing the illustrated in the diagram (see Fig. 6-36). Multiple sutures
visibility of ripples and folds by increasing the quantity are usually needed to produce such a correction. The sur-
and quality of soft tissue padding over the implant and geon must make sure there is no distortion produced in
changing the characteristics of the implant. However, the skin contour when placing these sutures.
even when the soft tissue envelope is of adequate thick- As sutures are placed close to the dome or the most
ness (>1.5 cm), ripples or folds from the implant may still anterior aspect of the periprosthetic capsular space, there
be seen through the skin. I believe that properly fitting the tends to be a corresponding decrease in projection of the
implant into the periprosthetic capsular space minimizes implanted breast, producing a slight flatness to the breast
this occurrence. form. In some instances it may be necessary to remove
and replace sutures to achieve the desired capsular tight-
ening while preserving the optimal breast shape in terms
FOLDS FOLLOWING IMPLANT of projection. The first sutures are usually placed with the
RECONSTRUCTIONPERIPROSTHETIC implant having been removed; however, it is often possible
CAPSULAR SPACEIMPLANT to retract the implant with a narrow ribbon or Deaver
DISPROPORTION retractor to place additional sutures to fine tune the cor-
rection. I prefer to place 3-0 Prolene sutures because they
Disproportions between the implant size and volume and will not dissolve.
the volume and dimensions of the periprosthetic capsular These concepts were used in this patient (Fig. 6-44),
space are often responsible for the appearance of ripples who was dissatisfied with the folds in the upper outer
or folds following implant placement (see Table 6-1). aspect of her left breast reconstruction following a staged
Indeed the treatment of folds almost always involves tissue expansion and textured shaped silicone gel place-
addressing this disproportion, either by placing a larger ment. She had undergone the placement of an implant
implant in terms of dimension or volume or by decreasing with a base dimension of 13.9 cm and a gel volume of 540
the volume of the previous periprosthetic capsular space cc. Note the folds in the upper pole of the left breast
by placing sutures in the capsule to tighten it while plac- reconstruction (Fig. 6-44A), especially in its outer aspect
ing a larger implant. As noted earlier, I most often perform (Fig. 6-44B).
a combination of these maneuvers. The operative plan included two maneuvers. We per-
It is my belief that the periprosthetic capsular space formed a suture modification of the periprosthetic cap-
can be altered in a predictable way by suture placement sule with slight elevation of the IM fold. The implant was
internally to plicate the capsule (see Fig. 6-36). This changed to a smooth-surfaced device with a greater base
requires removal of the implant for direct visualization of dimension, greater volume, and higher profile (14.2 cm,
the capsule. As previously illustrated, this maneuver can 650 cc, high-profile silicone gel; Fig. 6-44C). The problem
be done to raise the level of the IM fold or to reposition an was corrected and the patient shows an excellent appear-
implant more medially by closing down the lateral recess ance of the breast at a 9-month postoperative follow-up
of the periprosthetic capsular space. These alterations and is very pleased with the results of this reoperative pro-
entail suture placement at the base of the periprosthetic cedure (Fig. 6-44D,E).
capsule (see Fig. 6-36), where such suture placement In summary, the correction of ripples and folds in the
almost always produces a change in the external contour setting of breast reconstruction is difficult. When reopera-
or visual outline of the breast. Alterations can be subtle or tion to treat ripples and folds is undertaken, the surgery
dramatic, as previously demonstrated for correction of involves at a minimum altering the periprosthetic capsu-
various asymmetries. However, the volume of the lar space by tightening it and changing the implant with
periprosthetic capsular space can be decreased without regard to dimension, volume, surface texture, or all three.
altering the obvious visible dimension or contours of the Surgery may also involve providing additional padding
breast by placing the sutures away from the base. When tissue in the form of a flap. The flaps most commonly used
viewed in cross section or sagittal section, such suture for this purpose are the TRAM flap and the latissimus
placement is usually in the middle zone of the capsule (see dorsi flap.
Ch06.qxd 11/28/05 5:27 AM Page 290
FIGURE 6-44. A, Skin folds are noted in upper pole of left

breast reconstruction done with shaped textured silicone gel
implant after previous tissue expansion. B, Lateral folds were
especially objectionable to patient. C, She underwent removal of
textured silicone implant (13.9 cm, 540 cc) and had insertion of
smooth-walled high-profile silicone gel implant (14.2 cm, 650
cc). Nine-month follow-up of her appearance on AP (D) and
oblique (E) views shows correction of folds.
Ch06.qxd 11/28/05 5:27 AM Page 291
IMPLANT DEFLATION version. The latter option appeals to many previous

implant reconstruction patients and is discussed in the
Deflation is a definite potential reality after placement of a next section.
saline implant. The deflation rate I quote is 2% per year.
This is true for both breast augmentation and reconstruc-
tion. There does not appear to be any difference in defla- COMBINATION BREAST DEFORMITY
tion rates between smooth- and textured-surface devices. IMPLANT MALPOSITION, ADVANCED
I advise all of my saline implant patients of the possibil- CAPSULAR CONTRACTURE, IMPLANT
ity of deflation, and I tell them that if deflation occurs, IMMOBILITY, AND QUALITATIVE
they should seek treatment as soon as possible because TISSUE DEFICIENCYTREATMENT BY
the capsule around the implant will contract if the defla- AUTOGENOUS CONVERSION
tion is not treated within the first week. If the capsule con-
tracts it will be necessary to restore the volumetric An alternative strategy for patients presenting with
dimensions of the preprosthetic capsular space with a implant rupture is to remove the implant completely and
capsulotomy(ies), which makes it more difficult to dupli- replace it with a flapthe so-called autogenous conver-
cate or restore the symmetry that may have existed before sion of a previous implant reconstruction. It is uncom-
the deflation. mon to resort to this strategy when folds alone are the
Long-standing implant deflations require considerably presenting problem. However, when they are seen in con-
more surgical intervention from the standpoint of junction with other issues such as implant malposition,
periprosthetic capsule manipulation. With such addi- advanced degree of capsular contracture, qualitative tis-
tional surgery comes a greater chance for asymmetry. For sue deficiency resulting in a significant asymmetry, then
this reason I tell all of my patients to report such events as autogenous conversion is often a good treatment option.
soon as they happen so that the best possible outcome can The following patient illustrates this scenario.
result from the most minimal surgery. This 54-year-old female (Fig. 6-45) had undergone an
implant reconstruction after a mastectomy. She was dis-
satisfied with the result, which was very suboptimal from
IMPLANT RUPTURE FOLLOWING the standpoint of breast dimension, volume asymmetry,
BREAST RECONSTRUCTION WITH capsular contracture, superior malposition of the implant
A SILICONE GEL IMPLANT with a step-off deformity superiorly, and obvious ripples
in the superior aspect of the breast reconstruction (Fig.
The considerations for treatment of implant rupture fol- 6-45A,B). The plan was for autogenous conversion using a
lowing breast reconstruction with a silicone gel implant free microvascular TRAM flap. The free TRAM (Fig.
are similar to those outlined in Chapter 4. The goal should 6-45C) was selected here because of the significant tissue
be to limit the potential for granuloma formation, which requirements to match the opposite breast (Chapter 7)
can occur when silicone gel comes in contact with the soft and because the patient had a relatively narrow waistline
tissue overlying the implant. At a minimum, if the patient and we needed three zones of tissue to match her opposite
presents with a mass, this requires making a diagnosis to breast. To address the patients skin deficit in the most aes-
differentiate granuloma formation from a recurrent thetically optimal way, the TRAM flap skin paddle was
tumor. At times this may mean the resection of additional positioned inferiorly and most of the TRAM flap adipose
skin and soft tissue overlying the implant, which can fur- tissue was distributed superiorly and in the central part of
ther compromise the aesthetic outcome of an implant her breast, where there was a need for significant breast
reconstruction. For this reason I see my patients who have volume.
undergone implant-based breast reconstruction at an The flap afforded an excellent simulation of the oppo-
interval of no longer than every other year and advise site breast from the standpoint of base dimension, vol-
them to inform me if there is any change in the appear- ume, and contour (Fig. 6-45D). There was complete
ance of their reconstruction. If I suspect a rupture of the correction of the superior pole rippling. A nipple recon-
device from a clinical standpoint, I obtain magnetic reso- struction using an inferiorly based modified star flap
nance imaging (MRI) of the breast reconstruction to con- (Fig. 6-45E) and a subsequent intradermal tattoo for the
firm or disprove this suspicion. I believe that implants areolar area completed the patients reoperative breast
that are ruptured should be removed and replaced. I will reconstruction continuum (Fig. 6-45F,G).
most often perform a total capsulectomy unless con- Autogenous tissue conversion of a previous implant-
traindicated by the local tissue conditions. As detailed in based reconstruction can provide an excellent solution to
Chapter 4, the options for patients presenting with rup- many problems resulting from a previous implant and
ture are removal with no replacement (which is rare in my therefore is an option for many patients who have under-
experience), implant replacement, and autogenous con- gone a previous implant breast reconstruction.
Ch06.qxd 11/28/05 5:28 AM Page 292
FIGURE 6-45. Autogenous conversion of very suboptimal right breast reconstruction done with
saline implant. A, Implant is of inadequate dimension and size, is malpositioned, and is severely con-
tracted (Baker IV). B, There is a step-off between upper pole of breast implant and patients upper chest
tissues. C, A free TRAM is optimal choice for reconstruction due to large requirements for adipose tis-
sue fill volume and skin and relatively limited tissue in lower abdomen. D, This flap produces excellent
restoration of patients breast form. (continued)
Ch06.qxd 11/28/05 5:28 AM Page 293
FIGURE 6-45. (CONTINUED) E, Inferiorly based modified

star flap provides symmetry with position and projection of
patients opposite nipple. FG, Intradermal tattoo adds the ulti-
mate finishing touch, converting reconstructed breast mound
into a natural-appearing breast.
Ch06.qxd 11/28/05 5:28 AM Page 294
CAPSULAR CONTRACTURE, A VEXING neous mastectomy and implant reconstruction. The sur-
UNSOLVED PROBLEMTHOUGHTS geon must exercise judgment and decide whether a cap-
AND POSSIBLE THERAPEUTIC sulectomy is safe to perform in a given circumstance.
APPROACHES Every patient who undergoes implant placement for
breast reconstruction is given a bacteriocidal dose of a
Capsular contracture remains a vexing, unsolved potential second-generation cephalosporin [e.g., cefazolin (Ancef),
problem in every breast procedure that involves the use of 1 g] before making the surgical incision. All of the intraop-
an implant. The etiology is unknown. The two main erative routines described in Chapter 3 for implant place-
hypotheses are hypertrophic scar formation around an ment during breast augmentation (e.g., antibiotic
implant and subclinical infection due to Staphylococcus irrigation, the use of barrier drapes on the skin, and filling
epidermidis. Neither of these has been confirmed. saline implants using a closed filling system) are per-
Consequently, a consistently effective treatment has not formed in the setting of reoperation for capsular contrac-
been established. Several observations seem to hold true, ture after implant breast reconstruction.
however. The clinical occurrence of capsular contracture
is more apparent and seems more common following
breast reconstruction than breast augmentation. This is RADIATION-INDUCED CAPSULAR
related to both qualitative and quantitative differences in CONTRACTURETREATMENT WITH
the covering tissue layer, which permits easy appreciation AUTOGENOUS TISSUE
of firmness after many implant-based breast reconstruc- SUPPLEMENTATION USING THE
tions. In general, textured implants seem to exhibit less LATISSIMUS DORSI MUSCLE FLAP
contracture than smooth-surfaced implants; however,
I have not been impressed with my clinical observations The latissimus flap has proved very helpful in providing
that this is translated into increased breast softness. additional soft tissue padding in a number of patients, and
When confronted with a capsular contracture my strat- this has given most of them and me the impression that
egy is to change something. As outlined in Chapter 3, this their breast reconstructions are softer and more natural
is the most common approach following breast augmen- feeling. Such a case is illustrated by the following patient,
tation and also for surgical interventions following breast who developed a recurrence of left breast cancer following
reconstruction. Most often this means altering the local previous lumpectomy and radiation to the breast. She
tissue conditions by performing a total periprosthetic cap- requested bilateral mastectomy and immediate recon-
sulectomy. This maneuver provides a fresh tissue bed into struction (Fig. 6-46A). She did not want a TRAM flap. She
which to place a new implant. I advocate changing the underwent a left latissimus dorsi flap reconstruction with
implant in all of these situations, most often substituting a a tissue expander positioned beneath the flap (Fig. 6-46B)
textured-surface implant for a smooth implant. The best and had a subpectoral tissue expander placed on the right
implant I have used in the treatment of capsular contrac- side. The subsequent implant exchange to smooth round
ture is the polyurethane-coated implant. The results of saline implants was complicated by a Baker III capsular
placing this implant after performing a total capsulec- contracture of the right breast reconstruction and a Baker
tomy are nothing short of astounding in many cases from II on the left (Fig. 6-46C). There was an asymmetry of skin
the standpoint of producing breast softness. Unfortu- envelope dimension in addition to the contracture (Fig.
nately, merely texturing the surface of either a saline or a 6-46D). The patient requested a procedure to improve the
silicone gel implant has not yielded anywhere near the symmetry between the breasts and to increase the soft-
same degree of success. Nevertheless, changing the ness of the right breast. The plan was to remove the
implant is a strategy. In essence it works in many cases at implant, perform a total capsulectomy, replace the skin
the time of exchanging a tissue expander for a breast deficit by adding skin in the center of the breast (Fig.
implant in that most of the time breasts that are recon- 6-46E), and to add soft tissue to the entire breast in the
structed with an implant are softer than the expander. form of a right latissimus dorsi musculocutaneous flap
In every case, it is important to create an adequate (Fig. 6-46F). This was carried out, and after a short period
pocket to accommodate the dimensions of the new of tissue expansion both implants were changed to
implant. When a smooth implant is inserted, I routinely smooth-walled high-profile silicone gels (12 cm, 425 cc).
institute displacement exercises. I do not advocate rou- This produced the expected symmetry of the envelopes
tinely moving or massaging textured-surface implants. and soft breasts bilaterally (between Baker I and II). The
Resecting the previous scar capsule is indicated in almost patient is awaiting intradermal tattoos following her nip-
every situation. This means performing a periprosthetic ple reconstructions (Fig. 6-46G,H).
capsulectomy. The major exception is when the skin over- The latissimus dorsi flap is a truly versatile tissue com-
lying the implant is excessively thin or attenuated. Such a posite that can be harvested through very small incisions
situation is not uncommon following a previous subcuta- (with or without the endoscope) and provides an excellent
Ch06.qxd 11/28/05 5:28 AM Page 295
FIGURE 6-46. A, Preoperative AP view of patient with recurrent left breast cancer following previous
lumpectomy and radiation therapy. She requests immediate bilateral breast reconstruction. B, Outline
for latissimus dorsi musculocutaneous flap reconstruction of left breast. Right breast was recon-
structed with tissue expander placed in subpectoral position. C, Following shaped textured silicone gel
implant placement (11.6 cm, 360 cc) patient has an asymmetry and a Baker III contracture of right
breast. D, Quantitative and qualitative (C) tissue deficiency in right breast. (continued)
Ch06.qxd 11/28/05 5:28 AM Page 296
FIGURE 6-46. (CONTINUED) E, Outline of the plan for reoperative surgery, including capsulectomy
and skin replacement in the central breast. F, Outline of right latissimus flap design. GH, Appearance
of breasts following replacement with 12-cm, 425-cc high-profile silicone gel implants bilaterally and
bilateral nipple reconstruction. Both breasts are soft and symmetry is excellent as patient awaits nipple
areolar tattoo procedure.
source of tissue to supplement an implant, or in some produce better aesthetics in terms of breast softness and
cases to convert an implant reconstruction to an autoge- symmetry, or as a form of salvage.5 The latissimus dorsi
nous tissue reconstruction. It is especially valuable in the muscle and musculocutaneous flap are finding increas-
postradiation patient. I prefer to keep it in reserve when I ing utility in my practice due to the increased prevalence
know the patient will receive radiation therapy following of adjuvant radiation therapy in many patients with
the mastectomy, and I advise patients that we can achieve breast cancer and in patients who have sustained a
a more predictably good outcome using a delayed breast recurrence after previous breast conservation and radia-
reconstruction strategy. tion as their primary treatment. Another flap that is very
Antecedent radiation therapy increases virtually all valuable in the treatment of persistent and/or recalci-
complications in patients who request staged tissue trant capsular contracture after an implant-based recon-
expansion implant-based breast reconstruction.5 Such struction is the TRAM flap, as illustrated in the following
patients often require conversion to a flap procedure to section.
Ch06.qxd 11/28/05 5:28 AM Page 297
ADVANCED CAPSULAR CONTRACTURE tion with a de-epithelialized TRAM flap and contralateral
TREATED WITH AUTOGENOUS vertical mastopexy for the right breast. The TRAM flap was
CONVERSIONIMPLANT REMOVAL, elevated on the single ipsilateral rectus muscle pedicle,
CAPSULECTOMY, AND TRAM FLAP completely de-epithelialized (Fig. 6-47C), and transferred
BREAST RECONSTRUCTION to the left breast. She healed without difficulty and demon-
strated a soft breast with a natural appearance on an 8-
Advanced capsular contracture (Baker IV) can produce year follow-up office visit (Fig. 6-47D).
discomfort, and patients presenting with it may benefit Capsular contracture in the setting of a previous
from autogenous conversion. This treatment was under- implant-based breast reconstruction is best and most pre-
taken in this 52-year-old patient who presented with dictably treated with explantation and replacement of the
advanced capsular contracture (Baker IV) 5 years follow- contracted implant with the patients own tissue in the
ing a left breast reconstruction with a silicone gel implant form of a flap. In the appropriate patient a TRAM is an
(Fig. 6-47A). The surgical plan included total capsulectomy excellent choice for such a conversion, as illustrated by
of the left breast with removal of her implant and autoge- the outcome demonstrated here (Fig. 6-47) and previously
nous conversion (Fig. 6-47B) of the left breast reconstruc- (see Figs. 4-56 and 4-57).
FIGURE 6-47. A, Baker IV capsular contracture of silicone gel implant used for left breast reconstruc-
tion has produced an asymmetry and is causing the patient discomfort. B, The plan is for explantation,
total capsulectomy, and left breast reconstruction with autogenous conversion to TRAM and contralat-
eral right vertical mastopexy. (continued)
Ch06.qxd 11/28/05 5:28 AM Page 298
FIGURE 6-47. (CONTINUED) C, Ipsilateral unipedicle TRAM is completely de-epithelialized and made
ready for transfer. D, Appearance of breasts at 8-year follow-up examination. Note preservation of excel-
lent symmetry.
FINISHING TOUCHES Chapter 2 reviews the relatively new technique of autol-

ogous fat grafting to treat small peripheral contour abnor-
Reoperative surgery on a previous implant breast recon- malities in the breast. This technique has been helpful for
struction can take many forms. The goals are good shape, me in the reoperative setting following breast reconstruc-
good contour, and symmetry. The visual impact of a tion with both TRAM flaps and synthetic implants. In addi-
breast reconstruction begins with the appearance of the tion, liposuction can be a valuable breast contouring
skin. Dog ears should be excised. They will almost never technique for both revising TRAM flap reconstruction
completely flatten out. Scars can be excessively wide after (Chapter 8) and refining the contour of the breast flaps in
expansion, and sometimes the previous incision may be selected implant breast reconstructions. The following
depressed or have other irregularities. In this situation case illustrates the use of liposuction to thin the superior
the scar should be excised and the best possible reapprox- breast flap of one breast, with the aspirated fat used as a
imation of the wound edges carried out in an attempt to graft to the skin flap of the opposite breast.
produce the best possible appearance of the scar. I saw this 62-year-old patient (Fig. 6-48) in consultation
The drape of the skin flap is an important contributor for a breast asymmetry after she had undergone a bilateral
to breast contour. This is true in delayed breast recon- implant-based breast reconstruction done in stages with the
struction with a TRAM flap, and it is true for an implant- immediate insertion of tissue expanders, followed by the
based breast reconstruction. Following the mastectomy placement of shaped textured silicone gel implants (13 cm,
the native mastectomy flap(s) may adhere in a slightly 450 cc). She was bothered by a breast asymmetry with the
unfavorable way, especially near the incision, and may left breast seeming bigger and more full superiorly (Fig. 6-
produce an asymmetry of contour. This may be subtle or 48A,B). There was no evidence of capsular contracture or
not so subtle. In this situation it may be necessary to re- implant malposition. An ultrasound did not reveal any
elevate a portion of the flap(s) at the time of implant abnormal fluid collection in either breast. Careful physical
exchange. I perform this maneuver to some extent in examination revealed what appeared to be a significant dif-
about 5% of my cases. It can make a nice difference in the ference in the thickness of the superior skin flaps on the
contour of the eventual breast reconstruction after the breasts, with the left breast flap considerably thicker than
placement of the implant. the right. The patient was noted to have a right parasternal
Ch06.qxd 11/28/05 5:28 AM Page 299
depression from a previous intravenous (IV) access catheter cc of adipose tissue was aspirated. This was centrifuged and
used for chemotherapy (Fig. 6-48C). She also had surgically the infranatant fluid was discarded. She then underwent
absent nipples and requested bilateral nipple reconstruc- autologous fat grafting for the parasternal contour defect in
tion. The plan was for liposuction of the superior skin flap of the right parasternal area with 40 cc of autologous fat placed
the left breast, bilateral nipple reconstruction using inferi- into this contour defect in conjunction with the bilateral nip-
orly based fishtail flaps, and autologous fat grafting to the ple reconstruction (Fig. 6-48E). She had a subsequent intra-
right parasternal contour defect (Fig. 6-48C). dermal tattoo for pigment addition to the areolae. The
The patient underwent liposuction of the superior skin patient is shown 3 years following that procedure with
flap (Fig. 6-48D) on the left breast after the injection of a wet- markedly enhanced symmetry between the breasts and a
ting solution containing 12.5 mg% lidocaine (Xylocaine) and very satisfactory correction of the contour deformity in the
epinephrine in a concentration of 1:1,000,000. A total of 70 right parasternal area (Fig. 6-48F,G).
FIGURE 6-48. A-B, This 62-year-old patient presented with an asymmetry of the breasts and a contour
deficit in the right parasternal area where an IV access catheter had been placed for chemotherapy. She
also had surgically absent nipples. C, The reoperative plan includes bilateral nipple reconstruction with
inferiorly based modified fish tail flaps, liposuction of superior skin flap of left breast, and autologous fat
grafting for the right parasternal defect. D, Adipose aspirate is removed from superior skin flap of left
breast. (continued)
Ch06.qxd 11/28/05 5:28 AM Page 300
FIGURE 6-48. (CONTINUED) E, Nipple has been recon-

structed and recipient area for fat graft is outlined. F-G, Patient
shows much improved symmetry between the breasts, excellent
contour of upper breast poles, realistic-appearing and well-posi-
tioned NACs, correction of the parasternal depression, and a
highly satisfactory overall aesthetic appearance of the breasts.
Note better contour of left breast in upper pole and correction of
the indentation in contour of superior medial aspect of right
breast.
This case illustrates the reoperative surgery and the of autologous fat grafting of peripheral contour defects
use of finishing touches that are important for both to be helpful in a variety of clinical settings involving
maximizing symmetry and converting a breast mound the breast. I predict that both of these techniques will
to a truly natural-appearing breast. I have found the have expanded application for the breast surgeon per-
techniques of skin flap contouring with liposuction fol- forming reoperative procedures on the breast in the
lowing implant-based breast reconstruction and the use years ahead.
Ch06.qxd 11/28/05 5:28 AM Page 301
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987988.
1. American Society of Plastic Surgeons Procedural Statistics. 7. Lassus C. Update on vertical mammaplasty. Plast Reconstr Surg.
Arlington Heights, Ill: American Society of Plastic Surgeons; December 1999;104(7):22892298; discussion 22992304.
2000; 2003. 8. Spear SL, Majidian A. Immediate breast reconstruction in
2. Radovan C. Reconstruction of the breast after mastectomy two stages using textured, integrated-valve tissue expanders
using a temporary tissue expander. Plast Reconstr Surg. and breast implants: a retrospective review of 171 consecu-
1982;69:195206. tive breast reconstructions from 1989 to 1996. Plast Reconstr
3. Gabriel SE, Woods JE, OFallon WM, et al. Complications Surg. January 1998;101(1):5363.
leading to surgery after breast implantation. N Engl J Med. 9. Ryan JJ. A lower thoracic advancement flap in breast recon-
March 6, 1997;336(10):677682. struction after mastectomy. Plast Reconstr Surg. August
4. Collis N, Sharpe DT. Breast reconstruction by tissue expan- 1982;70(2):153160.
sion. A retrospective technical review of 197 two-stage 10. Shestak KC, Restifo RJ. Revision and salvage of the subopti-
delayed reconstructions following mastectomy for malignant mal TRAM flap reconstruction. In: Spear SL. Surgery of the
breast disease in 189 patients. Br J Plast Surg. January Breast: Principles and Art. Philadelphia: Lippincott; 1998.
2000;53(1):3741. 11. Baxter RA. Intracapsular allogenic dermal grafts for breast
5. Spear SL, Onyewu C. Staged breast reconstruction with implant-related problems. Plast Reconstr Surg. November
saline-filled implants in the irradiated breast: recent trends 2003;112(6):16921696; discussion 16971698.
and therapeutic implications Plast Reconstr Surg. March 12. Dowden DI. Correction of implant rippling using allograft
2000;105(3):930942. dermis. Aesthetic Surg J. 2001;21:81.
6. Handel N, Silverstein MJ, Gamagami P, et al. Factors affect-
ing mammographic visualization of the breast after augmen-
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C h a p t e r 7
Technical Tips for Avoiding

Complications in TRAM Flap Breast
Reconstruction
TRAM Flap Procedure Selection 303 Immediate Breast ReconstructionPreserving

the Envelope 331
Patient Selection in TRAM Flap Breast
Reconstruction 306 Skin-Sparing Mastectomy Incisions 333
Aesthetic Analysis of the Contralateral Breast Delayed ReconstructionWorking the

308 Envelope 333
Creating the Breast MountFlap Inset 321 Envelope Reduction 335
The Inframammary Fold in TRAM Flap Breast Final Flap Assessment 335
Reconstruction 327
The Abdominal Wall Closure 337
The Skin Envelope in Breast Reconstruction with
the TRAM Flap 328 References 338
Since its introduction in 1981, the transverse rectus abdo- technique with attention to detail, in that order. I believe
minis musculocutaneous (TRAM) flap1 has become the that the importance of planning in breast reconstruction
gold standard in breast reconstruction worldwide. This (and in virtually all plastic surgery procedures for that
procedure provides the reconstructive surgeon with the matter) cannot be overstated, and for TRAM flap breast
ability to create a natural-appearing permanent breast reconstruction the adage an ounce of prevention is worth
mound using the patients own tissue, which can simulate a pound of cure is very applicable.
the appearance of almost any opposite breast. Indeed, the The goal of TRAM flap breast reconstruction is to
TRAM flap is a great operation. However, it is a demand- reconstruct the best possible breast while keeping the
ing procedure for both the patient and the surgeon. complication rate to an absolute minimum. Toward this
Obtaining consistently good aesthetic results requires end there are two important considerations: procedure
careful preoperative planning and technical proficiency. selection,2 or choosing the appropriate TRAM flap proce-
Despite these efforts, TRAM flap breast reconstruction dure type for a given patient, and patient selection, or
can be compromised by a multiplicity of factors, includ- carefully analyzing individual patient comorbidities to
ing vascular insufficiency in the flap or ischemia of the select only appropriate candidates for the procedure.3
native breast skin flaps, errors in aesthetic planning and This chapter emphasizes these concepts and presents
judgment, and errors in technique while reconstructing what I believe to be important points of surgical tech-
the new breast. nique.
As discussed later in this chapter, consistently excellent Postoperative breast asymmetry following TRAM flap
outcomes in reconstructive and aesthetic plastic surgery breast reconstruction is not uncommon. The etiology of
are the result of intense preoperative study. The most suboptimal outcomes is directly related to either errors in
important factors for achieving consistent success with planning or vascular compromise in the flap, producing
TRAM flap breast reconstruction results are having an fat necrosis or various degrees of flap loss. Errors in plan-
individualized artistic plan and using careful operative ning may be due to a number of factors (Table 7-1),
302
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Chapter 7 Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction 303
TABLE 7-1 Suboptimal Outcomes Following TRAM Appropriate patient selection2,3 is a critical component
Flap Breast Reconstruction Related to of limiting complications following TRAM flap breast
Errors in Planning reconstruction. There are a number of factors that have
Skin envelopeunderreplacement or overreplacement been shown to increase the incidence of complications
Breast contour asymmetry following TRAM flap reconstruction. Most notably these
Breast volumeinsufficient or excess are cigarette smoking, obesity, previous abdominal inci-
Projection asymmetryflap inset problems sions, and antecedent radiation therapy.
IM fold discrepancy
Fat necrosis
Partial or significant flap loss TRAM FLAP PROCEDURE SELECTION
Donor site problemsbulges or hernias
IM, Inframammary. From an aesthetic standpoint, tissue requirement (i.e., the
amount of skin and adipose volume needed to achieve the
desired breast reconstruction) is important to consider in
each patient. Simply put, this is the amount of skin and
including skin replacement miscalculations, breast vol- subcutaneous adipose tissue that must be transferred
ume discrepancies, suboptimal flap inset positioning, and from the lower abdomen to produce symmetry with the
inframammary (IM) fold asymmetries. More significant opposite breast.
suboptimal outcomes are usually secondary to vascular Accurately estimating the volume of the breast to be
compromise in the flap. This can result in fat necrosis or matched with the TRAM flap reconstruction is a critical
various degrees of flap loss, ranging from minor to major. first step. For me this is both a visual and tactile analysis.
Likewise, complications in the donor site region are also I carefully study the breast from the standpoint of its pro-
not uncommon. These relate to skin necrosis in the lower jection and distribution over the anterior chest wall
abdominal incision area, postoperative seroma accumula- (Fig. 7-1A). Normally the breast extends from the second
tion, and eccentricity and/or partial necrosis of the to the sixth intercostal spaces and from the parasternal
umbilicus, but more significantly they relate to contour area to the anterior axillary line. Some breasts extend
deformity both in terms of bulges and frank hernia in the more superiorly and/or more laterally than others. I obtain
lower abdominal region, both of which can be quite dis- a true estimate of the tissue needed for the volume
turbing or debilitating for the patient. restoration by grasping or gently cupping the patients
Unfortunately, despite careful patient selection and breast with my hand. This gives me an appreciation of the
appropriate procedure selection, as well as consistent sur- superior extent of the breast tissue and the thickness of
gical technique, complications do occur that can compro- the tissue in this superior area (Fig. 7-1B).
mise the outcome of a TRAM flap breast reconstruction. Measurement of the skin deficit is a more straightfor-
Chapter 8 addresses the common complications observed ward task in that it can be done using a tape measure
after TRAM flap breast reconstruction and presents my placed over the existing breast, first in the vertical mid-
approach to addressing each of these. breast meridian (measured from the midclavicular point
A considerable amount of text in this chapter is devoted down through the nipple to the IM fold) (Fig. 7-1C) and
to outlining my approach to planning as it relates to patient then horizontally across the most anteriorly projecting
selection and procedure selection (i.e., the type of TRAM part of the breast. In the case of a delayed breast recon-
flap selected), which is determined by aesthetic require- struction, the surgeon can gain an accurate estimate of
ments and specific patient comorbidities (Table 7-2). how much skin needs to be replaced by subtracting the
smaller numbers on the side of the mastectomy from the
larger skin dimensions on the contralateral breast.
I will then perform a similar maneuver in the lower
abdominal region, again gently cupping the adipose tissue
TABLE 7-2 TRAM Flap Procedure Selection on either side of the lower abdominal midline (Fig. 7-1D)
TRAM flap procedure selection is determined by the balance of the with my hand. This gives me the best idea of how much
following: adipose tissue there is on one side of the lower abdomen
Tissue requirements and patient comorbidities and whether it will be enough to recreate a breast with
Smoking adequate volume.
Obesity Clinical concepts about the circulatory dynamics of
Previous incisions
the superiorly based TRAM flap were initially proposed
Radiation therapy
by Hartrampf3 after a thorough analysis. His observa-
Diabetes mellitus
tions gave rise to the idea of dividing the tissue of the
Collagen vascular disease
lower abdomen into four zones (Fig. 7-2) based on the
Ch07.qxd 14/12/05 4:14 AM Page 304
FIGURE 7-1. A, Aesthetic requirements for delayed TRAM flap breast reconstruction are related to the
tissue required to match the opposite breast. This includes the volume of adipose tissue, which is best
determined by cupping the breast with the hand (B), and skin replacement dimensions (C).
Replacement of the skin deficiency in the vertical and horizontal dimension is the key to achieving sym-
metry with the opposite breast in a delayed breast reconstruction. This assessment is both visual and
tactile and can be facilitated by direct measurements. D, Estimation of the tissue available on one side
of the lower abdomen is important. It is determined by direct manual palpation or cupping of the
abdominal tissue volume below the umbilicus. (continued)
Ch07.qxd 14/12/05 4:14 AM Page 305
IV III
II
I
FIGURE 7-2. The concept of TRAM flap zones as originated by

Dr. Hartrampf. It is based on the relationship of the adipose tis-
sue in the lower abdomen to the underlying rectus muscle car-
rier. Zone I and Zone III are more well perfused than Zone II.
Zone IV in a single muscle flap has a random pattern blood
supply and therefore is not at all reliable.
proximity of the adipose and skin tissue components to The TRAM flap can be designed as a unipedicle superi-
the nutrient muscle pedicle. He observed decreasing pre- orly based flap13 (Fig. 7-2) in those clinical cases where it
dictability in survival of tissue as one progressed laterally is determined that the tissue on one side of the lower
from zone I, the tissue overlying the muscle, to the ran- abdominal midline (zones I and III in Fig. 7-3A) will pro-
dom pattern circulation in zone III on the ipsilateral side, vide sufficient volume for the reconstruction (or a total of
and then to the transmidline tissue in zone II and further two zones or 50% of the total tissue in the lower
laterally across the midline to zone IV, which is the tissue abdomen). If more tissue than this is required, the sur-
across the midline most distant from the musculocuta- geon must incorporate a maneuver to provide additional
neous perforators. The clinical observations of vascularity to the flap, such as performing a preliminary
Hartrampf3,4 and Bostwick5 have corroborated the surgical delay911 of the TRAM flap procedure (Fig. 7-3B),
anatomic studies of Taylor.6,7 transferring it as a free microvascular12,13 flap (Fig. 7-3C),
This leads to a very important aspect of successful or using two muscles in the form of a bipedicle TRAM14,15
TRAM flap breast reconstruction, namely procedure flap (Fig. 7-3D). These alternatives have been shown to
selection. For me this is the process of determining which increase the amount of lower abdominal skin and adipose
type of TRAM flap technique should be used to carry the tissue that can be reliably transferred while limiting the
tissue needed for the reconstruction that will best simu- complications of fat necrosis and partial flap loss. My
late the opposite breast. Different techniques provide dif- experience with the amount of lower abdominal adipose
ferent degrees of vascular perfusion to the adipose tissue tissue and skin that can be reliably transferred with a min-
zones2,3,8 in the flap. Therefore the procedure is selected imum of fat necrosis is depicted in Figure 7-3AD.
based on predicted adequacy of the blood supply in an As stated earlier, both patient selection and procedure
effort to minimize the risk of fat necrosis and other selection are important considerations in TRAM flap
ischemia-related complications. breast reconstruction.2
Ch07.qxd 14/12/05 4:14 AM Page 306
Unipedlcle flap
Delayed tram flap
III
III I IV
III
II I II
Zone II 10% 30% zone II

Zone I 100% 100% zone I
Zone III 80% 90% zone III
A B
FIGURE 7-3. A, Tissue area in lower abdomen that is reliably vascularized by single pedicle TRAM
flap in my clinical experience. B, Tissue area in lower abdomen that is reliably vascularized by a surgi-
cally delayed single pedicle TRAM flap in my clinical experience. C, Tissue area in lower abdomen that
is reliably vascularized by a free microvascular TRAM flap in my clinical experience. D, Tissue area in
lower abdomen that is reliably vascularized by a bi-pedicle TRAM flap in my clinical experience.
(continued)
PATIENT SELECTION IN TRAM FLAP 556 TRAM flaps, citing smoking, previous abdominal
BREAST RECONSTRUCTION scars, and radiation therapy as the key risk factors that are
especially predictive of an increased postoperative com-
Patient selection has been stressed by Dr. Hartrampf,4 plication rate.
who not only is credited as being the originator of the pro- I believe that patients who smoke must stop completely
cedure but also should be saluted for carefully studying for at least 6 weeks2,16,17 before surgery if a pedicled TRAM
his patients postoperatively and identifying the risk fac- flap is to be considered. Otherwise, the incidence of vascu-
tors that put a patient at increased risk for complications lar compromise in the tissues of the flap and the native
(Table 7-2). This assessment involves taking a careful his- skin of the breast region and abdominal wall skin increase
tory and performing a physical examination. According to dramatically.17 I carefully explain to each patient who
Hartrampf, factors that have been shown to increase the smokes that it has been clearly documented that smoking
risk of complications include cigarette smoking, signifi- increases the complication rate from surgical procedures
cant obesity (Fig. 7-4), underlying systemic diseases (e.g., everywhere in the body and stress that the patient can
hypertension, diabetes, and collagen vascular disorders), help herself immeasurably by quitting smoking com-
abdominal wall scars form previous surgical procedures, pletely before surgery.16 If the patient cannot do this then
and prior radiation therapy. Watterson et al.5 corrobo- another form of breast reconstruction should be consid-
rated Hartrampfs initial observations in their review of ered, or if the TRAM flap is the only option a free
Ch07.qxd 14/12/05 4:14 AM Page 307
Free TRAM flap

Bipedicle flap
III IV
II II
II
I I
70% zone II
100% zone I 100% zone I
100% zone III 80% zone II
C D
microvascular TRAM should be done because this proce- dehiscence or delayed healing. In summary, the breast
dure takes advantage of the dominant blood supply to this reconstructive surgeon should carefully analyze every
tissue and minimizes the amount of tissue undermining abdominal wall with previous scars to determine whether
the upper abdomen.12,13 Procedure selection is discussed free TRAM or bipedicle procedure modifications are
later in this chapter. needed to complete the TRAM flap reconstruction with an
It is also critical to note the presence and location of adequate margin of safety.
previous incisions,18 especially a right subcostal incision, Also important to note before surgery is the location,
that may have been used in the performance of a cholecys- thickness, amount, and distribution of abdominal wall
tectomy. Such incisions carry the risk of having transected adipose tissue, and in particular its relationship to the
the rectus abdominis muscle and the superior epigastric underlying muscle. Sufficient adipose tissue in the lower
artery, thereby eliminating the blood supplied to the hemi- abdomen is an obvious requirement for TRAM flap breast
TRAM flap by this vessel. In addition, this incision may reconstruction. Patients with a thin adipose layer and
also compromise the healing of the lower abdominal skin extensive musculoaponeurotic laxity resulting in signifi-
flap, which is advanced to close the donor site. Other inci- cant abdominal protuberance are at increased risk for
sions in the abdomen may also negatively impact the cir- both breast and donor-site complications. Similarly,
culation to the flap tissues.18 These include a lower patients who are obese and who have the majority of their
abdominal midline incision or McBurney-type oblique adipose tissue below the arcuate line often show
incision, especially if either was complicated by wound decreased vascular supply to this fat tissue (Fig. 7-4) and
Ch07.qxd 14/12/05 4:15 AM Page 308
struction if appropriate procedure selection is

employed.21,22
AESTHETIC ANALYSIS OF THE

CONTRALATERAL BREAST
From an aesthetic standpoint it is important to analyze

the opposite breast for its size, base width and height
dimensions, volume, volume distribution, projection, IM
fold level and definition, and overall orientation on the
chest wall. Breast shape or form can be visualized accord-
ing to whether the breast mound exhibits a vertical, verti-
cal oblique, or transverse form when viewed in the frontal
plane.
In my experience the most common breast shape
encountered is the vertical-oblique form, which is marked
by moderate inferomedial fullness that tapers more supe-
riorly along the parasternal region as the woman moves.
The breast tissue is located beyond the anterior axillary
line inferiorly but also extends obliquely upward toward
the tail of Spence (Fig. 7-6). Patients with this breast
shape are most readily reconstructed by a TRAM flap that
is positioned in a vertical-oblique manner.
A vertical breast form (Fig. 7-7) demonstrates a narrow
base width, less breast volume lateral to the anterior axil-
lary line, moderate fullness medially in the parasternal
area, and a superior extension of breast tissue to the sec-
ond intercostal space. This type of breast is more common
in tall, thin patients.8 Certain patients present a breast
form with more lateral fullness, less vertical height, and
FIGURE 7-4. This patient is too obese for the safe performance significantly more anterior projection. These patients
of a pedicle TRAM flap and exhibits an unfavorable abdominal exhibit a horizontal or transverse orientation of their
pannus that hangs off the abdominal wall. Much of the tissue
below the arcuate line and cannot be reliably transferred in breast when viewed anteriorly (Fig. 7-8).
TRAM flap breast reconstruction. The aesthetic analysis is conducted to estimate tissue
requirements and to determine if the contralateral breast
can be matched by a TRAM flap or whether a modifica-
tion of that breast will be necessary. If opposite breast
are suboptimal candidates for TRAM flap reconstruc- modification is to be undertaken I prefer to perform this
tion4,19,20 because of the increased complication rate seen surgery at the time of the primary TRAM flap transfer so
in this population. that both breasts can evolve together.
Interestingly, in my experience patients who are rela- As previously mentioned, for me, a very critical aspect
tively thin or who have a mesomorphic-type build and a of TRAM flap breast reconstruction is the estimation of
strong abdominal wall muscle layer are the best candi- the skin and adipose tissue required to produce a new
dates for TRAM flap reconstruction (Fig. 7-5AF) and breast mound (see Fig. 7-1AD). The surgeon must accu-
achieve excellent aesthetic outcomes. rately gauge the tissue needed in this regard. The skin
TRAM flap reconstruction is a procedure with tremen- envelope is perhaps the critical component of every breast
dous aesthetic potential, but unfortunately the chance of reconstruction.2,8 Recognizing this fact, the reconstructive
complications occurring is great. As previously men- surgeon must have a clear idea of how much skin must be
tioned, a highly individualized reconstructive plan is replaced in every reconstruction. In the setting of delayed
essential if the aesthetic result is to be maximized and the breast reconstruction, this is readily determined by meas-
incidence of complications is to be minimized. uring the amount of skin on the contralateral breast
Studies have shown that in experienced hands there is (Fig. 7-9A) in the superior-inferior and mediolateral
no appreciable difference between free microvascular dimensions and making corresponding measurements on
TRAM flap reconstruction and pedicled TRAM flap recon- the side of the mastectomy (Fig. 7-9B). This skin deficit
Ch07.qxd 14/12/05 4:15 AM Page 309
FIGURE 7-5. A, Thin patient with right mastectomy defect on anteroposterior (AP) view. B, Oblique
view reveals thin waistline and minimal skin and adipose tissue excess in the lower abdomen. C, AP
view of TRAM flap reconstruction with good aesthetic outcome in breast and abdomen. D, Oblique
view of postoperative result in same patient. (continued)
Ch07.qxd 14/12/05 4:15 AM Page 310
FIGURE 7-5. (CONTINUED) E, AP view of very thin patient with recurrence of left breast cancer fol-
lowing lumpectomy and radiation therapy. Preoperative plan for single muscle TRAM flap is outlined.
F, AP view of postoperative result following immediate reconstruction with TRAM flap.
Vertical oblique inset of Tram
Vertical inset of Tram
FIGURE 7-6. The most common breast shape is that of a verti-

cal oblique orientation. Such a breast is reconstructed by placing
the TRAM flap in this manner with a rotation of about 75
degrees in a clockwise orientation or 115 degrees in a counter- FIGURE 7-7. The second most common shape of the mature
clockwise orientation. A unipedicle TRAM flap provides two female breast is that of a vertical orientation. To duplicate such a
zones of reliable tissue for such a reconstruction. shape, the TRAM flap should be inset in a vertical orientation.
Ch07.qxd 14/12/05 4:15 AM Page 311
Horizontal inset of Tram more tissue than is present on more than one side of the
lower abdominal midline (more than two zones of tis-
sue)2,3 (see Fig. 7-2) is needed to achieve the reconstruc-
tion, additional blood supply must be provided to the
transferred tissue. This brings into consideration the
options of free flap transfer, the incorporation of both rec-
tus muscles as carrier pedicles, and the recently developed
option of preliminary surgical delay of the flap.
The circulation of the abdominal wall, and more
specifically the TRAM flap tissue, has been well studied
over the past 15 years. The most significant contributions
to our knowledge in this area are derived from the many
anatomic investigations and injection studies of Taylor.6,7
Boyd et al.6 initially investigated the circulation of the
lower abdominal wall by means of dye injection studies.
These studies illustrate that the blood supply is derived by
FIGURE 7-8. The least common breast shape is that of strong three sources, namely the deep inferior epigastric artery
anterior projection with minimal upper pole fullness. Such a (DIEA), the superior epigastric artery, and the intercostal
shape is duplicated by a transverse inset orientation of the
TRAM flap. arteries, with the deep inferior epigastric being the domi-
nant pedicle.6
The determinants of circulation to the superiorly based
TRAM flap (Fig. 7-10) are the blood flow through the
superior epigastric vascular pedicle, the flow through the
intramuscular vascular arcade of the midrectus muscle,
the number and flow through the musculocutaneous per-
must be replaced if the reconstructed breast is to show the forating vessels, the blood flow across the midline, and
best possible symmetry with the opposite breast (see Fig. venous outflow from the flap.2,8
7-1C). Using the measurements taken the surgeon can The mechanics of circulation in the superiorly based
produce a skin template (Fig. 7-9C) that can be drawn on TRAM flap were further elucidated by Moon and Taylor7
the lower abdominal skin before surgery after the appro- in another series of contrast injection studies in cadavers.
priate orientation for the TRAM flap inset has been This landmark work demonstrates a stepwise decrease in
selected (see Figs. 7-6, 7-7, and 7-8). blood flow through choke vessels, giving rise to the con-
The other critical dimension to be considered in every cept of angiosomes23 (Fig. 7-11) in the TRAM flap and
breast reconstruction is the base width of the breast. This anatomically reinforcing the clinical observations of
is visually appreciated from the frontal [anteroposterior Hartrampf3 and Bostwick.5
(AP)] view. It is determined by measurements from the In a subsequent publication Wagner and Hartrampf15
parasternal area to the midaxillary line and is discussed outlined the safe zones of a unipedicle TRAM flap that
later in this chapter. included approximately 2.5 zones of lower abdominal tis-
To achieve consistent success in TRAM flap reconstruc- sue as the amount that can be transferred by a single rec-
tion, the surgeon must accurately gauge the tissue needed tus muscle carrier pedicle. This report describes an
to reconstruct the breast and determine whether there is amount of adipose tissue that is reliably perfused by one
sufficient tissue on one side of the lower abdominal midrectus muscle with the superior epigastric artery as its
line to accomplish this important aesthetic goal (see Fig. blood supply, which is slightly more than we would pre-
7-1D). This analysis is critical for selecting the type of dict from our own clinical experience (see Fig. 7-3A).
TRAM flap procedure, i.e., whether a single pedicle, free Over the past decade I evolved concepts of predictability
TRAM, double pedicle, or delayed TRAM is best suited to regarding the tissue perfused by a unipedicle TRAM flap
achieve the aesthetic and reconstructive goals while mini- and have come to believe that 100% of zone I, which is
mizing the complications of fat necrosis or partial flap directly over the rectus muscle; 80% of zone III, which
loss. is adjacent and lateral to the pedicle; and no more than 10%
Procedure selection therefore depends on the tissue of zone II, which is the tissue across the midline, can be
needed for the reconstruction, the tissue present in the consistently transferred and remain viable when one rectus
lower abdomen, and an understanding of the circulatory muscle is used as a carrier pedicle (see Fig. 7-3A). In practi-
dynamics of the tissues in the lower abdominal wall. cal terms, I believe that the transmidline tissue in a single-
Where possible, I prefer to use a superiorly based unipedi- pedicle TRAM flap is not predictably reliable. Therefore,
cle TRAM flap (see Fig. 7-3A). However, if significantly whenever there is a need for this tissue in the reconstruction
Ch07.qxd 14/12/05 4:16 AM Page 312
FIGURE 7-9. A, Quantitative skin defect by direct measure-

ment of the contralateral breast. B, Quantitative skin surface
dimensions over mastectomy defect with tape measure. C,
Outline of probable skin paddle dimension (black hash marks
in left lower abdomen) and relationship to rectus muscle drawn
preoperatively in patient undergoing delayed breast recon-
struction.
Ch07.qxd 14/12/05 4:16 AM Page 313
Cross section of TRAM flap before the definitive operative procedure; or incorporat-
illustrating blood flow ing both rectus muscles as tissue carriers, thereby creat-
subdermal collateral ing a bipedicle14 TRAM flap.
vessels across midline A free flap takes advantage of arterial inflow through
the DIEA, and I believe that this provides increased vascu-
larity to the tissues on the both the ipsilateral and approx-
imately half of the tissue on the opposite side of the
midline (zones I, III, and 70% of the tissue in transmidline
zone III) (see Fig. 7-3C). As noted, this DIEA pedicle has
been shown by Boyd et al.6 to represent the dominant cir-
culation to the lower abdominal wall musculature and
overlying soft tissues and it increases the reliable adipose
tissue element in the flap to almost a full three zones,
umbilicus deep inferior namely zone I, III, and 70% of III (see Fig. 7-3C).
epigastric artery In situations where almost all of the adipose tissue in
the lower abdomen is necessary for volume that will pro-
FIGURE 7-10. The determinants of circulation in the unipedi- duce symmetry, a bipedicle TRAM flap can be done. This
cle superiorly based TRAM flap are illustrated. These include the
technique of flap elevation equates to the elevation of two
size and flow through the superior epigastric pedicle, the flow
through the intramuscular arcade of the midrectus muscle (the hemi-TRAMs and converts the circulatory dynamics of a
angiosomes described by Taylor7), the number and flow through zone I to zone III to a double zone I and II (for the tissue
the musculocutaneous perforating vessels, the flow across the of each side of the midline). In my experience such a flap
midline, and the venous outflow from the flap. can reliably carry all of the tissue between the anterior
superior iliac spines by providing the increased arterial
inflow (see Fig. 7-3D).
of the breast I resort to a different TRAM flap procedure, The venous circulation of the unipedicle flap was stud-
which is described in the following paragraphs. ied by Carramenha et al.24 and subsequently also by
If more tissue than that mentioned in the previous Taylor.7 These injection studies demonstrate that the veins
paragraph is required to satisfy the volume requirements of the flap accompany the arteries within the muscle but
for the new breast, then additional blood supply must be that there are valves in the connecting veins that are ori-
provided. As noted, the additional options are a free ented inferiorly such that reversal of flow in these oscillat-
microvascular transfer or free TRAM; a preliminary surgi- ing8,24 veins (Fig. 7-12) must occur if venous outflow in the
cal delay9,10 of the flap done between 10 days and 3 weeks superiorly based flap is to progress normally.
HIGH SUPERIOR
EPIGASTRIC ANASTOMOSIS
ARTERY
INFERIOR
EPIGASTRIC ANASTOMOSIS
ARTERY
MIDLINE ANASTOMOSIS
PRESSURE
NEXT
ANASTOMOSIS
TERRITORY
NEXT
ANASTOMOSIS
TERRITORY
LOW
FIGURE 7-11. The angiosomes of the rec-
tus muscle as described by Moon and Taylor.
HIGH LOW
(Reprinted from Williams & Wilkins, PRS,
FLOW 1988, with permission.)
Ch07.qxd 14/12/05 4:16 AM Page 314
muscle (Fig. 7-14A) side increases the size of the blood

vessels in the muscle. The laboratory and clinical investi-
gations of Restifo9,26 strongly suggest that ligation of these
pedicles [superficial inferior epigastric artery (SIEA) and
DIEA] increases the diameter of the superior epigastric
vessels and the blood flow through this vessel. I have uti-
lized this strategy in preference to performing free tissue
transfer or to elevating the flap as bipedicle TRAM in
cases where 2.5 zones of tissue are needed (the ipsilateral
and 25% of the contralateral transmidline tissue) (see Fig.
7-3B). The procedure to ligate the DIEA and the SIEA can
be performed as an outpatient under local anesthesia with
sedation. Occasionally it may incorporate a superior inci-
sion made over the pedicled side of the flap to increase cir-
culation to the skin. In rare cases where more than 40% of
Zone II tissue is needed, an incision across the abdomen
Valves in
veins
above the umbillicus can be done (see Fig. 7-17C). This
Venous oriented will carry 6070% of the tissue in Zone II. The location of
drainage to decrease the incisions and position of the ligated pedicles are illus-
of pedicted outflow trated in Figure 7-14A. Generally I perform this within 2
TRAM flap weeks of the anticipated surgery and patients seem to tol-
erate it quite well.
Transferring the flap tissue as a free microvascular flap
FIGURE 7-12. The venous circulation of the TRAM flap reveals has many advantages. The vascularity of the adipose tissue
veins that accompany the arteries and oscillating veins. Venous
outflow must overcome the orientation of the valves in the oscil- is increased as demonstrated by the decreased incidence of
lating veins, which are oriented against the direction of outflow fat necrosis.27 The procedure entails less dissection at the
from the flap. costal margin in the area of the tunnel made to connect the
abdominal wound to the breast area, and therefore free
Maneuvers to increase the circulation in the TRAM flap TRAM patients appear to manifest slightly less pain.28
are listed in Table 7-3. These include designing the skin There is a small but definitely increased risk of total
paddle as a midabdominal25 TRAM to take advantage of flap loss following free flap transfer, and vigilance must be
capturing the maximal number of musculocutaneous per- exercised in flap monitoring for the 72 hours immediately
forating vessels. Employing the vascular angiosome con- after flap transfer.29 Nevertheless, in experienced hands
cepts of Taylor,23 this can be thought of as moving the flap this procedure represents a tremendous refinement in
to a more proximal angiosome (Fig. 7-13AC). TRAM breast reconstruction.21,22
There has been increasing enthusiasm for performing a The choice of performing TRAM flap reconstruction as
preoperative delay911 of the flap in situations where there a microvascular tissue transfer depends on the experience
is an increased tissue requirement or where there is addi- and confidence level of the surgeon with microsurgery.21,22
tional comorbidity such as moderate obesity, collagen vas- Several studies have tried to analyze which is a better pro-
cular disease, or diabetes mellitus. Favorable reports by cedure, and the conclusions are that the best results are
Bostwick11 and Restifo9 have clinically corroborated the obtained when the surgeon performs the procedure that
injection studies of Moon and Taylor7 that suggested that he or she is most accustomed to and skilled at.21,22
preliminary ligation of the superficial and deep inferior The choice of recipient vessels is between the thora-
epigastric vascular pedicles on the ipsilateral rectus codorsal axis and the internal mammary vessels. Most of
the time I prefer to use the thoracodorsal vessels (Fig.
TABLE 7-3 Increasing Circulation to the TRAM Flap 7-15A). They are of ample size and in the operative field
Midabdominal TRAM designmoving flap 1 angiosome proximally
when almost any incision is used. Alternatively, the sur-
Surgical delayligation of the ipsilateral DIEA and SIEA 10 to 21 geon may choose the internal mammary vessels. These
days before surgery can be accessed in the bed of the third or fourth costal car-
Supercharging the flapanastomosis of the DIEA to a regional tilage30 (Fig. 7-15B). They require a more medially located
pedicle at the time of flap transfer incision on the breast, but they are very consistent in their
Free TRAM transfer size and position.
Bipedicle flap design The free TRAM flap donor muscle is either the ipsilat-
TRAM, Transverse rectus abdominis musculocutaneous; DIEA, deep inferior eral rectus, which is preferred when a vertical or vertical-
epigastric system; SIEA, superficial inferior epigastric system. oblique inset of the flap is preferred for the best breast
(text continues on page 319)
Ch07.qxd 14/12/05 4:16 AM Page 315
FIGURE 7-13. A, Midabdominal TRAM flap design in high-

risk patient requiring immediate left breast reconstruction for
recurrent disease after radiation. Note that 70% of flap is
designed superior to the umbilicus (arrow). B, Intraoperative
photography illustrating that flap is moved up one angiosome
to midabdominal rectus muscle. C, On table appearance of
healthy TRAM flap skin paddle and abdominal skin incision
line of closure that lies above the umbilicus.
Ch07.qxd 14/12/05 4:16 AM Page 316
Vascular anatomy of TRAM flap

illustrating delay procedure
superior
epigastric artery
superior
inferior epigastric
artery
deep inferior
epigastric
artery
A
FIGURE 7-14. A, Ligation of the ipsilateral DIEA, vena comitantes, ipsilateral SIEA, and accompanying
veins, which constitutes the most commonly used preliminary surgical delay of the unipedicle TRAM flap.
B, Left mastectomy defect in patient with limited lower abdominal tissue available for TRAM flap recon-
struction and significant tissue requirements for breast reconstruction. C, Preliminary surgical delay proce-
dure included ligation of both DIEAs and SIEAs and creating upper transverse skin incision on the side of
the flap pedicle. D, Postoperative result at 7 years. Delay procedure resulted in a well-perfused TRAM flap.
Ch07.qxd 14/12/05 4:17 AM Page 317
sternum
1st rib
deep inferior
epigastric art. & vein internal
flap vessels mammary art.
internal
mammary v.
thoracodorsal
art. & vein
recipient vessels
A B
superior extension
of subcutaneous fat
fascia and
muscle
incision
flap
deep inf.
epigastric
vessels
FIGURE 7-15. Recipient vessels for a free TRAM are either the thoracodorsal vessels (A) or the inter-
nal mammary system (B). C, When reconstructing a vertically oriented or verticaloblique breast with a
free TRAM the ipsilateral flap (ipsilateral DIEA) is chosen to facilitate pedicle orientation to the recipi-
ent vessels and shape of the reconstructed breast. D, Preoperative view of patient who requires three
zones of tissue to reconstruct a vertically orientated breast. (continued)
Ch07.qxd 14/12/05 4:17 AM Page 318
flap
FIGURE 7-15. (CONTINUED) E, The ipsilateral donor vessels (DIEA) for the free TRAM are chosen.
The outline of the mastectomy skin sacrifice is illustrated. F, The flap is harvested and made ready for
transfer. G, Postoperative result at 3 years showing good symmetry with the opposite breast. H, When
reconstructing a transversely oriented breast, the contralateral flap is chosen to facilitate pedicle orien-
tation and shape of the reconstructed breast.
Ch07.qxd 14/12/05 4:17 AM Page 319
aesthetics (Fig. 7-15C). This is illustrated by this 52-year-

old patient (Fig. 7-15) with a vertical-oblique breast who
requested an immediate breast reconstruction and who
required almost three zones of her lower abdominal tis-
sue. A very satisfactory reconstruction was achieved with
the use of an ipsilateral DIEA pedicle for her free TRAM,
for which the thoracodorsal pedicle served as the recipient
vessels (Fig. 7-15DG). The contralateral rectus muscle is
chosen when a horizontal inset of the free TRAM flap will
produce the best shape of the reconstructed breast (Fig. 7-
15H). As I have previously mentioned, the free TRAM
operation is an excellent procedure when performed by an
experienced microvascular surgeon. The goals with free
flap transfer must be to ensure flap survival and to maxi-
mize the aesthetics of the reconstructed breast.
There are rare instances when the circulation of a uni-
pedicle TRAM flap is not as robust as anticipated. This FIGURE 7-16. Dissection of a segment of the DIEA, which is
may be recognized while the flap is still in its anatomic routinely elevated with the pedicled TRAM flap for use if micro-
location on the abdominal wall or after transfer to the surgical supercharging is needed.
breast region. I make it a routine practice to dissect out a
significant length of the deep inferior epigastric vascular
pedicle in every case. This adds between 10 and 15 min- extends over the lower sternal area and is wide so that it in
utes to the procedure, but having this vessel available for fact encroaches on the inferior medial aspect of the opposite
microsurgical anastomosis if a boost30 to the circulation is breast (Fig. 7-17D). Making the tunnel in this way allows the
needed proves helpful. The procedure of supercharging or most favorable redraping of the skin in the area of the
turbocharging30 should not be envisioned as a primary xyphoid. This technique, when performed in conjunction
procedure because in many ways it is technically more with selective harvest of the rectus muscles while elevating
difficult to do than a primary free tissue transfer (due to the TRAM flap and sectioning of all of the intercostal nerves
flap positioning and muscle pedicle tethering). However, to the rectus muscles, most often results in a very acceptable
it can be very helpful in the rare case of compromised vas- contour in the inferior-medial aspect of the reconstruction.
cularity in the flap. Therefore I always dissect out a 5- to I attempt to perform fascial closure without mesh
7-cm segment of the DIEA and the accompanying vena application in every case of bipedicle flap harvest. If the
comitantes to have it available in the instance when it is patients abdomen is wide and somewhat lax preopera-
necessary to supercharge the TRAM flap (Fig. 7-16). tively, this is often possible (Fig. 7-18A). However, any
The bipedicle TRAM flap provides an exuberant degree attenuation of this fascial closure14 is an indication for
of arterial inflow and venous outflow to the lower abdom- supplementation of the closure with mesh (Fig. 7-18B) in
inal skin and adipose tissue. As mentioned, it allows the an effort to proactively avoid subsequent hernia forma-
reliable transfer of all of the tissue in the lower abdomen tion. Closure of the donor site requires the use of reinforc-
to the breast (see Fig. 7-2D). In situations requiring more ing synthetic material in the majority of cases
than three zones of tissue for the reconstruction it is my (Fig. 7-18B). For this purpose I prefer an onlay of proline
procedure of choice. I favor the method of split-muscle mesh.14 Despite this additional dissection for flap harvest
bipedicle flap14 (see Fig. 7-17A) transfer, which provides and the frequent need for supplemental mesh repair of the
essentially the same vascular augmentation of whole mus- donor area, the split-muscle bipedicle technique of TRAM
cle harvest but decreases the bulk of muscle in the tunnel flap reconstruction (Figs. 7-2D, 7-17A) is a valuable
and at the costal margin. method of TRAM flap transfer.
The procedure involves the use of the 20-MHz ultra- A technique that is reserved for very high-risk patient is
sonic Doppler to localize the arterial signals in the rectus the midabdominal TRAM. It is an exaggeration of what
muscles (Fig. 7-17B). This area of muscle with overlying many surgeons who perform pedicled TRAM flaps rou-
fascia is then selectively harvested and preserved to the tinely do, namely, attempt to capture more of the proxi-
flap (Fig. 7-17C). It is imperative to section all of the inter- mally located perforating vessels from the rectus muscle
costal nerves at the costal margin to promote maximal by moving the line of incision above the umbilicus and
muscle atrophy. beveling the incision superiorly. The procedure is most
When performing a bipedicle TRAM flap reconstruction useful in the considerably obese patient where the tissue
my preference is to split the rectus muscles. The tunnel at in the lower abdominal area hangs off the lower abdomen
the side of the breast reconstruction is made such that it and will not be helpful in the reconstruction. At first
Ch07.qxd 14/12/05 4:17 AM Page 320
FIGURE 7-17. A, Split-muscle bipedicled TRAM flap elevation. B, Handheld 20 MHz ultrasonic
Doppler is used to localize the arterial signals in the rectus muscle for a split-muscle bipedicle TRAM
flap elevation. C, Selective harvest of the central 50% of the rectus muscles in a split-muscle bipedicle
TRAM flap. D, Tunnel for passage of bipedicle TRAM flap to breast. Note that the dissection is greater
in dimension than that required for a unipedicle TRAM flap. In fact, it encroaches on the medial aspect
of the contralateral breast. This allows excellent skin redraping in this area, which in my experience
minimizes muscle pedicle visibility.
Ch07.qxd 14/12/05 4:18 AM Page 321
glance many of these patients are not at all felt to be can-

didates for TRAM flap reconstruction. In this procedure
the skin paddle design is shifted more proximally toward
the costal margin, or up one angiosome. It is described by
Slavin and Goldwyn,25 who used it in patients such as the
woman illustrated in Figure 7-13AC.
This obese patient had undergone previous lumpectomy
and radiation therapy for a left breast cancer, only to
develop a recurrence. She required a total mastectomy to
treat this recurrent lesion (Fig. 7-13A). I believed that her
best option was to use autogenous tissue for reconstruc-
tion. Her abdominal habitu was such that only a midab-
dominal TRAM was feasible (Fig. 7-13B). Note the design
of the skin paddle above the umbilicus and the eventual line
of closure that is located above the level of the umbilicus
(Fig. 7-13C). The blood supply to the flap was robust and
she healed without difficulty, demonstrating a satisfactory
aesthetic outcome. Although not commonly employed, this
can be a very helpful modification in selected patients.
The options outlined are all useful in specific clinical
situations and underscore the importance of procedure
selection for consistent success in TRAM flap breast
reconstruction.
CREATING THE BREAST MOUNTFLAP

INSET
Aesthetically, it is always important to reconstruct

the breast from superior-medial to inferior-lateral2,14
(Fig. 19AF). In addition, it is important to place the best
vascularized portion of the flap in the medial location
whenever possible (Fig. 19CE). This is the area where
contour is most critical for breast aesthetics and where
ischemic tissue loss is difficult to recover from and will
have the most deleterious effect on cosmetic outcome.
Therefore, when using a single-pedicle flap I always try to
place zone I tissue in the medial location and attempt to
use proximal zone III tissue for the lateral and inferior-lat-
eral tissue fill. This is illustrated for a delayed breast recon-
struction using the contralateral rectus muscle with
180-degree counterclockwise tissue rotation (Fig. 19AF).
This transverse inset was done to simulate the opposite
FIGURE 7-18. A, Closure of the split-muscle bipedicle TRAM breast, which exhibited strong projection and minimal ver-
flap donor site without the use of synthetic mesh. This is usually tical height. The main principle is to begin the breast
only possible in patients with wide, lax abdomen. B, Application
mound creation from medial to lateral, and whenever pos-
of synthetic mesh to the anterior rectus fascia with an onlay
technique to increase the strength of closure. I prefer to use sible I prefer to place the best-vascularized tissue medially.
Prolene mesh (Ethicon, Inc., Somerville, NJ) and 0 Surgilon When performing pedicle TRAM flap breast recon-
sutures (Sherwood-Davis & Geck, St. Louis, Mo) to tack the struction, the surgeon should overbuild the breast volume
mesh in place. I believe that any attenuation in the fascial clo- by a factor of 20% to 25%.2 This will compensate for vol-
sure is an indication for mesh application.
ume loss due to muscle atrophy. It is a simple and
straightforward matter to reduce volume excess in a
TRAM flap, which remains too large after the expected
muscle atrophy. In my experience, this is the most com-
mon revision procedure performed on these TRAM flap
Ch07.qxd 14/12/05 4:18 AM Page 322
FIGURE 7-19. A, Building the breast with a TRAM flap. The reconstruction should proceed from supe-
rior-medial to inferior-lateral. Preoperative appearance of patient who desires TRAM flap reconstruction
for left postmastectomy defect. B, Paper template used to outline area of abdominal tissue to be used for
TRAM flap. The contralateral rectus muscle and overlying adipose tissue is used because there is much
more adipose on this side of the lower abdomen in this particular patient. C, Tissue composite seen
before transfer at surgery. Paper template simulates the muscle pedicle orientation and flap position. D,
The flap inset position simulated preoperatively with a paper template. E, The flap position at surgery
exactly as planned by the paper template. F, The postoperative result at 2 years following surgery.
Ch07.qxd 14/12/05 4:18 AM Page 323
breast reconstructions. A drain is routinely portioned structed breast is narrower, this is something that the eye
beneath the flap to minimize seroma fluid accumulation. will immediately detect and the brain will register. The
It is usually not necessary to suspend the flap from the base width of the breast to be reconstructed corresponds
chest wall or to the overlying skin. I believe that the skin to the vertical distance between the upper incision, usu-
inset suture line fixation provides the most effective ally made just above the umbilicus, to the lower incision
method of achieving flap stabilization. Inset incisions just above the pubic region. In a flap with a vertical inset
should be closed as meticulously as possible using intra- the base width is exactly analogous to this distance. For a
dermal or subcuticular sutures. vertical-oblique inset the line is not precisely vertical but
As previously stated, only after careful analysis of base is slightly oblique in its orientation, allowing for the cre-
width, shape, projection, and skin dimensions can the ation of a slight increase in the base width and providing a
TRAM flap be planned. A particularly important dimen- means of compensation when the vertical distance is less
sion to simulate is the base width of the breast. The skin than ideal. Finally, a flap with a transverse inset orienta-
available to create the base width dimension is different tion provides the greatest degree of flexibility in duplicat-
for different types of TRAM flap inset patterns. ing the base width but provides the smallest amount of
If the breast shape dictates a vertical TRAM flap inset vertical height for the reconstructed breast.
and a pedicled flap is used, then the vertical dimension In a single muscle or unipedicle flap I always prefer to
between the upper periumbilical area and the pubic area use the ipsilateral31 muscle to carry the flap when it is
becomes the base width of the breast (Fig. 7-20A). If this available (a long subcostal incision may eliminate it). This
dimension is less than the necessary base width of the allows passage of the TRAM flap tissue through a tunnel
reconstructed breast, a slightly oblique orientation of the made in the central aspect of the IM fold (see Fig. 7-21A)
inset will increase the skin availability for the base width and avoids dissection over the xyphoid area, which is nec-
dimension (Fig. 7-20B). essary for a contralateral muscle carrier. There is preser-
From an aesthetic standpoint it is important to dupli- vation of much of the IM fold with this method of flap
cate the base width of the opposite breast. If the recon- transfer (Fig. 7-21B). Conversely, the passage of the
Ch07.qxd 14/12/05 4:18 AM Page 324
FIGURE 7-20. A, Preoperative plan for immediate left breast reconstruction. The vertical dimension
from the upper incision on the TRAM flap skin paddle to the lower incision is the base width of the
breast when a vertical flap inset is chosen. B, The available dimension to reproduce the necessary base
width can be increased by insetting the flap in a slightly oblique orientation (outlined with white line).
FIGURE 7-21. A, When using the ipsilateral muscle pedicle as the vascular carrier for immediate
breast reconstruction only the central portion of the IM fold is disrupted (area between the lines) to
allow easy passage of the flap. This avoids blunting of the medial aspect of the IM fold. B, The centrally
positioned tunnel preserves (saves) the medial and lateral aspect of the IM fold. This minimizes any
fullness or bump that can be seen at the IM fold following TRAM flap reconstruction using the con-
tralateral rectus muscle carrier pedicle. (See Fig. 7.25.)
Ch07.qxd 14/12/05 4:18 AM Page 325
contralateral rectus muscle creates a prominence or For single-pedicle flap procedures I prefer a whole
bump that results from the muscle being passed through muscle harvest, preserving a narrow (1- to 2-cm) strip of
the tunnel in this position and disrupts the medial aspect fascia over the rectus muscle from the proximal adipose
of the IM fold. For this reason I believe that it should be tissue of the flap to the costal margin (Fig. 7-22).
avoided whenever possible. Inferiorly I isolate the DIEA and accompanying veins and
Design and elevation

of ipsilateral
single
pedicle
TRAM
flap
A B
C D
FIGURE 7-22. A-D, A strip of anterior rectus fascia is routinely preserved on the surface of the rectus
muscle. This minimizes disruption of the tendinous inscriptions and potential injury to intramuscular
vasculature of the flap immediately beneath the tendinous inscriptions.
Ch07.qxd 14/12/05 4:19 AM Page 326
then dissect it toward its origin from the external iliac (Fig. 7-24AD) are inconsequential in terms of the circula-
artery for a distance of 6 to 8 cm. Following transection of tory dynamics of the flap. At one time it was thought that
the rectus muscle inferiorly, the flap is mobilized to the using the contralateral muscle as a carrier for the flap pro-
costal margin and a release of the rectus muscle laterally duced a more gentle and natural curve of the muscle facil-
above the costal margin (Fig. 7-23A) allows a tension-free itating arterial inflow and venous outflow of the flap.
transposition of the flap to the breast region. The muscle Subsequent studies of unipedicle TRAM flap breast recon-
is turned back on itself in a 180-degree arc as the flap is struction have shown that the vascular perfusion to the
passed through the tunnel to the breast region (Fig. 7- flap is independent of the pedicle that is used.31
23B). An additional slight rotation of the muscle is per- In harvesting the unipedicle flap, both rows of muscu-
formed to achieve the necessary inset of the skin and locutaneous perforators are preserved to the flap, and dis-
adipose tissue of the flap (Fig. 7-24AD). The inversion or section is carefully done with a scalpel precisely to the site
180-degree folding of the muscle across the costal margin of emergence of these vessels through the rectus fascia. It
and the slight additional twist of the muscle pedicle is almost always possible to visualize the small rents, or
FIGURE 7-23. A, Release of the rectus muscle above the costal margin laterally is necessary in every
case of pedicle TRAM flap reconstruction to facilitate a tension-free transposition of the flap to the
chest. B, Elevation and transposition of the ipsilateral rectus muscle pedicle through the tunnel. Note
that the flap is turned back 180 degrees on itself.
Transfer and
A inset of single
pedicle ipsilateral
TRAM flap
v
e
ue
r
liq
t
ob
i e
c
a
l
D
FIGURE 7-24. A, Ipsilateral single muscle TRAM passed horizontal B
through tunnel by turning muscle back on itself 180 degrees. B, folding and
Vertical inset requires slight twist in muscle pedicle so that flap slight twist
can turn 80 degrees. C, Vertical oblique inset requires slight twist of ipsilateral
single pedicle
in muscle so that skin paddle can rotate 60 to 120 degrees. D, A TRAM flap for
different
horizontal inset requires that skin paddle be turned back on inset patterns.
itself 180 degrees. C
Ch07.qxd 14/12/05 4:19 AM Page 327
openings, in the rectus fascia, which admits each of these fascia. Its architecture varies from patient to patient, but
vessels. Incising the fascia just lateral to the lateral row its anatomy has been elucidated by several studies over
and just medial to the medial row achieves maximum the past decade.32,33 The surgeon performing TRAM flap
preservation of the rectus fascia. As noted, I routinely pre- breast reconstruction encounters the fold in its existing
serve a narrow strip of fascia over the proximal rectus state in immediate breast reconstruction and in a signifi-
muscle and employ a full-width harvest of the muscle to cantly altered state in delayed reconstruction (Fig. 7-25).
the costal margin. The incisions in the rectus fascia are In immediate breast reconstruction, it is important to
carried up over the costal margin with the fascia being preserve the skin envelope and maintain the IM fold to
released high above the costal margin to eliminate any as great an extent as possible. Breast tissue does not rou-
points at which the muscle can be kinked as it is turned tinely extend beneath the IM fold so there is no onco-
over on itself superiorly and passed through the tunnel logic reason for it to be transgressed during the
that connects the abdominal wound with the mastectomy mastectomy. I have found that simple communication
defect. The tunnel must be of sufficient size to admit the with the oncologic breast surgeon is all that is required
flap, and I use the width of my hand (which is 9 cm) as a to alert him or her to the importance of this structure,
guide. After the flap is passed to the mastectomy defect, and the surgeon will then preserve the fold during the
I insert my index finger around the muscle at the costal mastectomy. As previously mentioned, when I perform a
margin to ensure that there is not tension on the muscle unipedicled TRAM flap my strong preference is to use
pedicle along its course to the breast area. All of the inter- the ipsilateral rectus muscle as the vascular carrier pedi-
costal nerves to the muscle are divided before passing the cle. This is because this method produces minimal dis-
flap through the tunnel. This produces maximal atrophy ruption of the IM fold, and it does not disrupt the most
of the rectus muscle and minimizes any prominence that medial and most lateral aspects (see Fig. 7-21A,B) of the
the muscle might produce at the costal margin. The fold, which are critical for the aesthetics of the recon-
desired inset orientation of the flap (vertical, vertical- structed breast. As previously mentioned, I disrupt the
oblique, or horizontal) is achieved with the inset maneu- fold for a distance of 7 to 9 cm, or just enough to admit
ver. The donor area is then closed as outlined later in this my hand. This usually permits the passage of the TRAM
chapter. flap without difficulty. In cases where more definition of
It is possible to split the rectus muscle during elevation the fold is required after passing the flap (see Fig. 7-
of the flap, which I routinely do when using a bipedicle 21C), I often place sutures of 3-0 coated polyglycolic
technique. The procedure involves the use of a 20-MHz acid at the medial-most and lateral-most ends of the fold
handheld Doppler to pinpoint the location of the medial dissection. After passage of the TRAM flap I secure these
and lateral row of arteries within the muscle. The location as a method of recreating some of the fold that has been
of these arterial signals is marked on the anterior muscle
fascia surface with methylene blue (see Fig. 7-17B). The
dissection of the fascia is begun at the inferior aspect of
the flap by isolating the DIEA at a point midway between
the umbilicus and the pubic region. It is usually found
at the junction of the medial and lateral third of the mus-
cle. This vessel usually corresponds to the location of the
lateral row of perforators. The central 60% of the muscle
can then be elevated with the DIEA and vena comitantes
using the methylene blue lines drawn on the superior
aspect of the muscle as a guide. This method spares a
medial and lateral segment of muscle, is faster to perform,
and may result in an easier closure of the donor area (see
Fig. 7-17C). It probably does not preserve meaningful
function of the rectus muscle.
THE INFRAMAMMARY FOLD IN TRAM

FLAP BREAST RECONSTRUCTION
The IM fold has a powerful effect on breast aesthetics in

many settings. This is particularly true following TRAM
flap breast reconstruction. It is a structure that anchors FIGURE 7-25. Tunnel for passage of bipedicle TRAM flap to
the skin of the lowest contour of the breast to the muscle breast.
Ch07.qxd 14/12/05 4:19 AM Page 328
disrupted. It is important that the surgeon does not dim- When recreating the defect following mastectomy in
ple the skin in the IM fold with the placement of these the setting of delayed breast reconstruction, my initial
sutures. inferior dissection stops 2 cm above the intended level of
During an immediate breast reconstruction with a the new IM fold (Fig. 7-26B). This is because it is com-
free microvascular TRAM flap there is complete preser- mon for the fold to be lowered when the abdominal
vation of the fold. This is an advantage of free TRAM donor defect is closed. Any additional lowering of the
breast reconstruction. However, when the ipsilateral fold can be done after the lower abdominal incision is
muscle pedicle is used as described and the intercostal closed, and after the flap has been transferred with the
nerves to the muscle are sectioned, the resulting appear- patient in the sitting position.2 Simultaneously, deci-
ance of the IM fold is not too different from the fold in its sions about how much native breast skin to preserve and
native state. the final decision about TRAM flap skin paddle dimen-
For the patient who has undergone a mastectomy, the sions are made.
IM fold is most often absent or obliterated and needs to be
reconstructed. In cases of delayed breast reconstruction,
the most desirable level of the IM fold reconstruction can THE SKIN ENVELOPE IN BREAST
be determined by studying the opposite breast. This is RECONSTRUCTION WITH THE TRAM
most simply accomplished by extending a tape measure FLAP
from the patients opposite breast across to the side of the
mastectomy, placing it at the lowermost aspect of the IM The skin envelope is one of the most critical determi-
fold on the unoperated side. This will be at the midportion nants of the aesthetics of every breast reconstruction.
of the IM fold (Fig. 7-26A). The skin envelope, along with the placement of scars,
FIGURE 7-26. A, Transposition of the IM fold from the opposite breast to the site of the mastectomy
defect done with a tape measure placed from the lowest point of the fold on the unoperated breast to the
mastectomy defect (IM fold line). Arc of new IM fold is drawn on the opposite mastectomy defect site.
B, Left postmastectomy defect. Design for planning the dissection of the inferior flap with creation of
the new IM fold. Preliminarily this dissection must stop 2 cm above the intended level of the fold and be
adjusted after closure of the abdominal defect.
Ch07.qxd 14/12/05 4:19 AM Page 329
the shape, and the projection of the breast mound,

determines to a large degree the ultimate appearance of
the newly formed breast. Consistently excellent results
in TRAM flap breast reconstruction require a properly
oriented breast mound that simulates the shape and
projection of the opposite breast and an accurately posi-
tioned IM fold. But the ultimate quality and appearance
of every breast reconstruction depends on the quality
and aesthetics of the skin envelope. As noted by
Bostwick 8 and others,2 replacing the skin deficit is key
in all breast reconstructions, and it is particularly
important when performing a TRAM flap reconstruc-
tion (see Fig. 7-1C).
The dimensions of the skin envelopes must match
almost exactly for symmetry to be achieved. The TRAM
flap provides tremendous flexibility for the reconstructive
surgeon in terms of exactly replacing skin deficits in both
immediate and delayed breast reconstruction. In immedi-
ate reconstruction the skin that is to be resected is usually
replaced in the exact same dimension using the skin of the
TRAM flap. In delayed reconstruction the surgeon must
decide on how much skin to replace by carefully compar-
ing the mastectomy defect with the skin dimensions of the
contralateral breast (see Fig. 7-1AC).
It is important to simulate what the eye sees34,35 when
reconstructing the breast with a TRAM flap. In essence, this
means creating contours that match the opposite breast,
keeping the scars as low as possible in the superior aspect
of the breast mound, and avoiding a patch effect with the
skin paddle placement. The surgeon should use the skin as
part of the visual contour reproduction of the breast
mound. In delayed breast reconstruction this is often done
by using the inferior inset of the TRAM flap to create the IM
fold, thereby producing an aesthetic unit of the lower pole
and lateral aspect of the breast (Fig. 7-27A,B). In the setting FIGURE 7-27. A, Delayed right breast reconstruction with
of immediate reconstruction this is best done when the skin TRAM flap. Optimal aesthetic result requires the recreation of
of the TRAM is used to reconstruct the nipple areolar com- the aesthetic unit of the breast, or what the eye sees, by recreat-
plex (NAC) tissue removal where the mastectomy has been ing lateral and inferior breast contours. B, In such cases the
TRAM flap skin is used to create a new IM fold laterally and cen-
performed using a periareolar incision, thus sparing as trally. This restores lateral contour and avoids patch effect.
much skin as possible during
In an immediate reconstruction the mastectomy inci-
sions are drawn on the breast preoperatively and a tem-
plate of the skin to be sacrificed can be constructed. I ask
the oncologic breast surgeon to create such a template
from a sterile telfa pad before making the mastectomy
incisions (Fig. 7-28). This template is then kept on the
instrument table so that I can refer to it at the time of
flap inset. This way an exact replacement of the skin
that is sacrificed can be achieved.
Generally the incisions are kept as low as possible on
the breast so that the upper portion of the flap inset scar is
concealed in an evening dress (Fig. 7-29AD). When this
FIGURE 7-28. Sample templates from the skin tab excised
strategy is used, most often a previous biopsy incision can during the mastectomy with planned immediate reconstruction.
be excised and closed on a different part of the breast This is helpful in many cases of immediate breast reconstruc-
when necessary. tion, permitting precise replacement of the skin deficit.
Ch07.qxd 14/12/05 4:20 AM Page 330
There is an important difference between the breast reconstruction and that in delayed reconstruc-
approach to breast skin flap management in immediate tion.
FIGURE 7-29. A,The planning of skin paddle placement in breast reconstruction. The best aesthetic
results are obtained when the incisions are limited to an area below the white lines illustrated on the
upper part of the breast. B, The TRAM flap skin paddle is placed to reconstruct skin deficit and achieve
good aesthetics. Note that it is below the previously illustrated white lines. C, Skin paddle reduction is
done at the time of nipple reconstruction. D, A subsequent tattoo of the nipple areolar complex provides
finishing touches and an overall aesthetically acceptable breast appearance.
Ch07.qxd 14/12/05 4:20 AM Page 331
IMMEDIATE BREAST establishing the desired breast shape and appearance.

RECONSTRUCTIONPRESERVING THE Preservation of the envelope is so important that I believe
ENVELOPE it is essential for the reconstructive surgeon to convey this
to the oncologic surgeon performing the mastectomy and
As previously noted, in immediate breast reconstruction to continually reinforce how vital it is to preserve maximal
the emphasis is on preserving the envelope. This means skin and the IM fold.
not only saving the maximum amount of skin possible but Most important, the reconstructive surgeon should
also preserving the IM fold and tacking the lateral chest design the actual skin incisions for the mastectomy in
skin to the muscle fascia after an axillary dissection has conjunction with the ablative surgeon. Such a partnership
been done (Fig. 7-30A,B). This is accomplished without between the oncologic and reconstructive teams holds
causing dimples in the skin of the lateral chest by tying air many benefits for the patient. Incisional strategies to
knots over a hemostat (Fig. 7-30B), which prevents the accomplish the oncologic objectives while facilitating the
accumulation of fluid and edema acutely and minimizes eventual aesthetic appearance of the reconstructed breast
long-term swelling along the lateral chest wall. More are well recognized. These include variations of the tennis
important, it re-establishes the correct internal dimen- racquet incision (Fig. 7-31AC) and, most recently, an ulti-
sions of the accepting skin envelope or breast pocket, and mate skin-sparing approach using a periareolar incision
this maintains the TRAM flap in the optimal position for (Fig. 7-32A,B).
Lateral chest
wall space
needs to be
closed
down
suture of lateral chest

wall skin flap to chest wall
Note! "Air" Knots to avoid
dimpling of skin
FIGURE 7-30. A, Immediate breast reconstruction following modified radical mastectomy requires
tacking of the lateral chest wall skin flap to the musculofascial layer of the chest wall at the point
denoted (arrows). B, Tacking the lateral chest skin down to the muscle fascia with sutures placed to
establish correct internal volumetric dimensions of the mastectomy cavity for the TRAM flap to fill.
Ch07.qxd 14/12/05 4:20 AM Page 332
A C
FIGURE 7-31. Common skin incisions used for skin-sparing mastectomy incision designs. A, Short
ellipse with lateral extension. B, Tennis racquet incision. C, Periareolar-only incision.
FIGURE 7-32. A,The ultimate skin-sparing mastectomy is done with a periareolar incision to remove
the breast tissue. A separate incision used for axillary dissection, which limits the additional incisions
on the breast. B, Outcome of the immediate TRAM flap breast reconstruction where TRAM skin paddle
fills the resected nipple and areolar skin defect demonstrating outstanding visual symmetry.
Ch07.qxd 14/12/05 4:20 AM Page 333
SKIN-SPARING MASTECTOMY DELAYED RECONSTRUCTION

INCISIONS WORKING THE ENVELOPE
In cases of intraductal carcinoma where the diagnosis I find that it is much harder to achieve consistently excel-
has been established by conventional open incisional lent results in delayed breast reconstruction than in
biopsy, it is customary to include the biopsy incision as immediate reconstruction. In this setting the surgeon is
part of the mastectomy specimen, along with the NAC. confronted with skin loss, complete loss of breast volume
Where possible, skin excision should be limited to these and projection, obliteration of architectural landmarks
areas of the breast because skin sparing during the mas- (e.g., the IM fold), and the effects of scar tissue formation.
tectomy has become widely used and has been demon- In delayed breast reconstruction a comprehensive analy-
strated to be oncologically safe. Excellent clinical studies sis and careful planning are of paramount importance.
by Kroll et al.36 at MD Anderson Cancer Center show no The operative approach here is to recreate the defect
increase in local recurrence rates when a skin-sparing while restoring key landmarks of the breast form before
approach for mastectomy is compared with wider skin positioning and insetting the TRAM flap. The emphasis is
removal when patients are stratified for tumor size or T on reshaping and restoring distensibility to the residual
stage. It is important to communicate this to the onco- mastectomy skin flaps, positioning the skin scars as low as
logic surgeon and to emphasize that elliptical skin exci- possible, which I refer to as working the envelope.
sions designed to remove dog ears are not necessary In terms of planning, many of the steps are the same as
because they definitely damage the final appearance of in immediate reconstruction. Namely, it is important for
the reconstructed breast. the surgeon to carefully quantitate the amount of skin and
When the diagnosis of breast cancer has been estab- adipose volume to be replaced (see Fig. 7-1C). This
lished by fine needle aspiration cytology and the tumor requires a visual analysis and careful palpation of the
does not lie adjacent to the skin it is not necessary to opposite breast and abdominal tissues. As noted previ-
excise the skin of the needle tract, thus allowing the mas- ously, I find that it is easiest to quantitate the skin deficit
tectomy to be performed through a periareolar incision by directly measuring the skin on the contralateral breast
only (Fig. 7-32A). The axillary dissection is readily accom- in the vertical and horizontal dimensions and then per-
plished through a separate transverse incision. This ulti- forming a similar measurement on the side of the mastec-
mate skin-sparing mastectomy preserves all but the nipple tomy (Fig. 7-33). The skin dimensions to be replaced can
and areola skin and results in the most natural appear- then be directly outlined on the skin of the TRAM flap pre-
ance of the reconstructed breast (Fig. 7-32B). We are cur- operatively while it is in place on the abdomen.
rently encountering more and more patients presenting Following a mastectomy there is always scar tissue in
with multifocal ductal carcinoma in situ (DCIS) where the the skin flaps at the interface between the subcutaneous
treatment of choice is total mastectomy or simple mastec- adipose tissue and the underlying pectoralis muscle. This
tomy. These patients are usually ideal candidates for a scar impedes the way these flaps drape over the buried
mastectomy done through a periareolar incision. The portion of the transferred TRAM flap, very often limiting
results of such a reconstruction are often very much like the contour reproduction in the upper portion of the
those shown in Figure 7-32B. breast reconstruction where it is so critical. Therefore it is
As previously noted, to facilitate symmetry it is
important to precisely match the skin envelope of the
reconstructed breast to that of the contralateral breast.
This begins with careful marking, making any adjust-
ments that may be required to address any pre-existing
skin asymmetry. Regardless of the skin incision
approach used, a template matching the shape and
dimensions of the skin to be excised with the mastec-
tomy specimen is created. I prefer to fashion the tem-
plate from sterile telfa gauze (Fig. 7-28) at the beginning
of the mastectomy and have the scrub nurse or surgical
technician preserve it on the back table, where it can be
retrieved when the reconstructive portion of the proce-
dure is underway. The template provides the exact
dimensions of the skin to be replaced, which is impor-
tant because primary skin contraction on the specimen
decreases the actual surface area of the skin removed FIGURE 7-33. Comparing and measuring both breasts for skin
during the mastectomy by 30%. dimension before TRAM flap reconstruction.
Ch07.qxd 14/12/05 4:20 AM Page 334
essential to restore as much suppleness, pliability, and dis- breast by gently compressing the breast against the chest
tensibility to these flaps as possible. For this reason I rou- wall (Fig. 7-34A). Once elevated, the surgeon should excise
tinely resect the scar tissue from the deep surface of these as much scar tissue as possible from the underside of the
flaps in the following way. The previous mastectomy inci- mastectomy flaps. Scar tissue is always present at the
sion is excised and the elevation of the mastectomy skin interface of the pectoralis muscle and the adipose tissue
flaps from the pectoralis muscle is performed with a on the deep surface of the skin flaps (Fig. 7-34B). This can
scalpel or electrocautery unit. This is done after carefully be safely done using the coagulation mode of the electro-
noting the extent of superior fullness of the opposite cautery unit at a low setting. As this is done the surgeon
FIGURE 7-34. A,Outlining superior extent of opposite breast by

gentle pressure directed posteriorly. This will guide the extent of
superior mastectomy flap re-elevation. B, As the first step of recre-
ating the defect, the previous superior mastectomy flap is ele-
surgical excision of
vated. C, The scar tissue on the underside of the mastectomy flap scar tissue on
is resected to produce maximal distensibility and optimal drape of deep surface of flap
these flaps over the TRAM flap tissue that will be transferred. C
Ch07.qxd 14/12/05 4:20 AM Page 335
will immediately note how this maneuver permits the maximize the circulation to the inferior skin flap. This
return of more distensibility of the elevated skin flap(s) strategy achieves a reduction in the mastectomy skin
and how this produces better drape of this skin flap(s) envelope and can result in excellent symmetry following
over the TRAM flap. combined TRAM flap breast reconstruction and con-
As previously noted, in the setting of delayed recon- tralateral vertical mastopexy (Fig. 7-35D,E).
struction loss of additional breast skin is decidedly
uncommon. However, the surgeon must exercise some
judgment while performing this maneuver in the presence FINAL FLAP ASSESSMENT
of extremely thin skin flaps, previous scars, and
antecedent radiation therapy. In the absence of these con- Before completing the inset of the TRAM flap the surgeon
ditions, I have not found this maneuver to cause injury to must analyze the appearance of the flap, including the
the mastectomy skin flaps. vascularity of the skin paddle. If there is any suspicion of
After the quantity of skin that needs to be replaced has vascular compromise, the orientation of the pedicle, ten-
been established, the next step is to identify the optimal sion on the pedicle, and position of the pedicle in the tun-
position in which to place the TRAM skin on the recon- nel are checked before closure is completed. With a
structed breast. The location of the skin on the flap and the unipedicle TRAM flap it is not uncommon to note mild
inset orientation can be determined using a template. I find venous congestion because of the orientation of the valves
that paper towels obtained from a roll are most helpful. in the oscillating veins. A flap that is noted to be venous
Such a template can take into account the point of rotation congested during elevation may benefit from removal of
of the muscle pedicle, as well as the dimensions of the adi- the ligature or clip on the deep inferior epigastric vein
pose tissue needed for the reconstruction (see Fig. 7-19AF). (DIEV), which drains the venous blood from the flap.
The surgeon then needs to decide whether to preserve Repeatedly unclipping the DIEV often helps to decongest
some of the patients native breast skin above the newly the flap. Mild venous congestion (a flap with pink color
created fold or to use the TRAM flap skin itself to create and rapid capillary refill) is rarely ever a problem, and in
the fold. It is aesthetically desirable to avoid the patch my experience it reverses itself within the first 24 hours
effect produced by placing the TRAM flap skin paddle in after surgery. More profound venous congestion may ben-
the center of the reconstructed breast (Fig. 7-35A,B). The efit from a microvascular anastomosis between the DIEV
patch effect occurs when a significant amount of native and a local vein on the chest wall.
breast skin is maintained above the IM fold. I find that a Likewise, arterial insufficiency, which is typified by a flap
strip of skin 1 to 2 cm in width can be preserved while still that is pale or mottled in color, merits an analysis. After the
avoiding this effect. absence of pedicle kinking or excessive tension is ensured,
Using this approach I have achieved the best symmetry the flap should be warmed by the application of sponges or
of the IM folds, optimal restoration of breast skin enve- towels that have been immersed in warm saline. To prevent
lope dimensions, and good breast shape. connective heat loss and vasoconstriction in the skin pad-
dle, it may be helpful to place the flap in a bowel bag. If the
flap continues to manifest signs of arterial insufficiency
ENVELOPE REDUCTION additional measures to increase the blood supply may be
undertaken. Most often this entails a microscope-assisted
The breat reconstruction surgeon will be confronted with anastomosis between the DIEA and a regional artery in the
situations in which reducing the existing skin envelope of area of the chest wall. This is the so-called supercharging or
both breasts facilitates post-operative symmetry. This is turbocharging30 maneuver described earlier. The thora-
often performed using a Wise pattern or vertical mammo- codorsal artery is the most commonly used recipient artery
plasty type of skin pattern. When using the vertical mam- to accomplish this additional arterial inflow to the flap.
moplasty design (Fig. 7-35A), I feel it is helpful to Dressings over the flap are kept to a minimum so that
de-epithelialize the skin between the vertical lines rather the flap can be easily inspected throughout the immediate
than to incise completely through the skin in order to postoperative course.
Ch07.qxd 14/12/05 4:21 AM Page 336
FIGURE 7-35. A, Young patient who will undergo a left mas-

tectomy with an immediate breast reconstruction. The skin
envelope will be reduced with a vertical mammoplasty pattern
with de-epithelialization (not resection) of the skin between the
vertical skin incisions. She will have a concomitant right vertical
mastopexy. B-C, A paper template is uesed to stimulate transpo-
sition and inset of the TRAM flap. D, The appearance of the
breasts at 6 weeks following surgery. E, The appearance follow-
ing left nipple reconstruction demonstrates excellent symmetry.
Ch07.qxd 14/12/05 4:21 AM Page 337
THE ABDOMINAL WALL CLOSURE umbilicus can be treated by placation of the contralateral
rectus muscle fascia at the time of closure.
It is imperative to achieve a secure closure of the abdomi- An exception to the rule of performing primary fascial
nal wall donor defect following TRAM flap harvest. defect closure without mesh is the thin patient with a nar-
Hartrampf3,4 has stated on more than one occasion, it is row waist and minimal muscle laxity (see Fig. 7-5E,F). In
not a good trade for a woman to receive a bulge in the such patients, it is advisable to use mesh at the time of fas-
abdominal wall for an elegant breast reconstruction. cial38 closure to avoid displacement of the umbilicus and
Therefore, the donor defect in the abdomen must be to maintain the spatial relationship of the other muscle
repaired in the best possible way. groups.
I believe that it is possible to achieve a surgically sound Primary mesh application is helpful in other settings as
repair of the flap donor defect in the abdominal wall fol- well.38 For example, if there is any evidence of attenuation
lowing unipedicle TRAM flap elevation without the use of of the fascial closure during the repair, I immediately
synthetic mesh in most cases. This is said knowing full apply a piece of synthetic mesh as an onlay to supplement
well that many authors are currently advocating the use of the fascial closure. As previously noted, this is usually rare
synthetic mesh for primary defect repairs in all patients in unipedicle flaps where a single muscle is harvested.
regardless of the type of TRAM flap used. However, synthetic mesh as reinforcement is much more
The technique of closure has been described by many commonly employed in a double muscle harvest. In this
authors, but I subscribe to the method outlined by Kroll,32 circumstance, 80% of my fascial closures are supple-
who emphasizes the importance of approximating the mented with mesh reinforcement.
anterior rectus fascia and oblique fascia, laterally, to It is apparent in the literature that there is a definite
the linea alba, medially. There are two layers of fascia trend toward using mesh during the primary repair of
in the lateral defect in the fascia, and both of these must nearly every pedicled TRAM flap harvest. This varies from
be incorporated with each suture,37 I believe that the pur- the use of mesh advocated by Zienowicz and May39 to the
chase on the medial fascia must include the linea alba use of smaller segments advocated by Pennington and
(Fig. 7-36). Lam.40 This more liberal use of mesh has brought with it
I prefer to use permanent braided nylon sutures the beneficial effect of dramatically decreasing the bulge
(0 Surgilon) placed in a figure of 8 fashion using inter- and hernia rate to low single digits.
rupted suture technique. I ask the anesthesiologist to dis- In summary, my practice has been to close the vast
continue nitrous oxide and to administer muscle relaxants majority of single muscle harvest procedures without the
to promote maximum relaxation of the abdominal wall use of mesh but to use mesh much more liberally in the
musculature. This usually allows a tension-free closure of closure of the bipedicle muscle harvest deficit.
the fascial defect that results from the harvest of a single A secure closure of the abdominal donor defect is a key
muscle TRAM flap. part of the TRAM flap procedure. The surgeon must be
In harvesting the unipedicle flap, both rows of muscu- satisfied that this situation exists before completing the
locutaneous perforators are preserved to the flap, and abdominal wall closure. The use of supplemental syn-
dissection is carefully done right to the site of emergence thetic mesh for all types of TRAM flaps is increasing
of these vessels through the rectus fascia. It is possible to
visualize the small rents, or openings, in the rectus fascia
that admit each of these vessels. Incising the fascia just
lateral to the lateral row and just medial to the medial
row achieves maximum preservation of the rectus fascia.
As noted earlier (see Fig. 7-22), I routinely preserve a nar-
row strip of fascia over the proximal rectus muscle and
employ a full-width harvest of the muscle to the costal
margin.
Closure of the defect following a unipedicle flap transfer
always results in a deviation of the umbilicus to the side of
the flap closure. How much deviation occurs is dependent
on the width of the abdomen in the area of the waist, the
relative degree of muscle laxity, and the length of the umbil-
ical stalk. Patients who have a larger waistline and more
laxity of the muscles manifest less displacement of the
umbilicus. In addition, a long umbilicus stalk can be pulled FIGURE 7-36. The application of synthetic mush to abdominal
back closer to the midline and more ideally positioned than well following TRAM flap harvest. Mesh must absorb and negate
an umbilicus with a short stalk. Minimal eccentricity of the a significant tension stress.
Ch07.qxd 14/12/05 4:21 AM Page 338
worldwide. This appears to have a beneficial effect by 17. Chang DW, Reece GP, Wang B, et al. Effect of smoking on
complications in patients undergoing free TRAM flap breast
reducing the incidence of postoperative bulges and her- reconstruction. Plast Reconstr Surg. June 2000;105(7):
nias. However, despite careful attention to detail and use 23742380.
of these techniques the incidence of bulges in the lower 18. Takeishi M, Shaw WW, Ahn CY, et al. TRAM flaps in patients
with abdominal scars. Plast Reconstr Surg. March
abdomen remains between 3% and 6%. Many of these 1997;99(3):713722.
patients request correction of these hernias. I illustrate 19. Kroll SS, Netscher DT. Complications of TRAM flap breast
my current approach to the treatment of a TRAM flap her- reconstruction in obese patients. Plast Reconstr Surg.
December 1989;84(6):886892.
nia defect using the intrapintoneal38 placement of syn- 20. Chang DW, Wang B, Robb GL, et al. Effect of obesity on flap
thetic mesh to treat established hernias in Chapter 8. and donor-site complications in free transverse rectus abdo-
I believe that this technique represents a significant step minis myocutaneous flap breast reconstruction. Plast
Reconstr Surg. April 2000;105(5):16401648.
forward in successfully managing the difficult problem of 21. Grotting JC, Urist MM, Maddox WA, et al. Conventional
abdominal wall hernia in the patient who has undergone TRAM flap versus free microsurgical TRAM flap for immedi-
TRAM flap breast reconstruction. ate breast reconstruction. Plast Reconstr Surg. May
1989;83(5):828841; discussion 842844.
22. Serletti JM, Moran SL. Free versus the pedicled TRAM flap: a
cost comparison and outcome analysis. Plast Reconstr Surg.
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sion 10521053.
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TRAM flap hernias using intraperitoneal synthetic mesh Louis, Mo: Mosby; 1983.
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discussion 6366. Louis, Mo: Quality Medical Publishers; 2000.
39. Zienowicz RJ, May JW Jr. Hernia prevention and aesthetic Grotting, JC, ed. Reoperative Aesthetic and Reconstructive Plastic
contouring of the abdomen following TRAM flap breast Surgery. St. Louis, Mo Quality Medical Publishers; 1995.
reconstruction by the use of polypropylene mesh. Plast Spear SL, ed. Surgery of the Breast Principles and Art.
Reconstr Surg. November 1995;96(6):13461350. Philadelphia, Pa: Lippincott-Raven; 1998.
40. Pennington DG, Lam T. Gore-Tex patch repair of the anterior Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. New
rectus sheath in free rectus abdominis muscle and myocuta- York, NY: Little, Brown and Company; 1994.
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Ch08.qxd 11/28/05 9:17 PM Page 340
C h a p t e r 8
Revision and Salvage of the Suboptimal

TRAM Flap
Complications following TRAM Flap Breast The Aesthetic Unit of the Breastthe
Reconstruction 341 Importance of the Skin Paddle and Skin
Scars 379
Acute Complications following TRAM Flap Breast
Reconstruction 341 Skin Envelope Discrepancy 382
The Skin Envelope 341
Skin Paddle Reduction 386
Native Breast Flap Skin Loss in Immediate
Reconstruction 341 Skin Envelope and Volume Adjustment by
Excision 386
Skin Loss following Immediate Breast
Reconstruction with a TRAM Flap 343 Inframammary Fold Asymmetries 386
Management of Skin Loss after TRAM Flap Inframammary Fold Too High 386
Reconstruction 344
Inframammary Fold Too Low 389
Early Operative Dbridement of Open
Wounds following TRAM Flap Breast Treatment of Contour Deficits following
Reconstruction 348 TRAM Flap ReconstructionMalpositioned
Hematoma 353 Volume 389
Infection 353
Seroma 356 Increasing Flap Projection following TRAM Flap
Acute Fat Necrosis 358 Reconstruction 395
Skin Loss with Underlying Fat Necrosis 358
Increasing Projection of a TRAM Flap by Vertical
TRAM Flap RevisionVolume Excess 362 Mammoplasty Technique 396
Volume Reduction by Excision 366 Augmenting TRAM Flap Volume with Adjacent
Tissue 396
Adjacent Contour Adjustment 368
Combining Multiple Reconstructive Modalities
Correction of the Inferior Medial Bulge by Rectus in Revising the Truly Suboptimal Result 396
Muscle Excision 368
Treating Breast Contour Deficits with
Volume Insufficiency 372 Redistribution of TRAM Flap Volume 396
The Internal Flip-Flop Fat Flap 396
The Use of Implants to Treat Tissue Loss in the
TRAM Flap 377 Treating Breast Contour Deficits with Adjacent
Tissue by Transposing the Muscle Pedicle of
Staged Reconstruction with Tissue Expander the Flap 399
and Subsequent Implant for TRAM
Salvage 378 Reconstructing Contour Defects with Autologous
Fat Grafts 404
340
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Chapter 8 Revision and Salvage of the Suboptimal TRAM Flap 341
Fat Necrosis 405 TRAM Flap Donor Site Problems 414
Flap Loss Following TRAM Flap References 419

Reconstruction 407
COMPLICATIONS FOLLOWING TRAM rior aesthetic outcomes when the breast reconstruction is
FLAP BREAST RECONSTRUCTION done at the time of the mastectomy as opposed to when it
is done at a later stage in the patients recovery. There are
As outlined in Chapter 7, proper patient selection, preoper- certain complications that are almost unique to immedi-
ative planning, and consistent surgical technique are all ate reconstruction, most notably mastectomy skin flap
important factors in achieving consistent success with necrosis, which is outlined later.
transverse rectus abdominis myocutaneous (TRAM) flap
breast reconstruction. Nevertheless, despite careful atten-
tion to detail, complications can and do occur following
ACUTE COMPLICATIONS FOLLOWING
breast reconstruction with the TRAM flap.1,2 These may
TRAM FLAP BREAST
occur in the immediate postoperative period or may
RECONSTRUCTION
become apparent later in the course of the patients recov-
ery. Table 8-1 lists the complications that can occur in both
The Skin Envelope
the acute and subacute phases of the patients postopera-
tive healing in both the breast and abdominal donor areas. Consistently excellent results in TRAM flap breast recon-
Although the complication rate in immediate breast struction require a properly oriented breast mound that
reconstruction is higher than that in delayed reconstruc- simulates the shape and projection of the opposite breast
tion with the TRAM flap and other techniques, it appears and an accurately positioned inframammary (IM) fold.
that this approach is increasingly preferred by both sur- But the ultimate quality and appearance of every breast
geons and patients.3 I find that it is easier to achieve supe- reconstruction depends on the quality and aesthetics of
the skin envelope.
TABLE 8-1 Complications Following TRAM Flap NATIVE BREAST FLAP SKIN LOSS IN
Breast Reconstruction IMMEDIATE RECONSTRUCTION
Complications in Complications in the
the Breast Abdominal Donor Area Vascular ischemia, which can result in partial necrosis of
the patients native mastectomy flaps with development of
Subacute/ Subacute/ an open wound and delayed wound healing, is not an
Acute Chronic Acute Chronic
uncommon occurrence.4 Factors contributing to native
Skin loss Excess volume Seroma Hypertrophic scars breast skin flap necrosis following mastectomy proce-
Open wounds Insufficient Skin loss Contour problems dures are listed in Table 8-2.
volume open In my experience the strongest contributing factors are
wound(s) excessive length of these random pattern skin flaps (unfa-
Seroma Skin excess Umbilical Abdominal bulges
vorable length-to-width ratio), a history of current ciga-
necrosis
rette smoking in the patient,57 antecedent radiation
Hematoma Contour Contour Abdominal hernia
problems deformities formation therapy,2 and perhaps most importantly the presence of
Infection Inadequate Pain/neuroma
projection formation
TABLE 8-2 Factors Contributing to Native Breast
Fat necrosis Lack of upper Umbilical
Skin Flap Necrosis following Mastectomy
pole fullness eccentricity
Scars Long random pattern skin flap(s)
Fat necrosis Current cigarette smoking
Partial flap loss Previous incisions on the breast
Major flap loss Antecedent radiation therapy
Complete flap loss Superficial location of the breast tumor
Excessively thin skin flaps(s)
TRAM, Transverse rectus abdominis myocutaneous.
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previous breast incisions.8 A superficial location of the and the surgeon carefully notes the color and fluorescence
breast tumor resulting in a resection margin close to or in of all of the skin tissues. The skin should show a green-
the dermis and breast skin flaps that are simply very thin yellow color when normally perfused (Fig. 8-1A). A purple
in relation to the underlying breast tissue are also strong or black or black color is indicative of areas with poor per-
contributing factors to mastectomy skin flap ischemia. fusion and these should be excised (Fig. 8-1B). If certain
The aesthetic importance of maximally preserving regions show equivocal fluorescence I examine the tissues
native breast skin when performing immediate breast again at 15 minutes following fluorescein infusion. After
reconstruction has been previously emphasized. Con- this second examination decisions about mastectomy skin
versely, any nonviable native breast skin should be flap resection or retention of the skin on the mastectomy
resected before establishing the final dimensions of the flap are made (Fig. 8-2A).
skin paddle to be preserved on the TRAM flap. However, I have found this method of determining skin flap via-
the exact determination of how much of the breast skin bility to be extremely helpful for decreasing the incidence
flap will be ischemic is not always easy to establish. The of and problems with native skin flap necrosis, which
color of the skin flap and capillary refill often provide little often results in open wounds with unfavorable scars and
information about viability. This is especially true in dark- contour abnormalities. This occurrence produces delays
skinned patients. Similarly, the presence of bleeding at the in the administration of chemotherapy. I believe that this
edge of the flap and color of the blood can be deceptive.
Nevertheless, it is the responsibility of the reconstruc-
tive surgeon to make the decision as to how much native
breast skin is retained as part of every immediate breast
reconstruction. Toward this end, the surgeon should eval-
uate the skin flaps for uniformity of thickness and the
length-to-width ratio, or the distance from the edge to the
blood supply at the base, and take these observations into
account along with the general appearance of the skin sur-
face features, specifically noting any signs of bruising or
mottling.
Realizing the importance of this determination and
the limitations of clinical assessment, I have over the
past 5 years taken a more proactive approach by using
intravenous (IV) flourescein9 and a Woods lamp to help
me make the final decisions about the vascular perfusion
of the skin flaps, and ultimately about their viability. This
ultra vital dye has been used for decades by both general
surgeons and plastic surgeons, and it provides useful
and reliable information as to the arterial perfusion of
various tissues, including skin. It is simple to use as
described.
Because exceedingly rare instances of anaphylaxis have
been reported following the administration of fluorescein,
a test dose of 1 cc (100 mg) is given intravenously and the
patient is carefully monitored for any changes in vital signs
over the next 10 minutes. If no changes are observed then a
dose of 10 to 15 mg/kg is administered intravenously and
10 minutes of circulation time are allowed to elapse before
the skin is examined using a Woods lamp.9 To use a Woods
lamp all of the lights in the operating room are turned off
and the lamp, which has been turned on for 1 minute, is
brought to the operative field. With care being taken to
avoid contamination of the operative field, the Woods
lamp is held about 1 foot (12 inches) from the patients
FIGURE 8-1. A, The appearance of normally perfused skin fol-
skin. Before this fluorescein-aided visual examination takes
lowing IV fluorescein administration. Note the yellow green
place, the TRAM flap should be transferred and allowed to sit color. B, The appearance of nonperfused skin reveals a purple or
beneath the native mastectomy flaps. The skin on the black color. These areas (along the margins of skin incision)
abdomen, both breasts, and the TRAM flap are illuminated should be excised.
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FIGURE 8-2. A, The ultimate skin-sparing mastectomy in which the procedure is performed through
a periareolar incision with planned immediate unipedicle TRAM flap breast reconstruction. B,
Appearance of reconstructed breast following nipple areola reconstruction with periareolar scar only
and underlying TRAM flap.
technique is especially useful in dark-skinned patients. SKIN LOSS FOLLOWING IMMEDIATE

The dye will turn the urine a yellow-orange color for 48 to BREAST RECONSTRUCTION WITH A
72 hours, and it also imports a yellow tinge to the skin and TRAM FLAP
sclera. Patients should be told about this before fluores-
cein administration. As previously mentioned, skin loss following immediate
In summary, I strongly believe skin-sparing mastec- breast reconstruction with a TRAM flap is not an uncom-
tomy has dramatically improved the aesthetic outcome of mon problem in my practice. Indeed, it may become more
immediate breast reconstruction. However, immediate prevalent as the popularity of ultimate skin-sparing mas-
reconstruction is plagued by the potential for necrosis of tectomy increases (Fig. 8-2A). The advantage of this
the native skin flaps of the breast. As previously noted, extreme form a skin-sparing mastectomy is in the aes-
this is not an uncommon occurrence following immediate thetic restoration of the breast without visible scars except
breast reconstruction. In contrast, skin flap necrosis virtu- for those around the TRAM skin paddle inset10 (Fig. 8-
ally never occurs in delayed breast reconstruction proce- 2B). The predisposing factors for this problem are
dures. Finally, it is important to realize that open wounds described in Table 8-1, and the plastic surgeon must exer-
resulting from mastectomy flap necrosis in the setting of cise a high level of vigilance and take a proactive approach
immediate breast reconstruction become a plastic surgery to limit its occurrence. Despite intensified efforts at reduc-
complication, and every effort should be made to keep this ing this problem the incidence of skin loss in the mastec-
problem to an absolute minimum. tomy flap(s) remains between 5% and 10%.4
Ch08.qxd 11/28/05 9:17 PM Page 344
MANAGEMENT OF SKIN LOSS AFTER loss is limited to a small area, preferably laterally positioned;
TRAM FLAP RECONSTRUCTION there is no evidence of vascular compromise in the TRAM
flap tissue (i.e., no fat necrosis); and most importantly there
The next question is, how should skin loss on the recon- is no need for postoperative chemotherapy. If these condi-
structed breast be managed when it occurs? The options tions are present in a particular patient, the overwhelming
are expectant management with daily wound dressing likelihood is that the wound will heal without infection by a
changes done by the patient or early operative intervention combination of epithelialization and contraction and the
in the form of operative dbridement and wound reclosure. shape of the reconstructed breast will be minimally affected.
The course of nonoperative management is reasonable Such a case is illustrated in this 44-year-old woman
when the shape of the reconstructed breast is good; the skin (Fig. 8-3), who presented with a recurrence of a ductal
FIGURE 8-3. A, Preoperative appearance of patient who

requires right total mastectomy for recurrent DCIS. Note two pre-
vious biopsy incisions (arrows) in upper outer aspect of breast. B,
Outline of plan for immediate right breast reconstruction using
split-muscle bipedicle TRAM flap. C, Early postoperative appear-
ance reveals full-thickness skin loss on superior and inferior
native breast (mastectomy) skin flaps. (continued)
Ch08.qxd 11/28/05 9:17 PM Page 345
FIGURE 8-3. (CONTINUED) D, Appearance of wounds treated with wet to dry dressings for 2 months
illustrating healing by epithelialization and contraction. E, Appearance at 9 months following surgery
without additional treatment. Note maturation of scars.
carcinoma in situ (DCIS) in the upper outer right breast This consisted of simple wound care with wet-to-dry
following a previous lumpectomy and radiation therapy. dressings done at home, which led to epithelialization
The patient previously had two incisions in the upper within 2 months (Fig. 8-3D). At a 9-month follow-up she
aspect of the right breast (Fig. 8-3A). The plan was for exhibits stable wound healing and a very satisfactory
total mastectomy. Because of her strong desire for an breast appearance (Fig. 8-3E) without any additional sur-
autogenous tissue breast reconstruction and due to a rela- gery. In this patient the tradeoff of scars for shape proved
tive paucity of lower abdominal tissue and a lower mid- to be a good one.
line abdominal incision, the reconstructive plan was to If a treatment plan of active wound care with daily
use a split-muscle bipedicle TRAM flap (Fig. 8-3B). wound dressings is pursued to manage skin loss following
Following the total mastectomy and immediate breast immediate breast reconstruction with the TRAM flap, in
reconstruction with a split-muscle bipedicle TRAM flap, my opinion it is imperative that all the conditions listed in
the patient developed marginal ischemia of both the Table 8-3 be satisfied.
superior and inferior skin flaps, which was most likely
related to both the previous incisions and the antecedent
TABLE 8-3 Nonoperative Management of Skin Loss
radiation therapy. She went on to show full-thickness skin on TRAM Flap
flap necrosis and developed open wounds (Fig. 8-3C). The
shape of the breast was excellent, the bipedicle TRAM flap Well-vascularized TRAM flap (no evidence of fat necrosis)
had a robust blood supply as evidenced by early granula- Small area of skin loss that is well demarcated
tion tissue formation on the surface of the underlying Skin loss not located medially
No anticipated need for adjuvant chemotherapy
wound, and there was no need for postoperative chemo-
therapy. A course of expectant management was adopted. TRAM, Transverse rectus abdominis myocutaneous.
Ch08.qxd 11/28/05 9:17 PM Page 346
To employ this strategy it is especially important that ischemia of the native breast skin flap. This was perhaps
the adipose layer of the TRAM flap exhibit normal vascu- exacerbated by a small subcutaneous hematoma and her
larity. This impression is best confirmed by the rapid previous radiation therapy. However, the open wound was
appearance of granulation tissue on the surface of the positioned directly over the adipose tissue of the flap seg-
wound, which should be noted within the first week. ment across the midline, which had shown induration
It is important to have the patient become fully involved and firmness consistent with early fat necrosis. When this
in this program of active wound care. Most commonly the tissue became exposed the patient developed a cellulitis
treatment regimen consists of dressing changes performed that did not completely respond to antibiotic therapy. She
three times daily using gauze pads moistened in normal had approximately eight small wound dbridements per-
saline. The patient applies the gauze pads after she washes formed in the office to remove the marginally vascular-
her wounds in the shower. I like the patient to use a shower ized adipose tissue (fat necrosis) in the flap and was
massage apparatus11 that delivers pulses of water to the treated with wet-to-dry dressings. The patient went on to
wound surface. This is effective in preventing desiccation show eventual wound healing after 12 weeks of wound
and minimizing the accumulation of fibrous debris on the packing and dressing changes. She also exhibited a signif-
wound surface. If granulation tissue does not appear icant medial contour deficit on the anteroposterior (AP)
within this time frame then the risk of secondary infection view (Fig. 8-4C) and oblique view (Fig. 8-4D).
rises significantly, and this may substantially increase the This case illustrates three errors in judgment. The first
magnitude of the wound problem. For me this most often was improper flap selection for this patient with signifi-
dictates taking a more aggressive approach consisting of cant requirements for skin and adipose volume replace-
operative dbridement and wound closure at a much ear- ment, i.e., using a nondelayed single pedicle flap as
lier stage. Failure to intervene at an earlier stage when opposed to a surgically delayed TRAM, a free microvascu-
there is concern about the vascularity of the underlying lar TRAM flap, or a bipedicle TRAM flap. The second error
TRAM flap can result in a prolonged course to healing and in judgment was placing a significant amount of tissue in
produce a suboptimal cosmetic outcome. zone II (transmidline tissue) of this single pedicle flap in a
Such a case is illustrated in this patient (Fig. 8-4A), medial location. The third error was failing to intervene
who underwent a modified radical mastectomy for a left earlier in the immediate postoperative period with a more
breast cancer. She had a prior lumpectomy and radiation aggressive operative dbridement and flap repositioning,
therapy but developed a tumor recurrence. She received which may have prevented the significant deformity the
neoadjuvant chemotherapy and then underwent a total patient developed. I believe that the occurrence of wound
mastectomy using a nonskin-sparing approach. She was separation in the setting of underlying fat necrosis in a
reconstructed with a superiorly based unipedicle TRAM TRAM flap in most cases is an indication for early opera-
flap based on the contralateral rectus abdominis muscle, tive dbridement and wound reclosure. Most likely a more
which carried 2.75 zones of tissue from the lower aggressive approach involving dbridement at an earlier
abdomen, including a substantial portion of zone II (the stage on this patient (Fig. 8-4) may have been beneficial
transmidline zone), which was placed medially. At 10 days from the standpoint of expediting wound healing and
following surgery she was noted to have ischemia of the improving the eventual contour of the medial contour of
medial aspect of the TRAM flap skin (Fig. 8-4B) and the reconstructed breast as outlined in the next section.
Ch08.qxd 11/28/05 9:17 PM Page 347
FIGURE 8-4. A, Preoperative planning for patient who will have an immediate left breast reconstruc-
tion with a single pedicle TRAM flap based on the contralateral rectus abdominis muscle.
B, Appearance of TRAM flap breast reconstruction on postoperative day 10. Note ischemia in medial
aspect of TRAM in transmidline skin. C, Appearance of reconstruction at 2 years demonstrating a sig-
nificant contour deformity and scar. D, Oblique view demonstrates scarred and deformed medial breast
contour.
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EARLY OPERATIVE DBRIDEMENT OF firmed the presence of stage II disease and the need for
OPEN WOUNDS FOLLOWING TRAM postoperative chemotherapy. By postoperative day num-
FLAP BREAST RECONSTRUCTION ber 5 she showed a clear demarcation of the areas of
ischemia, but the adjacent skin of both the inferior and
More commonly I employ an aggressive approach of superior breast flaps appeared normally vascularized
wound management when an open wound results after (Fig. 8-5D). Because of the size of ischemic areas, the
immediate breast reconstruction. An example of such a clear demarcation, and the need for postoperative
case is the following. This patient (Fig. 8-5) presented with chemotherapy, she was returned to the operating room on
a multifocal intraductal carcinoma of the left breast. She the fifth postoperative day, where she underwent opera-
had previously undergone the excision of a benign tumor tive excision of the ischemic skin flaps (Fig. 8-5E),
in the superior aspect of the left breast with a long hori- removal of the sentinel skin paddle from the bipedicle
zontal scar in the upper aspect of the breast (Fig. 8-5A). TRAM flap, a volume reduction of the TRAM flap, and
Local control of her breast malignancy required a modi- wound reclosure (Fig. 8-5F). This resulted in primary
fied radical mastectomy. She was interested in an immedi- wound healing along the incision and a satisfactory aes-
ate reconstruction of the left breast and had a strong thetic outcome at 9 months following surgery (Fig. 8-5G).
preference for an autogenous tissue reconstruction. The reconstruction was completed at 18 months with the
Although she had a large (DD cup) opposite breast she creation of a nipple areola reconstruction (Fig. 8-5H).
vehemently declined any suggestion of reducing the In this case the skin loss was most likely related to the
contralateral breast (Fig. 8-5A). The patient had a lengthy previous breast incisions8 and perhaps to the weight of
scar across the upper aspect of her left breast (Fig. 8-5B). this large flap, producing mechanical compression or ten-
Because of the large tissue requirement for her breast sion at the skin flap margins. This early postoperative sur-
reconstruction she underwent a split-muscle bipedicle gical intervention, including decreasing the size of the
TRAM flap. She developed ischemic changes in both the TRAM flap, produced primary wound healing, permitted
superior and inferior native breast skin flaps marked by the timely institution of postoperative chemotherapy, and
mottling, ecchymosis, and epidermolysis along the mar- provided a satisfactory long-term aesthetic appearance of
gins of both flaps (Fig. 8-5C). Her axillary dissection con- the reconstructed breast.
FIGURE 8-5. A, Preoperative AP view of breasts in patient who will require a left modified radical mastectomy for
recurrent intraductal carcinoma. B, Oblique view of left breast before mastectomy. Note long scar in upper aspect of
breast. (continued)
Ch08.qxd 11/28/05 9:18 PM Page 349
FIGURE 8-5. (CONTINUED) C, Patient underwent immediate

left breast reconstruction with split-muscle bipedicle TRAM in an
attempt to match the size of opposite breast. On postoperative day
5 she shows evidence of epidermolysis of the superior and inferior
skin flaps surrounding the TRAM flap skin paddle, which is
demarcated. D, The outline for skin excision seen in the operating
room on postoperative day 5. E, Necrotic native breast skin is
excised; TRAM flap will be reduced in size and skin paddle on
TRAM removed.
Ch08.qxd 11/28/05 9:18 PM Page 350
FIGURE 8-5. (CONTINUED) F, Immediate postoperative

appearance of reconstructed left breast following dbridement
and reduction in the size of the TRAM flap. Patient shows allergic
reaction to cefazolin (Ancef) marked by a diffuse exfoliative der-
matitis. G, Appearance of breast at 9 months without additional
surgery. H, Appearance of breasts following left nipple reconstruc-
tion.
Ch08.qxd 11/28/05 9:18 PM Page 351
Another example of early dbridement is illustrated by cle location, and the dissection must be done well away from
this 38-year-old patient who underwent a right modified rad- the pedicle) and wound reclosure (Fig. 8-6E). She demon-
ical mastectomy to treat a large multifocal intraductal carci- strates satisfactory breast symmetry at 1 year without addi-
noma (Fig. 8-6A). Because of tissue requirements needed for tional surgery (Fig. 8-6F). Aggressive wound management in
symmetry (almost three zones) she was reconstructed with a this setting was important to achieving a satisfactory shape,
free microvascular TRAM flap (Fig. 8-6B). A skin-sparing minimizing subsequent scarring on the breast, and permit-
mastectomy was performed (Fig. 8-6C). She developed full- ting the administration of chemotherapy.
thickness necrosis in the lateral aspect of the superior mas- To summarize, management of open wounds on the
tectomy flap in an area where the mastectomy flap was thin reconstructed breast can be operative or nonoperative,
(Fig. 8-6D). This rapidly became demarcated. Because of the depending on the specific situation. In general most of
need for postoperative chemotherapy she was returned to these wounds are managed with operative dbridement
the operating room on postoperative day 10 for excision of and reclosure, but there is clearly a role for nonoperative
the nonviable skin segment (Fig. 8-6E). She also had a cau- wound management in certain cases, as outlined. Careful
tiously performed reduction in the size of the flap (reducing analysis of the multiple factors at play in a given patient
the size of a free TRAM reconstruction in the acute stage fol- and good surgical judgment are important for achieving
lowing surgery must be done with an awareness of the pedi- wound healing in the most expeditious way.
FIGURE 8-6. A, Patient with large intraductal carcinoma of right breast not amenable to lumpectomy.
Breast is a strongly projecting D cup. B, The reconstructive plan is for a free microvascular TRAM flap
based on the contralateral deep inferior epigastric (DIEA) pedicle because of tissue requirements for
volume match. C, Skin-sparing mastectomy performed with minimal skin sacrifice as evidenced by the
mastectomy specimen. D, Full-thickness skin necrosis as seen on postoperative day 9. Because of the
need for postoperative chemotherapy, she was immediately returned to the operating room for dbride-
ment. Note clear demarcation of the necrotic skin. E, Breast appearance at 10 days following dbride-
ment. F, Appearance of the breast 1 year postoperatively following chemotherapy without additional
surgery. Note the improved symmetry due to stretching of the skin envelope.
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Ch08.qxd 11/28/05 9:19 PM Page 353
Hematoma Infection
Hematoma following TRAM flap breast reconstruction is Infection following TRAM flap breast reconstruction has
decidedly uncommon in my experience. This is true also been an uncommon problem in my practice. It pres-
despite the fact that certain patients [patients with a his- ents as either a cellulitis or as a wound abscess. In the for-
tory of previous deep vein thrombophlebitis (DVT) or mer instance it is best treated with antibiotic therapy
those who are at increased risk for this problem]12 receive administered orally or intravenously. In more significant
subcutaneous heparin as a single injection of 5000 units 1 infections I use a second-generation cephalosporin [cefa-
hour before surgery as part of DVT prophylaxis.13 Also, it is zolin (Ancef) 1 g IV q6h]. This usually produces a clinical
customary in my practice to give 3000 units of heparin response within 48 hours and a resolution of the problem
intravenously to those patients undergoing free microvas- within 72 to 96 hours.
cular TRAM flap reconstruction before cross-clamping the On the other hand, a wound abscess may be the result
flap donor and recipient vessels. Hematoma formation in of an infected hematoma, but more often it has occurred
the site of the TRAM flap breast reconstruction probably in the setting of an open wound with underlying fat necro-
results from skin de-epithelialization in the portion of the sis, which again reinforces the importance of aggressive
flap that will be buried beneath the mastectomy skin flaps. surgical management of this combination of problems.
It is therefore important to carefully control any bleeding The following patient illustrates the consequence of
from the dermis or subdermal plexus before burying the delayed recognition and management of infection.
TRAM tissue and completing the inset of the TRAM flap. This 60-year-old patient (Fig. 8-7A) presented with a
The surgeon must be meticulous in raising the abdomi- left mastectomy defect following treatment for stage
nal flap from the standpoint of coagulating the musculocu- I intraductal carcinoma of the breast. She had a large con-
taneous perforators between the upper edge of the skin tralateral breast and the reconstructive plan was to per-
paddle and the costal margin. Similarly, in the area of the form a left breast reconstruction with a superiorly based
breast, bleeding points in the mastectomy wound, including TRAM flap using the right rectus muscle and a contralat-
both the pectoralis muscle and the undersurface of the mas- eral (right) breast reduction (Fig. 8-7B). The TRAM flap
tectomy skin flaps, or in the area of the axilla and lateral was elevated and all of zone I, 80% of zone III, and 30% of
chest wall. Any bleeding points in the tunnel, which com- the transmidline tissue in zone II was used. This trans-
municates the abdominal wound with the mastectomy midline tissue was placed medially after a horizontal flap
defect in pedicled flap reconstruction, must also be compul- inset and went on to develop fat necrosis. She developed
sively sought and controlled. Suction drains are routinely wound separation and then noted the onset of erythema
used, but they do not prevent hematomas. If the patient and drainage (Fig. 8-7C). Culture of the drainage was pos-
develops a significant hematoma it is best to return her to itive for Staphylococcus aureus. The patient was admitted
the operating room for its evacuation. This will prevent pro- to the hospital and treated with intravenous oxacillin (2 g
longed induration in the tissues at this site (either the breast IV q6h for 48 hours), which produced a resolution of the
or the abdomen) and reduce the incidence of contour erythema. She was then brought to the operating room for
abnormalities. I have surgically evacuated two such collec- surgical dbridement of the wound, at which time the
tions, both of which occurred in the lateral chest region. No area of fat necrosis was resected. The wound was left open
distinct bleeding point was determined in either case. (Fig. 8-7D) and subsequent epithelialization and contrac-
Smaller collections of blood do not require return to tion produced wound healing (Fig. 8-7E). A revision of her
the operating room for open drainage procedures. These reconstruction entailed excision of this wound with a
can be managed in the outpatient setting by percutaneous superior and medial translocation of the TRAM flap
aspiration under sterile conditions with or without the (Fig. 8-7F). The patient also had an internal reconstruc-
injection of a local anesthetic into the skin. This is most tion of the IM fold at a more superior location on her
often easily accomplished after the seventh postoperative chest wall (Fig. 8-7G). This reoperative procedure pro-
day when such collections begin to liquefy. duced an aesthetically pleasing appearance of her TRAM
Suffice it to say, in my experience the problem of post- flap, very good breast symmetry (Fig. 8-7H), and a dra-
operative hematoma is uncommon with consistent surgi- matic improvement in her overall appearance as noted in
cal technique. If it does occur it should be appropriately a comparison of her preoperative and postoperative views
addressed to maximize the aesthetic result. (Fig. 8-7I).
Ch08.qxd 11/28/05 9:19 PM Page 354
FIGURE 8-7. A, Left postmastectomy defect in patient desiring TRAM flap reconstruction of her left
breast. B, The operative plan is for a left breast reconstruction with a superiorly based unipedicle
TRAM flap and contralateral breast reduction. C, Infection of reconstructed left breast with cellulitis
and focal abscess in medial aspect of TRAM flap, which contains underlying fat necrosis. D,
Dbridement of TRAM flap with excision of fat necrosis was performed and wound left open because of
infection. (continued)
Ch08.qxd 11/28/05 9:19 PM Page 355
FIGURE 8-7. (CONTINUED) E, Wound healed by contraction

and epithelialization, resulting in an abnormal contour of the
medial aspect of the reconstructed breast. F, The plan for revi-
sion included elevation and mobilization of the TRAM flap,
which was moved in a medial direction; superior repositioning
of the IM fold; reduction in the superior TRAM flap volume with
liposuction; and nipple areola reconstruction with a modified
star flap. G, The postoperative result at 18 months following pro-
cedure illustrates very good symmetry with the opposite breast
and correction of the contour abnormalities.
Ch08.qxd 11/28/05 9:19 PM Page 356
FIGURE 8-7. (CONTINUED) H-I, Oblique view preoperatively (H) and 18 months following revision
of breast reconstruction (I) demonstrating excellent result.
Seroma
By contrast, seroma development in the abdominal
Seroma in the area of the breast reconstruction following donor site area is far more common. These seromas can
TRAM flap breast reconstruction is uncommon. I believe be minimized by leaving the suction drains in place until
that seromas are prevented by the use of suction drains. they are draining less than 30 cc of fluid per 24 hours. An
However, occasionally a seroma will occur, and it should additional maneuver that has proven helpful is progres-
be aspirated. The following case illustrates seroma forma- sive tension suturing,14 which is a quilting suture tech-
tion that occurred within 3 weeks of surgery. nique in which suture is placed between the deepest
This 37-year-old female (Fig. 8-8) was diagnosed with portion of the adipose layer and the muscle fascia. I prefer
multifocal DCIS, which necessitated a mastectomy. She 3-0 chromic suture on a large noncutting or atraumatic
had large breasts (Fig. 8-8A) and a strong desire for recon- needle. This technique has been published by Pollock14 for
struction with autologous tissue. There was sufficient use in aesthetic abdominoplasty.
issue in the lower abdomen to achieve a nice breast recon- When seromas develop in the abdominal donor site I
struction. The patient underwent immediate reconstruc- prefer to aspirate them. They usually occur in the most
tion of the right breast with a previously delayed TRAM dependent portion of the abdomen and are easily accessed
flap (Fig. 8-8B). She developed an unexplained and by percutaneous needle aspiration through a portion of
marked swelling of the breast 3 weeks postoperatively that the abdominal flap that is relatively insensate. This is
made the right breast almost twice as large as it had been done using sterile technique with an 18-gauge 2-inch nee-
immediately following surgery (Fig. 8-8C). She was returned dle and a couple of 60-cc syringes. I find that it is helpful
to the operating room when aspiration in the office was to have the patient standing and have an assistant place
unfruitful (Fig. 8-8D). At surgery we discovered approxi- pressure at edges of the fluid collection, which can most
mately 200 cc of fluid collected beneath the TRAM flap. often be appreciated by palpation of the skin. It is most
This was aspirated. There were minimal changes in the often necessary to perform several aspirations to resolve
fat of the TRAM flap to suggest fat necrosis (Fig. 8-8E). any collection in excess of 60 cc. If repeated aspirations
A suction drain [10-mm Jackson-Pratt (Ethicon, Inc., seem unsuccessful in resolving this problem, I have placed
Somerville, NJ)] was placed. She healed uneventfully and a small seroma catheter,15 which the patient can aspirate
demonstrated very good symmetry at the 6-month postop- several times a day at home. In this situation I find that an
erative follow-up (Fig. 8-8F). abdominal binder is a helpful adjunct to this treatment.
Ch08.qxd 11/28/05 9:20 PM Page 357
FIGURE 8-8. A, Young patient with multifocal DCIS of right breast who requires right total mastec-
tomy; AP view of bilateral breasts. B, The plan is for an immediate breast reconstruction with a previ-
ously delayed ipsilateral, superiorly based unipedicle (right) TRAM flap. C, Marked swelling of the
reconstructed right breast is noted 3 weeks postoperatively. D, Intraoperative photograph of operative
exploration done to aspirate 200 cc of fluid collected beneath the flap with removal of minimal areas of
fat necrosis.
Ch08.qxd 11/28/05 9:20 PM Page 358
that I returned them to the operating room for a surgical

removal of this tissue within the first 5 days after surgery.
These areas are usually large, and they become hard in the
early postoperative period and remain hard. They often
require reoperation to resect the tissue as part of a revi-
sion surgical procedure to salvage the breast reconstruc-
tion. An example of this is illustrated by this patient
(Fig. 8-9A), who underwent an immediate left breast
reconstruction with a single pedicle TRAM flap. She
developed a large area of fat necrosis in the transmidline
component (zone II) of the flap (Fig. 8-9A). This large,
hard mass was eventually excised 8 months following the
original surgery (see Fig. 8-37AE), when the revisional
procedure also included a simultaneous nipple recon-
struction (Fig. 8-9C).
Skin Loss with Underlying Fat Necrosis

Although the occurrence of and approach to the manage-
ment of fat necrosis16,17 is discussed in the section on the
management of subacute complications, the combination
of mastectomy flap necrosis and vascular compromise in
the TRAM flap in the form of fat necrosis deserves special
mention at this point. This is most often a very unfavor-
able situation in that it sets the stage for a prolonged
course to wound healing, which often produces a signifi-
cant shape change in the breast. Most often there is a need
for a significant wound dbridement, or more commonly
multiple dbridements, before achieving wound healing.
Therefore, whenever there is an open wound following
breast reconstruction, along with any concern about fat
necrosis in the TRAM flap, an aggressive approach to treat-
ing any problems with wound healing is indicated. This is
illustrated by the following case.
This 42-year-old patient with 38DD breasts (Fig. 8-10)
required a right mastectomy for a multifocal breast can-
cer. She desired autogenous reconstruction of her breast.
FIGURE 8-8. (CONTINUED) E, Small fragments of fat necro- The contralateral breast hypertrophy and ptosis dictated a
sis were removed from the TRAM flap. F, Appearance of the plan consisting of a comitant left breast reduction with an
breast at 6 months postoperatively shows excellent symmetry inferior pedicle technique along with an immediate breast
before nipple areola reconstruction. reconstruction using a TRAM flap, both performed
through an inverted T incisional pattern (Fig. 8-10A). To
optimize skin envelope symmetry the mastectomy was
carried out with the same inverted T incisional approach.
I believe that this approach carries a greater risk for skin
flap necrosis and the development of open wounds and
Acute Fat Necrosis
should be undertaken with caution, especially if a large
Fat necrosis that occurs in the acute stage is uncommon. TRAM flap will be placed. This particular patient had thin
I have seen it occur in about five (approximately 2%) of and somewhat stretched skin and therefore was at risk for
the TRAM flaps that I have performed during my career. skin edge necrosis at the T junction. This complication
Fat necrosis presents as an acutely painful area of the occurred and produced an open wound at the T junction
TRAM flap that is most often in the buried portion of the of the mastectomy flaps (Fig. 8-10B). Unfortunately the
flap with overlying erythema of the skin. This skin is most patient also developed fat necrosis in the TRAM flap in the
often tender to palpation. Three times in my career area beneath the open wound, which was not recognized
patients have been febrile and appeared ill to the degree until 4 weeks after surgery. Sequential office wound
Ch08.qxd 11/28/05 9:20 PM Page 359
FIGURE 8-9. A, Large area of fat necrosis in medial aspect of a

left breast reconstructed with a unipedicle TRAM flap. This was
noted in the immediate postoperative period and required
dbridement at a later stage. B, Area of fat necrosis isolated and
resected. C, On table appearance of breast following excision of
fat necrosis and nipple reconstruction.
Ch08.qxd 11/28/05 9:20 PM Page 360
dbridements and a prolonged course of wound packing and in reconstructing a nipple. The appearance of the
were necessary to achieve wound healing over a 3-month right breast at a 2-year postoperative follow-up shows a
period. The patient had an asymmetry of her skin persistent abnormality in the contour of the IM fold
envelopes that required reoperative surgery (Fig. 8-10C). (Fig. 8-10E).
Resection of the scarred skin inferiorly and advancement This case again emphasizes the importance of adopt-
of the medial and lateral skin flaps allowed the creation of ing an aggressive approach to wound management in
a modified star flap nipple reconstruction at the time of any case of breast reconstruction where skin loss occurs
her revision (Fig. 8-10D). This revision procedure was suc- in the setting of underlying fat necrosis in the TRAM
cessful by improving the lower pole contour of the breast flap.
FIGURE 8-10. A, Preoperative plan for treatment of a patient who will undergo a right total mastec-
tomy for multifocal DCIS. The plan is for a unipedicle ipsilateral TRAM flap with concomitant left
breast reduction. There will be simultaneous reduction of the skin envelope of the right breast with an
inverted T incisional pattern. B, Patient developed skin loss at the junction of the vertical and horizontal
scars on the right reconstructed breast with underlying fat necrosis that required multiple outpatient
office dbridements. This resulted in an indentation of the lower breast contour. (continued)
Ch08.qxd 11/28/05 9:20 PM Page 361
FIGURE 8-10. (CONTINUED) C, The operative plan was for

release of the scar tissue and inferior repositioning of the TRAM
flap to be reinset over a base of de-epithelialized skin. D, The
patient will undergo simultaneous nipple reconstruction with a
medially based modified star flap. E, The result of this treatment
is illustrated at an early follow-up. Note incomplete correction of
the lower pole contour deformity but overall improvement in
appearance.
Ch08.qxd 11/28/05 9:21 PM Page 362
TRAM FLAP REVISIONVOLUME Technically this is a straightforward surgical proce-

EXCESS dure. The areas with adipose tissue volume excess in the
flap are noted with the patient standing and are carefully
The most common revision procedure in my practice fol- outlined on the skin with a marking pen as in other lipo-
lowing TRAM flap breast reconstruction is that of suction procedures. It is helpful to mark this excess using
decreasing the volume in the flap reconstruction. As circles (Fig. 8-11B), denoting which areas of the adipose
noted, it is my common practice to overbuild the single tissue are to be most aggressively treated which are to be
pedicle TRAM flap by 20%, which is done to compensate feathered as a way of blending the breast reconstruction
for the anticipated atrophy in the muscle component of a with the surrounding contours of the chest wall.
pedicled TRAM flap. Most of the time this muscle atrophy This revision procedure can almost always be carried
results in a decrease in breast volume and reasonably out comfortably under local anesthesia with deep con-
good symmetry. However, many times there exists a resid- scious sedation. I prefer to inject small volumes (30 to 50
ual excess of flap volume, composed of adipose tissue in cc per breast) of 0.25% lidocaine (Xylocaine) with epi-
the TRAM flap, which the patient would like reduced to nephrine in a concentration of 1:400,000. Small volume
promote optimal symmetry. The simplest way of reducing injection tends to minimally distort the contour of the
the adipose tissue component in the TRAM flap is by breast that is being altered. After allowing 10 minutes
lipocontouring the breast using liposuction.18 for the hemostatic effect of the epinephrine to become
FIGURE 8-11. A, Preoperative AP view of patient who requires mastectomy and will undergo left
breast reduction. The plan is for a right breast reconstruction with bipedicle TRAM flap. B, Three
months postoperative appearance with excess volume in the right breast. The plan is for liposuction vol-
ume reduction of the reconstructed breast and nipple reconstruction. (continued)
Ch08.qxd 11/28/05 9:21 PM Page 363
FIGURE 8-11. (CONTINUED) C, Result at 4 months following surgery with very satisfactory symme-
try and appearance of the reconstructed nipple.
established, liposuction is used to achieve symmetry in the right breast with a split-muscle bipedicle TRAM flap.
terms of volume and contour. The breast was reconstructed from superomedial to infero-
I have found that conventional suction-assisted liposuc- lateral to maximize superomedial fullness, which I believe is
tion with syringe aspiration works well, although machine- a hallmark of every attractive breast reconstruction. There
generated suction is also helpful. It is important to aspirate was a concomitant left breast reduction (Fig. 8-11A). Note
in the deeper layers of the TRAM flap. An aggressive the excess volume in the central and lateral aspects of the
approach is generally adopted with adipose excess in the lat- breast, which were marked preoperatively immediately
eral breast contour. However, it is important to be more con- before her flap revision (Fig. 8-11B). She underwent lipore-
servative with suction in the superior and medial aspects of duction and contouring of the TRAM flap and concomitant
the reconstructed breast. I usually leave the access incisions nipple areola reconstruction. The resulting improvement in
open and apply nonstick topical foam to the treated areas. contour and enhancement of breast symmetry are as shown
The technique entails liposuction deep within the sub- (Fig. 8-11C). The next patient underwent an immediate
stance of the reconstructed breast. I prefer to use small right breast reconstruction with a single pedicle TRAM flap
cannulae (3.0- and 3.7-mm). The adipose tissue is aspi- (Fig. 8-12A). At 8 weeks following surgery the reconstructed
rated very easily in most cases. The limited injection of breast is globally larger than the opposite left breast (Fig. 8-
local anesthesia usually allows relatively precise correc- 12B). The revision procedure included liposuction of the
tion of the abnormal contours and volume excess. The reconstructed breast mound and nipple reconstruction
improvement in contour is most often immediately appar- (Fig. 8-12C). This reoperative procedure produced excellent
ent on the operating table. The patient usually notes and symmetry between the breasts (Fig. 8-12D).
appreciates this on the first postoperative visit, which usu- This next patient underwent a delayed left breast recon-
ally occurs 5 to 7 days following surgery. struction with a TRAM flap and simultaneous right breast
Examples of volume reduction in a TRAM flap using reduction for a severe imbalance of her chest and breast
liposuction are illustrated in the following three patients. area following treatment for a left breast cancer (Fig. 8-
The first patient underwent an immediate reconstruction of 12E). This combination resulted in an asymmetry, with the
Ch08.qxd 11/28/05 9:21 PM Page 364
FIGURE 8-12. A, Preoperative plan for patient who will undergo immediate right breast reconstruction with a single pedicle TRAM
flap. The plan was to restore maximum superomedial fullness. B, Excellent shape of the breast with evidence of slight excess fullness
in the superomedial aspect of the reconstructed breast and inferomedial aspect of reconstruction at xyphoid. C-D, The plan for
revision of the TRAM flap included liposuction for volume reduction, liposuction of the medial aspect of the IM region below the
xyphoid, and nipple reconstruction. (continued)
Ch08.qxd 11/28/05 9:21 PM Page 365
FIGURE 8-12. (CONTINUED) E, Preoperative view and plan for

left breast reconstruction with single pedicle TRAM flap and
simultaneous right breast reduction. F, Six-week follow-up view
demonstrates excess volume in reconstructed left breast. G, The
plan was for lipocontouring of left breast and nipple areola recon-
struction. Liposuction of medial IM fold was also planned.
Ch08.qxd 11/28/05 9:21 PM Page 366
FIGURE 8-12. (CONTINUED) H, Two-year follow-up AP views after liposuction of 125 cc of adipose tissue and nipple reconstruc-
tion. Note excellent symmetry between reconstructed left breast and right breast. I, Oblique view of postoperative result.
TRAM flap reconstruction breast larger than the reduced It is important to taper the edges of the adipose tissue
breast (Fig. 8-12F). Figure 8-12G illustrates the use of lipo- resection with scissors. I personally prefer sharp, curved
suction to address the resulting asymmetry by reducing the Mayo scissors to sculpt flaps in all areas of the body. These
TRAM flap volume and recontouring the inferomedial scissors are especially useful for modifying the TRAM flap
aspect of the IM fold. This was done with a simultaneous adipose tissue.
nipple reconstruction. The concomitant nipple reconstruc- The following case illustrates the simultaneous excision of
tion and the liposuction produced excellent symmetry in the excess skin and removal of fat. This patient underwent delayed
AP view (Fig. 8-12H) and on the oblique view (Fig. 8-12I). reconstruction of the right breast with a stacked TRAM flap
Lipocontouring is a powerful technique for breast volume along with a simultaneous contralateral left breast reduction.
reduction following a TRAM flap. It can also produce excel- The stacked TRAM was done to facilitate positioning of the
lent adjustment of not only the breast but also adjacent con- flap tissue to achieve the necessary volume and shape in the
tours. At times, however, it may be easier or preferable to reconstructed breast mound by placing two unipedicle flaps,
directly excise the excess adipose tissue in a TRAM flap using one on top of the other (Fig. 8-13A). This resulted in a breast
scissors or a scalpel as described in the following section. that was too large for the opposite breast (Fig. 8-13B).
The patient underwent two revision operations. The first
procedure entailed the use of liposuction, during which it
VOLUME REDUCTION BY EXCISION was difficult to extract the desired amount of adipose tis-
sue. In retrospect I felt that this was due to the dermal layer
The open excision of adipose tissue is used in cases where of the more deeply positioned or buried flap, which acted
it is necessary to remove both excess skin and fat from the like a barrier to the liposuction cannula. She demonstrated
same region of the reconstructed breast. As with volume a persistent breast asymmetry with the right breast remain-
reduction by liposuction, the areas to be addressed are ing larger than the reduced left breast. The asymmetry
identified and marked preoperatively. When the contour required a second procedure that included an open resec-
change entails skin excision or a skin mobilization and tion of excess adipose tissue volume from the breast (Fig. 8-
shifting, it is a straightforward matter to directly resect 13C). Following this additional procedure the patient
the excess adipose tissue through the open wound used to demonstrated the desired improvement in breast symmetry
excise the excess or redundant skin. as seen in a 6-month follow-up photograph (Fig. 8-13D).
Ch08.qxd 11/28/05 9:21 PM Page 367
FIGURE 8-13. A, Intraoperative view showing two flaps to be rearranged for breast reconstruction. Flap b was entirely de-epithelial-
ized and placed beneath flap a. B, Eight-month postoperative view demonstrating significant asymmetry between the reconstructed right
breast, which was much larger than the left breast, which was reduced. Asymmetry was present despite attempt at lipocontouring of right
breast excess. C, Intraoperative view of open fat excision of stacked TRAM flaps and simultaneous nipple reconstruction. D, Six-month
postoperative view following the second revision procedure demonstrating excellent symmetry between reconstructed right breast and
opposite left breast.
Ch08.qxd 11/28/05 9:21 PM Page 368
ADJACENT CONTOUR ADJUSTMENT
The use of liposuction also permits the surgeon to adjust

contours adjacent to the reconstructed breast. Most often,
this is the area lateral to the breast and the area of the
inferomedial IM fold. Often the IM fold region will be
prominent due to the course of muscle pedicle to the
TRAM flap in the subcutaneous region of this area. I have
previously alluded to the importance of transecting all of
the intercostal nerves to the muscle for a unipedicle flap
reconstruction and splitting the muscle in a bipedicle
TRAM flap to minimize any prominence due to the mus-
cle itself (Chapter 7). Nevertheless, a prominence from the
muscle pedicle may often persist.
It is usually possible to reduce the prominence here by
liposuction of the subcutaneous tissue. This will thin the
adipose tissue in the area and make it seem less promi-
nent. A typical example is illustrated in Figure 8-14. This
50-year-old patient presented 9 years following a left mas-
tectomy and requested autologous breast reconstruction
(Fig. 8-14A). Because there was more tissue on the right
side of the lower abdomen than on the left she underwent
a delayed left breast reconstruction with a contralateral
(right) unipedicle TRAM flap (Fig. 8-14B). This resulted in
persistent fullness in the IM fold and over the xyphoid
region (Fig. 8-14C). The deformity was treated by liposuc-
tion of the superficial and deep adipose layers at the infer-
omedial IM fold region (Fig. 8-14D). Following the
liposuction the area of contour correction was immedi-
ately splinted with a topical foam dressing (Fig. 8-14E).
The resulting contour improvement is as shown. Note the
definition in the area of the IM fold, which can be
achieved using liposuction alone (Fig. 8-14F). In addition,
she had a nipple areola reconstruction.
CORRECTION OF THE INFERIOR MEDIAL

BULGE BY RECTUS MUSCLE EXCISION
In some cases either two muscles are used to carry the cir-
culation to the TRAM tissue or the individual unilateral
rectus muscle is very large. Either situation may cause a
bulge even after the anticipated muscle atrophy has taken
place. In such cases it may be necessary to transect the
muscle pedicle and resect it. This maneuver should not be
performed until at least 6 months have elapsed since the orig- FIGURE 8-14. A, Preoperative AP view of patient who has
inal procedure.19 In addition, the pedicle should not be undergone a left modified radical mastectomy with resection of
resected if the breast region into which the flaps are placed medial aspect of pectoralis major muscle near IM fold. Note con-
tour deficit (arrows). B, The plan for a unipedicle TRAM flap
has undergone previous radiation therapy. Radiation ther-
breast reconstruction using contralateral (right) rectus muscle
apy may diminish or eliminate the angiogenesis occurring as a flap carrier. This approach was chosen because patient had
between the recipient bed and the TRAM flap, making this more adipose tissue in the right lower abdomen than the left
pedicle transection potentially dangerous. lower abdomen. The ellipse in the right lower quadrant muscle
In summary, it is possible for the surgeon to achieve con- of the TRAM flap outline is the planned skin island replacement.
(continued)
tour improvement in the areas adjacent to the TRAM flap.
These enhancements are best and most easily performed in
a straightforward manner with suction-assisted lipectomy.
Ch08.qxd 11/28/05 9:21 PM Page 369
FIGURE 8-14. (CONTINUED) C, Early postoperative appearance demonstrating lack of definition of the IM fold in the area of the tun-
nel. This fullness is related to both the adipose tissue of the TRAM flap and the muscle of the TRAM flap. D, The plan for revision included
aggressive liposuction of adipose tissue (not muscle) in the inferior aspect of the reconstructed left breast and superiorly based modified
start for nipple. E, Application of custom tailored topical foam to splint the improved contour and appearance of nipple following the nip-
ple reconstruction. F, Four months after revision note excellent restoration of IM fold contour medially and good appearance of nipple
reconstruction and overall excellent symmetry between reconstructed left breast and contralateral right breast.
Ch08.qxd 11/28/05 9:22 PM Page 370
VOLUME INSUFFICIENCY that accurately assessing the amount of adipose tissue

ESTIMATING AVAILABLE TISSUE available for transfer is of paramount importance in
VOLUME IN LOWER ABDOMEN determining whether the volume requirements to achieve
symmetry with the opposite breast can be met in a partic-
Volume deficiencies are either the result of partial flap ular patient.
loss or, more commonly, inadequate adipose tissue vol- It is also important to simultaneously estimate skin
ume in the TRAM flap at the time of the primary breast replacement needs for every breast reconstruction. This is
reconstruction procedure. As previously emphasized, an especially true in delayed breast reconstruction when a
essential aspect of the reconstructive plan includes an careful analysis of the characteristics of the mastectomy
analysis of tissue requirements needed to produce sym- deformity is undertaken. During this analysis the surgeon
metry with the opposite breast. This includes not only a must take into account the base width of the opposite breast
study of the volume, shape, and orientation of the con- (Fig. 8-16A) and the vertical dimension of skin that can be
tralateral breast but also an assessment of the amount of removed with the TRAM flap elevation because this vertical
tissue available for transfer on the patients lower abdomi- dimension (Fig. 8-16B) of the TRAM flap determines the
nal wall. I find it helpful to estimate the size of the breast base width and to some extent the projection of the recon-
by placing my hand around the breast in a cupping structed breast when a vertical inset of the TRAM tissue is
maneuver (Fig. 8-15A) to obtain a three-dimensional performed. This dimension is the distance from the upper
appreciation for the actual breast volume paying, particu- incision to the level of the proposed lower abdominal inci-
lar attention to the volume and thickness of the adipose sion, usually measured as a vertical line adjacent to the
tissue in the upper pole of the breast. I then again use my umbilicus but it can be oriented in a slightly oblique direc-
hand to accurately assess the adipose volume on the lower tion. This dimension of the flap, which is available to recre-
abdominal wall (Fig. 8-15B). When examining the abdom- ate the base width of the reconstructed breast, can be
inal wall, the surgeon must differentiate between true adi- increased by extending this line obliquely rather than verti-
pose volume and the volume of the tissue comprising the cally (Fig. 8-16B,C) as it occurs with a vertical oblique inset
adipose layer and any lax muscle tissue. Suffice it to say and to even a greater degree with a horizontal inset.
FIGURE 8-15. A, Estimating the volume requirements for breast reconstruction in a patient by exam-
iners cupping the patients contralateral breast. B, Similar cupping maneuver to assess the volume of
adipose tissue in the lower abdomen to be used for delayed left breast reconstruction.
Ch08.qxd 11/28/05 9:22 PM Page 371
FIGURE 8-16. A, Base width dimension of contralateral breast

is important in planning all breast reconstructions including
TRAM flap. B, The base width dimension available on TRAM flap
when flap is inset vertically. This dimension is the vertical distance
from the point above the umbilicus to the lower line. C, The base
width dimension available for reconstruction can be increased
when the flap is inset in a slightly oblique direction as illustrated
by the oblique (17 cm) line drawn on the abdomen.
Ch08.qxd 11/28/05 9:22 PM Page 372
atrophy of the skin, subcutaneous adipose, and at times

Volume Insufficiency
atrophy of the pectoralis major muscle tissues following
Taking into account these three-dimensional interrela- the tissue expansion, and this internal tissue discrepancy
tionships, I believe that the most common reason for must be addressed with the TRAM flap reconstruction. An
inadequate volume in the reconstructed breast following example of this is illustrated by the following patient.
the TRAM flap operation is an insufficiency of volume in This young patient underwent a lumpectomy and had
the lower abdominal area rather than tissue loss or mus- postoperative radiation therapy at 28 years of age as treat-
cle atrophy after the flap transfer. This should be noted ment for a right breast cancer. She then developed a sec-
and discussed with the patient preoperatively. At that time ond primary in the same breast 6 years later that
plans should be formulated to either reduce the contralat- necessitated a mastectomy at age 35. Because of a paucity
eral breast or to augment the reconstructed breast by of tissue in the lower abdomen, we planned a two-stage
placing an implant beneath the TRAM flap to maximize reconstruction with a tissue expander, followed by the
postoperative breast symmetry. Alternatively, a second placement of an implant. She underwent a submuscular
flap, most commonly the ipsilateral latissimus dorsi, can breast augmentation on the opposite left side to enhance
be added beneath or adjacent to the TRAM flap. In my symmetry between the breasts (Fig. 8-17A). The breast
experience an additional flap is most often provided to reconstruction procedure was complicated by severe cap-
treat the problem of flap loss, as is discussed later in this sular contracture (Fig. 8-17B), as many implant recon-
chapter, whereas an implant is most often used in this sit- structions following antecedent radiation therapy are. The
uation to increase the volume of the reconstructed breast. patient was bothered by a significant breast asymmetry
That said, when there is a question about the adequacy of (Fig. 8-17A), with the reconstructed breast smaller than
the TRAM flap volume, it is important to realize that it is the opposite breast, and she also complained of discom-
far more common to plan for and proceed with a volume fort in the reconstructed breast due to the capsular con-
reduction of the opposite breast using a standard breast tracture.
reduction operation. When breast reduction is part of the She desired a procedure to produce better symmetry
preoperative plan, I prefer to perform the reduction of the and relieve the discomfort in the right breast. Significant
contralateral breast at the time of the primary breast skin and volume requirements for the breast reconstruc-
reconstruction procedure so that the newly reconstructed tion but limited tissue in the abdomen prompted a plan
breast and the reduced breast can evolve simultaneously for two reconstructive procedures, beginning with a split-
(i.e., it is helpful to allow gravity to act on each breast dur- muscle bipedicle TRAM flap (Fig. 8-17B). Because of sig-
ing the initial healing phase of the patients recovery). nificant tissue atrophy in the infraclavicular (Fig. 8-17B
Revisions of either breast can then be performed at the arrow) area, a vertical inset of the TRAM flap was per-
time of nipple areola reconstruction, which in my practice formed (Fig. 8-17C,D). All of the tissue in the lower
is most commonly done 3 months after the primary breast abdomen was used, and the majority was employed to
reconstruction procedure. reconstruct the significant deficit of subcutaneous adi-
If the patient does not wish to have her opposite breast pose tissue in the infraclavicular area in the superior
reduced and there is an inadequate volume of adipose tis- breast. This provided an excellent skin envelope replace-
sue in the lower abdomen, then the TRAM flap volume ment and restoration of subcutaneous adipose tissue in
can be augmented with the placement of an implant the upper aspect of the breast extending almost to the
beneath the flap. This situation is common in patients clavicle but produced the anticipated inadequate volume
who are of a thin build with limited abdominal tissue but and projection in the lower pole of the patients breast.
who may have large breasts. It is also not uncommon to The deficit of volume and projection was subsequently
see this in patients who have had previous breast recon- treated by the placement of a textured saline implant
struction performed with tissue expanders followed by beneath the TRAM flap in a second procedure (Fig. 8-
implant placement who subsequently either request or 17E). This produced good symmetry with the augmented
require autogenous conversion. Such patients often show opposite breast (Fig. 8-17F).
Ch08.qxd 11/28/05 9:22 PM Page 373
FIGURE 8-17. A, Right breast reconstruction done with tissue

expander and implant exhibits severe capsular contracture. This
is quite common after previous radiation therapy. B, Patient
requested an autogenous conversion but requires reconstruction
of extensive soft tissue deficiency extending to infraclavicular area
due to tissue attrition produced by the expander and implant. The
plan is for two-stage reconstruction beginning with a split-muscle
bipedicle TRAM. C, Flap will be inset vertically and tissue from
left lower abdomen will be folded on itself. (continued)
Ch08.qxd 11/28/05 9:22 PM Page 374
FIGURE 8-17. (CONTINUED) D, Excellent skin and soft tissue

restoration resulted from TRAM flap placement but patient
shows anticipated volume deficiency. The plan is to address this
with a textured saline implant. E, Implant placement results in
good symmetry with opposite breast. F, Good symmetry of
breasts with tapering fullness in upper poles bilaterally.
Ch08.qxd 11/28/05 9:22 PM Page 375
Another example of inadequate volume in a planned Therefore an implant was placed 4 months following the
TRAM flap is illustrated by this 50-year-old patient, who original TRAM flap procedure, and this produced a sym-
had previously undergone a lumpectomy and radiation to metric breast (Fig. 8-18C,E).
treat a left breast cancer. She had a concomitant prophy- As reflected by these two cases, it is my preference to
lactic right total mastectomy with submuscular implant place such implants at a second stage for several reasons.
reconstruction because of a strong family history of breast I believe that it is easier to gauge volume requirements
cancer15 (Fig. 8-18A). She developed a recurrent left breast and symmetry after the atrophy in the TRAM flap muscle
cancer necessitating a completion mastectomy on the left pedicle(s) has occurred (this is usually complete after the
side. Because of severe radiation injury to the skin flaps of first 3 months following surgery). In addition, the rate of
the left breast she required autogenous conversion. The capsular contracture following delayed implant place-
best option for her was a TRAM flap. Here again the pre- ment may be lower than that following immediate
operative assessment revealed that there was inadequate implant placement.20 This is because the wounds at the
adipose volume to produce symmetry with the right site of TRAM flap breast reconstruction are usually open
breast; therefore we planned a staged reconstruction with for a lengthy period, perhaps increasing the incidence of
a TRAM flap transfer, followed by the subsequent place- contamination with Staphylococcus epidermidis, which
ment of a textured saline-filled implant. The TRAM flap has been implicated by many reports in the genesis of cap-
provided the necessary skin coverage and the soft tissue sular contracture. Finally I believe that the incidence of
reconstruction required to set the stage for a good breast capsular contracture following implant placement
reconstruction (Fig. 8-18B). However, there was a volume beneath the TRAM flap tissues is slightly reduced by the
deficit in the left upper breast region (Fig. 8-18B,D). use of a textured surface implant.21
FIGURE 8-18. A, Preoperative appearance of patient with postlumpectomy defect and breast cancer recurrence. Patient has had a
right subcutaneous mastectomy and implant reconstruction. She requires a left completion mastectomy. B, Placement of an implant
beneath the TRAM flap at the second stage provides excellent symmetry with the opposite breast. (continued)
Ch08.qxd 11/28/05 9:22 PM Page 376
FIGURE 8-18. (CONTINUED) C-E, Preoperative and postoperative views demonstrating increase in volume of left breast provided by
a saline implant placed beneath TRAM flap.
Ch08.qxd 11/28/05 9:23 PM Page 377
THE USE OF IMPLANTS TO TREAT

TISSUE LOSS IN THE TRAM FLAP
Another setting in which implants can help salvage a sub-

optimal TRAM flap breast reconstruction is in the setting
of tissue loss in the TRAM flap. In such cases it is best to
allow the wounds to heal after treatment with dressing
changes or appropriate dbridement and reclosure. In
short, the patient and the surgeon must be prepared to
wait the necessary time for tissue equilibrium to be real-
ized. This usually takes 3 to 6 monthsbut it may take
longer. I like to judge this by return of suppleness and
mobility to the TRAM flap tissues (skin and adipose) at
the site of the reconstruction. It is also very important for
the surgeon to ensure that the patient is psychologically
supported during this difficult time.
When tissue equilibrium has occurred, it is appropriate
to proceed with implant replacement. This process may
entail only one additional procedure, or it may require a
two-step approach of shifting of the TRAM flap to achieve
the optimal breast shape and skin envelope configuration,
followed by placing an implant beneath the TRAM flap tis-
sues. The use of an adjustable implant [Becker or
Spectrum (Mentor Corp., Santa Barbara, Calif)] can pro-
vide additional flexibility in this setting.
The following patient, who underwent a right mastec-
tomy and had immediate breast reconstruction with
a TRAM flap that was complicated by partial flap loss,
illustrates such a two-step salvage plan. She sustained
skin and fat loss at the medial flap inset, which necessi-
tated surgical dbridement on the 14th postoperative day
(Fig. 8-19A). This was done before an open wound had
become apparent. The dbridement resulted in a volume
deficit of both skin and adipose tissue (flap tissue) in
the medial aspect of the reconstruction that required
elevation and shifting of the TRAM flap medially (Fig. 8-
19B) with closure of the lateral wound employing a V-
Y concept (Fig. 8-19C). The V to Y closure method22 is
an important technique used in many situations involv-
ing tissue loss in the breast. It is critical to restore the
medial contour and also to replace as much of the soft
tissue lost in this medial area of the reconstructed
breast as possible before placing an implant beneath the
flap to complete the volume replacement after wound
maturation.
This case illustrates the point that an entire pedicled
TRAM flap can be elevated with its muscle pedicle and FIGURE 8-19. A, Appearance of right breast reconstruction on
moved on the chest wall after the initial surgery (Fig. 8- postoperative day 14 with fat necrosis and incipient open wound
19D). The surgeon must take care to recognize and elevate in the inferomedial area of the TRAM flap reconstruction. The
TRAM flap is elevated off the chest wall with its pedicle intact
the nutrient pedicle with the TRAM flap skin and adipose and is translocated medially to fill the defect in the parasternal
tissue. Another case at the end of this chapter illustrates a area. B, The wound is closed in a V to Y fashion. (continued)
similar technique involving total mobilization of a pedi-
cled TRAM flap at the recipient area of the breast. The
patients wounds healed but she was left with a breast
Ch08.qxd 11/28/05 9:23 PM Page 378
asymmetry due to a volume disparity and ptosis of the con-

tralateral breast. The plan for reoperative breast surgery in
this case included the placement of an implant beneath the
TRAM flap and a contralateral vertical mastopexy to uplift
and narrow the base width of the contralateral left breast
(Fig. 8-19D). This entailed the placement of a 280-cc tex-
tured round saline implant beneath the tissues of the
TRAM flap and a superior pedicle vertical mastopexy on
the opposite side. Postoperatively there was improved
symmetry with good volume approximation; however, she
was left with a slight contour deficit in the lateral aspect of
the right breast, which was accentuated by a mild (Baker
II) capsular contracture (Fig. 8-19D).
In summary, volume deficiencies following TRAM flap
reconstruction are either anticipated or the result of par-
tial flap losses. In either circumstance, the placement of a
breast implant can often provide a nice improvement for
most asymmetries related to inadequate TRAM flap vol-
ume. I prefer to place these at a secondary setting. These
implants can be either saline or silicone, round or shaped,
and textured or smooth, depending on the desired contour
restoration and surgeon preference.
STAGED RECONSTRUCTION WITH

TISSUE EXPANDER AND SUBSEQUENT
IMPLANT FOR TRAM SALVAGE
I have also employed the technique of staged secondary

reconstruction of the suboptimal TRAM flap using place-
ment of a tissue expander at a first stage to expand the
skin and soft tissue envelope before placing an implant at
a second stage. This permits expansion of the skin enve-
lope to address skin deficits in any portion of the previous
suboptimal TRAM flap breast reconstruction and allows
the expander to mould and reshape the skin envelope and
custom make a space into which to place a breast implant.
This strategy was used in this patient (Fig 8-20), who pre-
sented after medial and lateral tissue loss in a single pedi-
cle TRAM flap after an immediate reconstruction of the
right breast. At the time of her original procedure she had
undergone a mastopexy of the left breast. An analysis of
the resulting asymmetry revealed that there was a need for
an increase in both the skin envelope and breast volume
on the side of the TRAM flap reconstruction (Fig. 8-20A,B).
The patient did not wish to undergo a latissimus dorsi flap
as a means of salvaging her reconstruction. There was a
deficit of breast volume superiorly, a poorly positioned
skin paddle, and complete absence of IM fold definition.
For that reason we planned to reposition the TRAM flap
superiorly to address the superomedial volume and con-
FIGURE 8-19. (CONTINUED) C, Outline of the plan to treat tour deficit and to place a tissue expander to achieve the
resulting breast asymmetry consists of placing a saline implant
under the TRAM flap and performing a vertical mastopexy on desired envelope dimensions and shape (Fig. 8-20C). The
the left side. D, The postoperative appearance demonstrates sat- TRAM flap was repositioned in a more superior location
isfactory symmetry in AP view. (Fig. 8-20D) and a tissue expander was placed. This was a
Ch08.qxd 11/28/05 9:23 PM Page 379
textured shaped tissue expander with a base width of 14 but also allowed the implant to produce the necessary
cm and was placed beneath the adipose tissue of the volume increase in the upper pole of the reconstructed
TRAM flap. The preliminary tissue expansion was success- breast seen on both the frontal (Fig. 8-20H) and oblique
ful in achieving a larger skin envelope dimension and set (Fig. 8-20I) views preoperatively and at 10 months fol-
the stage for increasing the volume of the reconstruction lowing surgery.
by placing an implant (Fig. 8-20E).
Following the tissue expansion there was a discrep-
ancy in the upper breast pole fullness due to the lower THE AESTHETIC UNIT OF THE
IM fold on the right side (Fig. 8-20F). At a second stage BREASTTHE IMPORTANCE OF THE
the slight discrepancy in IM fold levels was corrected as SKIN PADDLE AND SKIN SCARS
planned with the preoperative skin markings (Fig. 8-20F)
with an internal reconstruction of a new IM fold at a In my opinion the hallmarks of a good breast reconstruc-
more superior level using 3-0 Prolene sutures (Ethicon, tion are a well-shaped breast mound, symmetry with the
Inc., Somerville, NJ; Fig. 8-20G). The simultaneous contralateral breast, and a reconstructed nipple areolar
placement of a textured shaped saline implant restored complex (NAC) that is positioned and pigmented to facili-
excellent symmetry between the reconstructed right tate breast symmetry. It is important to conceal as many
breast and the opposite left breast, which had under- of the scars on the reconstructed breast as possible, i.e., to
gone a mastopexy. This internal suturing of the tissue place them in locations where there is a normal change in
expander capsule not only raised the level of the IM fold contour (e.g., the IM fold) or anatomic feature (e.g., the
FIGURE 8-20. A, Breast asymmetry in patient who underwent immediate reconstruction of a right mastectomy with a pedicled
TRAM flap, along with a contralateral left mastopexy. The TRAM flap was complicated by patient flap loss. B, Lateral view of recon-
structed right breast shows inadequate upper pole fullness.
Ch08.qxd 11/28/05 9:23 PM Page 380
FIGURE 8-20. (CONTINUED) C, The reconstructive plan includes superior repositioning of TRAM flap remnant, elevation of IM
fold, and placement of a tissue expander of appropriate base width. D, The TRAM flap is mobilized on its pedicle and repositioned
superiorly. E, Clinical appearance after tissue expansion is complete showing increased skin envelope dimension and larger breast vol-
ume. F, Following the expansion there is an asymmetry of IM fold levels and a persistent upper pole volume deficiency. The plan is to
reconstruct the IM fold at a more superior location and to place a textured saline implant. (continued)
Ch08.qxd 11/28/05 9:24 PM Page 381
FIGURE 8-20. (CONTINUED) G, Internal capsule suture

placement using 3-0 Prolene sutures seen at surgery. This is an
important maneuver to raise the IM fold and to alter internal
volume dimensions of periprosthetic capsular space.
H, Excellent restoration of symmetry by combination of maneu-
vers and placement of saline implant seen in frontal view.
Ch08.qxd 11/28/05 9:24 PM Page 382
periareolar area) such that the eye will see and the brain
will perceive and register the reconstructed breast as nor-
mal (Fig. 8-21A,B). In the setting of immediate breast
reconstruction with a TRAM flap this is best achieved by
performing an ultimate skin-sparing mastectomy (Fig. 8-
21A) and then using the TRAM flap to replace the resected
breast tissue and skin deficit resulting from the resection
of the NAC (Fig. 8-21B). This blending of shape, skin pad-
dle appearance, and optimal scar placement produces the
best possible breast aesthetics. Whenever possible the
goal should be to match the aesthetic units of the recon-
structed breast (volume, contour, curves, and scar place-
ment) to the contralateral breast (Fig. 8-21C). This
requires careful preoperative planning in the setting of
both immediate and delayed breast reconstruction.
In general, the TRAM flap inset scars should be kept as
low as possible on the anterior breast skin, and they
should not cut across or transgress contours. Sometimes,
as in this case (Fig. 8-21D), suboptimal scar placement is
necessary due to the oncologic treatment of the breast
cancer (e.g., a large or superiorly located skin sacrifice or
tumor resection across the IM fold); however, excellent
breast aesthetics can be created if there is correct volume
of the TRAM flap, optimal distribution of that volume,
and overall contour of the flap (Fig. 8-21D).
Altering the shape of the breast and position of scars is
commonly done in the setting of revisional breast surgery.
This is especially true in TRAM flap revision and is illus-
trated in the following case. This patient underwent a
delayed reconstruction of the right breast (Fig. 8-22A)
using a unipedicle TRAM flap based on the contralateral
rectus muscle pedicle (Fig. 8-22A). The original recon-
struction procedure resulted in a breast that was larger
than the contralateral breast due to excess volume. In addi-
tion, the scar from the umbilical cutout on the TRAM flap
mound was positioned in the superomedial portion of the
replacement skin paddle on the TRAM flap (Fig. 8-22B).
This scar detracted from the overall aesthetic appearance
of the reconstructed breast. As previously outlined, the
aesthetic unit concepts of TRAM flap reconstruction indi-
cate that the surgical plan should, whenever possible,
exclude scars that detract from what the eye expects to see
as the primary breast mound. Therefore in this case the
revision procedure included not only lipocontouring of the
breast but also the superomedial translocation of the
entire flap (Fig. 8-22C), which permitted the excision of the
umbilical cutout scar. A simultaneous nipple reconstruc-
tion completed the reoperative procedure and produced a
better breast appearance (Fig. 8-22D).
FIGURE 8-20. (CONTINUED) I, Appearance of breasts on

oblique view reveals good symmetry. SKIN ENVELOPE DISCREPANCY
Skin envelope asymmetry is a common reason for postop-

erative breast asymmetry following TRAM flap breast
Ch08.qxd 11/28/05 9:24 PM Page 383
FIGURE 8-21. A, Preoperative appearance of patient who underwent immediate left breast recon-
struction with a TRAM flap done in conjunction with ultimate skin-sparing mastectomy.
B, Postoperative view of left breast reconstruction with periareolar incisions only. C, Subsequent nipple
reconstruction and intradermal tattoo complete excellent aesthetic reconstruction of left breast.
D, Lateral view of the same patient.
Ch08.qxd 11/28/05 9:24 PM Page 384
reconstruction. Most often the error is skin paddle overre- lower abdominal skin before flap transfer because its
placement. This problem is much more common in position is related to the anticipated flap inset orientation
delayed breast reconstruction than it is in immediate that results from the preoperative analysis of the opposite
breast reconstruction. In the former setting the plastic breast, as illustrated in Chapter 7.
surgeon should attempt to be precise by quantitating the In the setting of immediate breast reconstruction the
skin envelope disparity. This can be done by using a tape area of skin to be excised during the mastectomy can be
to measure the surface dimension from the midclavicular outlined on a sterile piece of telfa gauze, creating a tem-
point to the IM fold on the side of the normal or unaf- plate (Fig. 8-24) that the surgeon can use to achieve exact
fected breast and then comparing this measurement with skin replacement at the time of flap transfer. This is effec-
a corresponding measurement on the side of the mastec- tive when there is no discrepancy between the skin
tomy, as outlined in Chapter 7 (see Fig. 7-9A,B). This envelopes preoperatively. Nevertheless, disparities in the
enables the surgeon to make a relatively accurate estimate skin envelope dimensions are often present following the
of how much skin must be provided by the TRAM flap. In initial TRAM flap procedure and are corrected at the time
addition, the skin paddle outline can be positioned on the of TRAM flap revision. This situation is illustrated by this
FIGURE 8-22. Right postmastectomy defect in patient who requests autogenous tissue reconstruc-
tion. A, Preoperative plan outlined on breast and abdomen will use contralateral rectus abdominis mus-
cle. B, Appearance of right breast reconstruction following initial surgery. Note excess volume and
position of umbilical scar in superomedial aspect of breast. C, The operative plan for the revision of the
reconstruction included liposuction of the flap and excision of the skin in the superomedial position of
the flap including the umbilical cutout, which permitted superomedial transposition of the flap (arrow).
D, The postoperative appearance demonstrates improved symmetry and better overall aesthetics when
prerevision appearance is compared to postrevision appearance. (continued)
Ch08.qxd 11/28/05 9:24 PM Page 385

Ch08.qxd 11/28/05 9:24 PM Page 386
patient (Fig. 8-23), who is noted to have and asymmetry this patient (Fig. 8-25), who was placed on tamoxifen post-
following immediate breast reconstruction. The most obvi- operatively and gained 20 lb of body weight after her mas-
ous asymmetry is that of skin envelope mismatch. The goal tectomy with a single pedicle TRAM flap. The patients
should be to correct this asymmetry. In some cases the original presentation (Fig. 8-25A) and immediate postop-
problem is addressed in a straightforward manner by erative appearance after an ultimate skin-sparing mastec-
resecting the skin paddle and allowing the patients native tomy and TRAM flap reconstruction (Fig. 8-25B) are
breast skin to cover the reconstructed breast. In other cases illustrated. With the weight gain her TRAM flap breast
decreasing the size of the skin paddle and/or moving it to reconstruction became much larger than her opposite
the central position of the breast where it better simulates breast (Fig. 8-25C). To improve symmetry the plan was for
the appearance of the NAC is the appropriate maneuver. an open excision of breast tissue and a skin envelope
resection using an inverted T incisional pattern (Fig. 8-
25D). This combined skin envelope and TRAM flap vol-
SKIN PADDLE REDUCTION ume reduction procedure produced a very satisfactory
symmetry in one operation.
This patient (Fig. 8-24) had previously undergone an
immediate breast reconstruction using a unipedicle
TRAM flap. At the time of surgery the skin paddle was INFRAMAMMARY FOLD ASYMMETRIES
errantly placed in the area of the skin resection that was
performed as part of the mastectomy. Despite a previous The IM fold is perhaps the most important landmark in
revision of the reconstruction she exhibited a suboptimal determining breast aesthetics. This is clearly true in the
aesthetic result due to the abnormal and eye-catching setting of TRAM flap breast reconstruction. Therefore the
position of the skin paddle (Fig. 8-24AD). She subse- reconstructive surgeon should communicate the impor-
quently had a revision procedure, during which the skin tance of this structure to the general surgeon performing
paddle was resected. Along with this she had an internal the mastectomy, and every attempt must be made to pre-
reconstruction of the IM fold and liposuction of the entire serve the IM fold in the setting of immediate breast recon-
breast flap. This gave a more natural appearance to the struction. Discrepancies in the height of the IM fold are
reconstructed breast and produced better breast symme- immediately apparent in most situations and should be
try (Fig. 8-24D). corrected with the revision procedure. Such correction
can have a profound effect on the TRAM flap volume dis-
tribution, upper pole fullness, shape, and projection. This
SKIN ENVELOPE AND VOLUME underscores the importance of the IM fold and its utility
ADJUSTMENT BY EXCISION in revisional breast surgery. It is a powerful structure in
determining breast shape in all types of breast surgery.
As stated earlier in this chapter, I usually overbuild a pedi-
cle TRAM flap by 20%, anticipating a decrease in volume
as the muscle pedicle atrophies. This overreplacement INFRAMAMMARY FOLD TOO HIGH
usually produces a flap that has slightly more volume than
the opposite breast at 3 months following surgery. At In the situation where the IM fold is located more superi-
times this overreplacement is too great and causes a orly than that of the opposite breast, the problem can be
stretching of the skin envelope, producing an asymmetry addressed in a straightforward manner. If this condition
of volume and skin envelope. Such a case is illustrated by is present preoperatively it must be recognized so that it
can be corrected at the time of the revisional surgery
(Fig. 8-26AC).
This is illustrated in this patient (Fig. 8-27), who had
undergone a previous lumpectomy with postoperative
radiation therapy for a left breast cancer. She developed a
recurrence of her cancer that required a mastectomy.
Preoperatively the evaluation revealed an obvious contour
abnormality, skin deficiency, scar deformity, and volume
discrepancy (Fig. 8-27A). More subtle was the elevation of
the IM fold of the left breast. She required a completion
mastectomy for a recurrence and requested breast recon-
struction with a TRAM flap. Postoperatively the breast
FIGURE 8-23. Template of proposed skin excision made on symmetry was markedly enhanced by replacement of the
telfa gauze. skin deficit and necessary tissue volume from the TRAM
Ch08.qxd 11/28/05 9:24 PM Page 387
FIGURE 8-24. A, Suboptimal appearance of left breast following previous immediate breast recon-
struction with a TRAM flap. Note the errantly placed skin paddle, which is high on the breast.
B, Elements of asymmetry include skin paddle overreplacement, excess flap volume, and asymmetry of
the nipple heights and IM fold level as outlined in AP view of revision plan. C, The operative plan for
revision of the reconstruction is outlined on the skin in oblique view. It includes excision of the skin
paddle, liposuction to decrease flap adipose tissue volume, and superior repositioning of the IM fold.
D, The appearance of the breast is improved, as is the symmetry between the breasts.
Ch08.qxd 11/28/05 9:24 PM Page 388
FIGURE 8-25. A, Three-month postoperative appearance of patient who underwent skin-sparing

mastectomy and single muscle TRAM flap reconstruction. B, After 1 year and a 20-lb weight gain there
is breast asymmetry with a significant excess of skin and TRAM flap volume. C, Revision procedure
entails the excision of excess skin using an inverted T incisional pattern, resection of excess TRAM vol-
ume, and medial transposition of the reconstructed nipple. Patient will also undergo liposuction of the
lower abdominal flap and dog ear excision. D, This combination of skin resection and open excision of
TRAM tissue results in much improved breast symmetry.
Ch08.qxd 11/28/05 9:24 PM Page 389
flap and careful lowering of the IM fold so that it was sym- exposing the area of the fascia into which the sutures will
metric with the opposite breast (Fig. 8-27B). be placed. The 3-0 Prolene sutures are then placed across
Treatment of the IM fold that is too high can be accom- the length of the IM fold (Fig. 8-28E) using a headlight or
plished by incremental lowering of the fold. If this is done at lighted retractor to illuminate the wound. Several sutures
the time of TRAM flap reconstruction the lower abdominal are placed and the patient is then placed in a sitting posi-
donor wound must be closed first. In addition, the patient tion at 90 degrees on the operating table to check the ade-
should be sitting up at 90 degrees on the operating table. quacy of the correction (Fig. 8-28F). Additional elevation
Similarly, when the IM fold is being repositioned during a of the fold can be achieved by placing a more superior row
revision surgery the patient must be in the upright position, of sutures if necessary. It is important not to dimple the
or sitting at 90 degrees on the operating table. Careful incre- skin of the inferior breast flap because the resulting inden-
mental dissection is then carried out to lower the fold. I find tations are often visible and unattractive, and they are
that this is best done with the electrocautery device. likely to persist for a considerable length of time.
The maneuver of raising the fold not only restores sym-
metry to this important part of the anatomy of the breast
INFRAMAMMARY FOLD TOO LOW but can also increase the volume and projection of the
TRAM flap tissue (Fig. 8-28G). This next patient (Fig. 8-
Most often if there is a discrepancy in the level of the IM 29AD) illustrates a markedly asymmetric IM fold posi-
folds, the fold of the reconstructed breast is positioned tion following an immediate breast reconstruction with a
lower than the opposite breast. It is best to recognize such single pedicle TRAM flap that required correction. The
a problem preoperatively (Fig. 8-26AC) as it can have a patient required a mastectomy for a recurrence following
profound effect on the shape, volume, and projection of a previous lumpectomy and radiation to the breast. She
the reconstructed breast. More commonly an IM fold that requested a TRAM flap as the method of her breast recon-
is too low is recognized postoperatively. This occurs struction. The IM fold asymmetry problem was the result
because the IM fold is transgressed during the mastectomy of disrupting a large segment of the fold (Fig. 8-29B) at the
or because the muscle of a pedicle flap often settles slightly time of an immediate breast reconstruction because the
in the tunnel. Correcting an IM fold that is too low is more rectus muscle was very wide (Fig. 8-29C). The IM fold was
difficult than correcting an IM fold that is too high; how- reconstructed at a more superior position with placement
ever, a very nice correction is often easily obtainable (Fig of 3-0 Prolene sutures internally (Fig. 8-28C), as illus-
828AD). The surgical correction entails multiple suture trated in the previous case. The internal reconstruction of
fixation of the inferior skin flap to the muscle fascia of the the IM fold and corresponding folding of the lower pole of
chest wall (Fig. 8-28E). I prefer to use a permanent suture the TRAM increases the projection (Fig. 8-28D) of the
and find that a monofilament suture (3-0 Prolene) on a TRAM flap and restores symmetry to the breasts and IM
large needle works well. This technique is the same one folds (Fig. 8-29D).
used to correct fold discrepancies noted following breast
reconstruction with implants or breast augmentation.
This technique was used in this patient, who presented TREATMENT OF CONTOUR DEFICITS
with poor definition of the IM fold in her reconstructed FOLLOWING TRAM FLAP
breast following immediate reconstruction with a uni- RECONSTRUCTIONMALPOSITIONED
pedicle ipsilateral TRAM flap (Fig. 8-28A). The patient is VOLUME
analyzed in the standing position or sitting up at 90
degrees. I then use my fingers to simulate the correction Not uncommonly a contour asymmetry will be noted due
by displacing the fold upward and pressing the tissues to TRAM flap volume that is in the wrong place. This is
against the chest wall (Fig. 8-28B). After releasing the most often noted by inadequate volume in the superior or
pressure I place circles on the skin where the sutures on superomedial aspect of the breast. In Chapter 7 I com-
the inside will be placed (Fig. 8-28C) to achieve the same mented on the need to reconstruct the superomedial full-
correction and reconstruction of the IM fold. The patient ness of the breast as the first step when insetting the
is then brought to surgery for the correction. It is impor- TRAM flap. However, often there will be a deficiency of
tant to realize that the problem is not excess skin and that contour in this area that needs to be addressed. This
all of the skin in the IM region will be needed. The inferior deficit may be due to inferior settling of the flap, a TRAM
breast flap is elevated from the underlying TRAM flap flap with inadequate superior fill volume, or flap volume
beyond the circles that have been marked on the skin. inset in a horizontal orientation to provide increased pro-
Next, the lower margin of the TRAM flap is identified and jection that cannot adequately fill the upper breast pole.
mobilized in a superior direction off the chest wall fascia. The first two circumstances are best addressed by repo-
This will allow the superior positioning of the flap and sitioning the TRAM flap superiorly. This can be accom-
fold the lower TRAM tissue under the flap (Fig. 8-28D), plished by advancing the flap in a superior direction by
Ch08.qxd 11/28/05 9:25 PM Page 390
de-epithelealizing the superior skin edge of the flap and sue can be folded underneath the central portion of the
advancing it in a cephalic direction beneath the superior TRAM reconstruction (Fig. 8-29D) to increase the projec-
mastectomy flap, as illustrated previously (see Fig. 8-22D). tion. Internal reconstruction of the IM fold with sutures
When there is inadequate volume or projection in the cen- (see Fig. 8-28E) provides a solid foundation for maintain-
tral portion of the TRAM flap and excess TRAM flap tissue ing the TRAM flap in its corrected position. As previously
in the lower pole, tissue can be used to increase the projec- stated, changing the level of the IM fold with internal
tion and improve the contour of the TRAM flap recon- sutures is a powerful breast reshaping tool. This maneuver
struction. The technique involves mobilizing the TRAM significantly affects the internal dimensions of the space in
tissue from the surrounding tissues in the lower pole which the breast volume is contained and alters the distri-
(Fig. 8-28D) and moving it in a superior direction. This tis- bution of the TRAM flap fat, thus influencing shape, pro-
FIGURE 8-26. AC Patient demonstrates an IM fold asymme-

try with fold on the left situated at a higher level than the fold on
the right. In this case it was due to mild scoliosis. Such asymme-
tries should be recognized preoperatively.
Ch08.qxd 11/28/05 9:25 PM Page 391
FIGURE 8-27. A, Postoperative appearance of breast in patient treated with lumpectomy and radia-
tion. Note volume deficiency, nipple dislocation, and IM fold asymmetry. B, Because of local recurrence
the patient underwent a complete mastectomy and TRAM flap reconstruction with lowering of the IM
fold. Preoperative deformity and its correction by revision surgery are noted in side-by-side comparison
views. (continued)
Ch08.qxd 11/28/05 9:25 PM Page 392
FIGURE 8-28. A, IM fold asymmetry with poor definition and

inferior flap malposition following immediate left breast recon-
struction with a unipedicle, ipsilateral rectus TRAM flap. B, The
examiner simulates correction by gentle digital pressure placed
against the skin in the lower breast pole, displacing the TRAM
flap superiorly. C, Marks are made on the skin in areas where the
fold will be recreated using internal suturing. (continued)
Ch08.qxd 11/28/05 9:25 PM Page 393
Internal IMF reconstruction
3-0 PDS
Pectoralis fascia
Ribs
IMF
FIGURE 8-28. (CONTINUED) D, The lower pole of the TRAM flap is dissected free on its superior,
inferior, and posterior surfaces and folded underneath the middle pole to increase projection. The supe-
rior repositioning and reconstruction of the fold is done with internal sutures. E, Technique of suture
placement for internal reconstruction of IM fold. F, The correction achieved at surgery. G,
Postoperative correction illustrating symmetric IM folds. This case illustrates the powerful effect the IM
fold has on the shape and projection of the breast.
Ch08.qxd 11/28/05 9:25 PM Page 394
a a
Deepithelized
TRAM fat flap
tucked under
skin
b b
TRAM skin for
new breast
c
c TRAM flap fat
tucked under
FIGURE 8-29. A, Preoperative appearance of the breast in a patient who requires a mastectomy to
treat a breast cancer recurrence following lumpectomy and radiation therapy. B, Immediate right
breast reconstruction with unipedicle contralateral rectus muscle TRAM has resulted in a marked
asymmetry of the IM folds. (continued)
Ch08.qxd 11/28/05 9:25 PM Page 395
jection, and upper pole fullness of the breast. This influ-

ence of the IM fold is true in both aesthetic and reconstruc-
tive breast surgery. It has a profound effect on both
implant cases and TRAM flap breast reconstructions.
INCREASING FLAP PROJECTION

FOLLOWING TRAM FLAP
RECONSTRUCTION
Increasing the projection of the breast following TRAM

flap reconstruction can be done by placing an implant
beneath the flap (see Figs. 8-17 and 8-18), by elevating the
flap from the underlying chest wall and folding the infe-
rior portion underneath the central portion of the flap as
discussed (Fig. 8-27D and 8-29D), or by bringing the
medial and lateral pillars of the flap together by excising
a central segment as a means of conifying the recon-
structed breast. This is an excellent procedure when a
contralateral breast reduction has been performed.
Making more of a cone out of the breast tissue has long
been used as a means of increasing projection during
mammoplasty, and it is being used more and more as
method of increasing projection following TRAM flap
reconstruction. It is also very easy to reconstruct the
nipple at the time of such a procedure by using tissue on
the edge of either the medial or lateral skin flaps (on
either side of the vertical incision) that would otherwise
be discarded as demonstrated previously (see Fig. 8-
10D,E) and performing a wraparound or fishtail flap or
modified star flap. This technique was used in this
patient who underwent an immediate right breast recon-
struction with an inverted T skin excisional pattern and a
simultaneous left breast reduction also with an inverted T
skin excisional pattern (see Fig. 8-10A). To increase the
projection of the TRAM flap reconstruction she under-
went elevation of medial and lateral skin flaps. The tissue
at the edge of the medial flap was curled on itself in the
form of a fishtail flap (see Fig. 8-10D). Closure of the ver-
tical scar allowed increased projection and improved the
overall breast symmetry (see Fig. 8-10E).
The principle of conifying the breast can be applied to
the TRAM flap breast reconstruction in many settings. It
decreases base width and increases projection and can be
used to elevate nipple position and to decrease the vol-
ume of the breast. This is illustrated in the previously
described patient (see Fig. 8-25A), who developed pro-
gressive ptosis of her reconstructed breast with weight
gain such that it became larger than the opposite breast
(see Fig. 8-25B). There was an associated disparity in the
FIGURE 8-29. (CONTINUED) C, Patient has large rectus mus- heights of the nipples. I felt that the best way to enhance
cle outlined along with planned correction. D, Internal suture symmetry was to resect skin and breast tissue in both a
correction of the IM fold to be accomplished with Prolene
sutures. E-F, Appearance of IM fold correction following supe- vertical and a horizontal dimension (see Fig. 8-25C). This
rior flap mobilization, subtotal rectus muscle transection, and permitted superior relocation of the NAC and much bet-
internal suture technique. ter global symmetry (see Fig. 8-25D).
Ch08.qxd 11/28/05 9:25 PM Page 396
INCREASING PROJECTION OF A TRAM in breast shape, projection, and IM fold position, with an
FLAP BY VERTICAL MAMMOPLASTY improvement in overall breast symmetry (Fig. 8-31E).
TECHNIQUE
In three patients I have actually used the vertical mammo- AUGMENTING TRAM FLAP VOLUME
plasty technique23,24 to narrow the base width of the WITH ADJACENT TISSUE
TRAM flap breast reconstruction and to increase the pro-
jection. This technique can be helpful, but it must be Another option for replacing volume deficits with local
borne in mind that the TRAM flap adipose tissue is not tissue is redistributing the TRAM flap volume or recruit-
endowed with the same abundant vascularity as normal ing adipose tissue from adjacent contour, such as the
breast parenchyma. Therefore good judgment must be axilla. Not uncommonly there is excess tissue lateral to
exercised when constructing and folding the created adi- the beast reconstruction in the form of a dog ear from the
pose flap within the existing TRAM flap. This predomi- original mastectomy flaps (Fig. 8-32E). This tissue can be
nantly means to leave the base of the flap (oriented mobilized (Fig. 8-32F) on a subcutaneous pedicle and
superiorly) of sufficient thickness to ensure adequate vas- transferred a short distance to treat a laterally positioned
cularity of the internal adipose flap. contour deficit. I learned this technique from John
The application of the vertical mammoplasty technique Bostwick,25 and it has helped in several cases over the
in the setting of a TRAM flap breast reconstruction is years. This is illustrated in the following case (Fig. 8-
illustrated by this next patient (Fig. 8-30AE), who had 32AG), in which mobilizing the lower pole and folding
originally undergone a lumpectomy and radiation for a this tissue under the central portion of the TRAM flap,
right breast cancer. She developed a recurrence that was along with reconstructing the IM fold, was combined with
treated by a right mastectomy. Because of tissue require- mobilizing and transferring the excess axillary fat or the
ments to match her opposite breast, the right breast was dog ear from the mastectomy procedure to correct a sig-
reconstructed with a split-muscle bipedicle TRAM flap. nificant asymmetry without the use of a synthetic
This produced an appearance of bilateral breast ptosis implant.
and decreased projection (Fig. 8-30A). The plan was for a
bilateral vertical mammoplasty and right nipple recon-
struction (Fig. 8-30B). At surgery the mastopexy was per- COMBINING MULTIPLE
formed on the left breast first. Next a similar procedure RECONSTRUCTIVE MODALITIES IN
was performed on the TRAM flap with a simultaneous REVISING THE TRULY SUBOPTIMAL
nipple reconstruction (Fig. 8-30C). This produced a better RESULT
appearance on the AP (Fig. 8-30D) and oblique (Fig.
8-30E) views. This case (Fig. 8-32AG) demonstrates the additive power
The application of this technique in the setting of a of a number of the previously discussed techniques. At
TRAM flap breast reconstruction is further illustrated by first glance it would appear that an implant will be neces-
this next patient (Fig. 8-31AE), who had originally sary for volume symmetry. However, the combination of
undergone a left lumpectomy and radiation for breast mobilizing the flap and folding it beneath itself (Fig.
cancer. She developed a recurrence that was treated by a 8-28D), along with reconstructing the IM fold through an
left mastectomy without a breast reconstruction (Fig. 8- external approach (Fig. 8-32C) (in most cases an internal
31A). She presented to me with the diagnosis of a multi- approach would be as powerful in reconstructing the
focal right breast cancer, which also required a reconstructed breast, i.e., as in Fig. 8-28E) and recruiting
mastectomy. She requested a bilateral breast reconstruc- and transpositioning the lateral dog ear (Fig. 8-32E, F),
tion with TRAM flaps at the time of her right mastec- dramatically changed the appearance of this TRAM
tomy. The procedure entailed the use of bilateral reconstruction from the standpoint of volume, shape, and
superiorly based unipedicle TRAM flap with more skin symmetry with the opposite breast (Fig. 8-32G).
replacement on the right side than on the left (Fig. 8-
31B). The postoperative appearance revealed a discrep-
ancy in the base widths of the reconstructed breasts,
TREATING BREAST CONTOUR
with that on the right larger than that on the left (Fig. 8-
DEFICITS WITH REDISTRIBUTION
31C). There was also less overall projection of the right
OF TRAM FLAP VOLUME
breast than that seen on the left and a slight discrepancy
of the IM folds (Fig. 8-31C).
The Internal Flip-Flop Fat Flap
To address this asymmetry we performed a vertical
mammoplasty procedure on the right TRAM flap (Fig. Most often there is not sufficient volume within the TRAM
8-31D). This resulted in a correction of these differences flap itself to allow the creation of internal flaps within the
Ch08.qxd 11/28/05 9:25 PM Page 397
FIGURE 8-30. A, Postoperative appearance on an AP view following mastectomy for locally recurrent
right breast cancer that required mastectomy and was reconstructed with a split-muscle bipedicle
TRAM flap. B, Note wider base width of TRAM flap reconstruction. The plan for revision includes nip-
ple reconstruction and lipocontouring of inferomedial flap area. C, At surgery we performed a vertical
mastopexy on the TRAM flap to narrow base width and increase projection. D, Postoperatively she
demonstrates better symmetry on the AP view.
Ch08.qxd 11/28/05 9:26 PM Page 398
FIGURE 8-31. A, Preoperative appearance of patient who is s/p a left modified radical mastectomy
with postoperative radiation therapy for stage II breast cancer. She requires a right mastectomy for a
new right breast cancer and will have a delayed left breast reconstruction with an immediate right
breast reconstruction. B, The preoperative reconstructive plan is outlined for bilateral, superiorly
based, single pedicle TRAM flap reconstructions. C, The postoperative appearance at 3 months demon-
strates an asymmetry of the breasts. The right breast is wider, with more lower pole fullness and with an
upper pole volume deficiency. D, Preoperative plans for revising the right TRAM flap reconstruction
using a vertical mammoplasty technique. This vascularity of the TRAM flap will be maintained from its
superior substance. (continued)
Ch08.qxd 11/28/05 9:26 PM Page 399
unfurled and transposed. The planning for such a flap

transposition is diagrammed in Figure 8-33AC.
The patient presented with a deficit in the volume and
indentation of contour in the superomedial aspect of her
reconstructed breast (Fig. 8-34A). Preoperatively, the IM
fold of the reconstructed right breast was higher than that
of the left, so superior transposition of the entire flap was
not an option. Therefore the operative plan included
reconstruction of the defect in the superomedial breast
by the internal flip-flop fat flap and a contralateral
mastopexy (Fig. 8-34B).
The superior inset incision was opened and the supe-
rior breast flap was elevated to the upper limit of the con-
tour deficit in the superomedial area of the reconstructed
breast beyond the limits of the TRAM flap. An incision in
the superior edge of TRAM flap 2 cm below the superficial
surface and a flap of the TRAM flaps adipose tissue of uni-
form thickness was made parallel to the superficial sur-
face of the flap, dissecting in an inferior direction. Next, a
second flap of adipose tissue based on the inferior and
deep tissue circulation of the TRAM flap was elevated in
the opposite direction by superior dissection such that it
could be turned over (Fig. 8-33C, 8-34C) to fill the volume
deficit in the superomedial aspect of the reconstructed
breast (Fig. 8-34D). The flap was tacked into position with
FIGURE 8-31. (CONTINUED) E, The postoperative results at several PDS sutures (Ethicon, Inc., Somerville, NJ; Fig.
1 year demonstrate more upper pole fullness, a narrower base
width of the breast, and much improved overall symmetry. 8-34E). The mastopexy with minimal breast tissue reduc-
tion was then performed to match the reconstructed right
breast. A 6-month follow-up demonstrates a significant
TRAM flap that can be repositioned. The exception to this improvement in symmetry and in the contour of the right
is a flap in the somewhat obese patient where the pannus breast (Fig. 8-34F), seen best in lateral view. It is impor-
from the abdomen is of overabundant thickness. In this tant to realize that this type of reoperative maneuver is
situation it is possible to create such an internal adipose only rarely possible and to emphasize that caution must
flap, which can be repositioned within the breast. be exercised when enacting such a plan to preserve suffi-
Dr. Ralph Millard26 was one of the first to describe the cient circulation to this internal flap so as not to produce
maneuver of elevating and turning over an internal flap of fat necrosis.
adipose tissue to treat contour deficits in various areas of
the body. He described this maneuver as the flip-flop fat
flap (Fig. 8-33AC). As noted, it is usually not feasible to TREATING BREAST CONTOUR
perform this maneuver in most TRAM flaps. However, in DEFICITS WITH ADJACENT TISSUE BY
the flap with significant thickness, specifically when the TRANSPOSING THE MUSCLE PEDICLE
TRAM flap may have been horizontally inset, there is OF THE FLAP
often excessive projection centrally and a deficiency in
vertical height, resulting in a step-off in the superior con- In the pedicled TRAM flap breast reconstruction with sub-
tour. Such a case is illustrated in this somewhat obese optimal projection or contour of the lower pole of the
patient (Fig. 8-34AF), who underwent reconstruction of breast, modest amounts of autologous tissue can be
the breast with a surgically delayed TRAM flap. The flap obtained from below the IM fold in the subxiphoid region.
was horizontally inset, which resulted in suboptimal At times the muscle bulge in this area does not fully atro-
upper pole fullness, especially in the superomedial region phy. In cases of double muscle or bipedicle flap recon-
of the reconstructed breast (Fig. 8-34A). struction, this can represent significant volume that may
In this situation the problem was addressed by elevat- be available to augment a TRAM flap reconstruction.19 As
ing an internal flap of adipose tissue that was superiorly mentioned in the Chapter 7, it is often possible to divide
based, as diagramed on the patients skin (Fig. 8-34B). The the muscle after 6 months have elapsed.
flap must be carefully planned so that enough blood sup- In situations where there is a volume deficit that has
ply is maintained at its base to allow viability once it is resulted in decreased breast projection (most often noted
Ch08.qxd 11/28/05 9:26 PM Page 400
Recreation of IMF from external approach

"The Ryan procedure"
De epithelialized
crescent with
full-thickness incision
pectoralis major
lower portion
de-epithelialized
FIGURE 8-32. A, Marked breast asymmetry after immediate crescent sutured
left breast reconstruction with single pedicle TRAM flap follow- to periosteum
c I
ing mastectomy for recurrent breast cancer after previous PL
M
AN
lumpectomy and radiation therapy. Note the volume deficiency epithelium
and IM fold level discrepancy. B, The initial plan for correction
included an external reconstruction of the IM fold using the
Ryan procedure and placement of an implant beneath the TRAM
flap. C, The Ryan procedure for recreating an IM fold by advanc-
ing and tacking de-epithelialized superior and inferior mastec-
tomy flaps. (continued) C
Ch08.qxd 11/28/05 9:26 PM Page 401
FIGURE 8-32. (CONTINUED) D, Appearance of the lower pole of the breast following mobilization of
inferiorly malpositioned TRAM flap that was folded under the central portion of the TRAM and recre-
ation of a new IM fold at a more superior level. Note residual volume deficit in the superior lateral
aspect of reconstructed left breast (outlined on skin). E, Elevation of lateral dog ear that will be de-
epithelialized and advanced medially by turning it under to fill volume deficit in lateral aspect of supe-
rior pole of the breasts. If there is a large dog ear with sufficient skin this maneuver is possible.
F, De-epithelialized dog ear is mobilized and ready to be transposed medially. G, Improved symmetry
between breasts noted following a combination of maneuvers using autogenous tissue only (i.e., with-
out an implant).
Ch08.qxd 11/28/05 9:26 PM Page 402
Internal flip-flop
fat flap
adipose flap to be
elevated
adipose flap elevated

and transposed
B
contour deformity
corrected
FIGURE 8-33. A, A diagram of the internal flip-flop fat flap

described by Millard. It may occasionally be helpful in shifting the
internal adipose tissue of the TRAM flap as is seen in this patient
(B). The key is to maintain a sufficient base dimension of the fat
flap to ensure its viability. C, Flap is inset to augment contour.
FIGURE 8-34. A, Breast asymmetry with step-off in superomedial contour of TRAM flap in patient
who had a delayed right breast reconstruction. Patients adipose layer in the abdomen was very thick.
Note that the IM fold on the side of the reconstruction is already higher than the IM fold on the opposite
breast. B, Preoperative plan for correction (flip-flop flat flap of superior TRAM tissue) outlined on the
skin. (continued)
Ch08.qxd 11/28/05 9:26 PM Page 403
FIGURE 8-34. (CONTINUED) C, Inferiorly based adipose tissue flap raised and made ready to be
turned over into the superomedial contour deficit in the TRAM flap. D, Sutures displaced in the adipose
flap to tack it into position. E, Adipose flap sutured into position. F, Correction of step-off deformity
best seen in lateral view.
Ch08.qxd 11/28/05 9:26 PM Page 404
and best documented photographically by looking down

on the breasts from above), the volume needed to
autoaugment the breast can be obtained from this divided
muscle pedicle(s). The possibility of producing flap
ischemia in the TRAM flap should be discussed with the
patient preoperatively, but the likelihood of this occurring
is not great.
To carry out this maneuver the inferior breast incision
is opened and the muscle(s) is identified below the subcu-
taneous tissue in the lower aspect of the TRAM flap. The
skin inferior to the IM fold is elevated inferiorly to expose
as much muscle as needed. The dissection is facilitated by
the use of a headlight or a lighted retractor. The muscle A
pedicle is transected and raised off of the muscle fascia
layer above the ribs. The inferior pole of the TRAM flap is C
also elevated to create a space into which to place the
muscle pedicle. The muscle pedicle itself usually has an
excellent retrograde blood supply. The rectus muscle vol- B
ume is most appropriately placed to correct inferomedial
volume deficiencies or deficiencies of central projection in
the TRAM flap (Fig. 8-35AD). The IM fold is then re- flap elevated
established by retacking the subcutaneous tissue to the and lower part
folded under
musculofascial layer. As previously noted, the TRAM flap
breast mound does not suffer from the late division of the
pedicle (although caution should be exercised in previ-
ously radiated beds).
D
RECONSTRUCTING CONTOUR FIGURE 8-35. A, Patient who had single pedicle TRAM flap
DEFECTS WITH AUTOLOGOUS FAT reconstruction with inadequate projection of lower pole of
GRAFTS TRAM flap. B, Skin flaps elevated to explore rectus muscle at
inferior aspect of the TRAM flap. C, Rectus muscle is transected
and folded under adipose portion of flap to increase lower pole
A simple method to improve or correct small or moderate projection, similar to maneuver described in Figure 8-28D. D,
contour deficits is autologous fat injection.27 The use of Increased projection of lower aspect of TRAM flap by autoaug-
this method to treat small contour deficits is exactly like mentation with rectus muscle pedicle.
that described in Chapters 6 and 9. It requires the harvest
of fat cells from a distant site, such as the lower abdomen,
lateral thigh, posterior hip, or knee, using standard lipo- injected with a solution of local anesthetic containing
suction instrumentation. Most often a cannula of 3.0 to lidocaine and epinephrine, again waiting until there is
3.7 mm is used. It is important to inject the fat donor area good vasoconstriction in the recipient bed as evidenced
with a solution containing lidocaine and epinephrine to by blanching of the overlying skin. The adipose tissue is
achieve vasoconstriction. This will permit a harvest of then injected in strands at multiple levels of the tissue in
adipose cells with minimal admixed blood. I prefer to use the recipient bed using a 14-gauge needle. It is important
0.25% lidocaine and concentrations of epinephrine to layer these strands into the defect and not inject the fat
between 1:400,000 and 1:1,000,000 per cc. It is important as a clump or ball. The fat aspirate is injected into all lay-
to wait for blanching of the overlying skin to occur before ers of the contour deficiency, including the muscle, and
harvesting adipose tissue. The fat is then aspirated using a into the subcutaneous space. Depending on the degree of
syringe aspiration system and is placed into 10-cc the contour deficit, several injections at multiple opera-
syringes and allowed to stand. The infranatant fluid is tive settings may be necessary. Injected fat tissue grafts
drained and the remainder of the oils can be removed by a have been documented in the medical literature over
simple wick application to the adipose tissue. The fat may many decades to be notorious for their difficulty taking or
also be centrifuged at 3000 rpm for 5 minutes as surviving. Therefore the need for several treatments must
described by Coleman.26 The limits of the contour deficit be explained to the patient preoperatively, along with the
to be corrected are outlined on the skin of the recon- fact that these fat grafts have a tendency to resorb with
structed breast with a marking pen. This area is also time. It is not uncommon to lose between 30% and 50% of
Ch08.qxd 11/28/05 9:26 PM Page 405
the initial correction. Nevertheless, such grafts are valu- resect the adipose tissue deep to Scarpa fascia in these tis-
able for correcting small deficits of contour, and they may sue zones if the volume requirements can be satisfied with
be redone within 6 months of the initial procedure. The the other adipose tissue in the TRAM flap. When fat
following patient illustrates the combined use of flap necrosis is noted following TRAM flap breast reconstruc-
reorientation, skin envelope modification, and autolo- tion, it is very important to point out these areas of firm-
gous fat graft injection to treat contour deficits after ness to the patient as soon as they are noted in the
TRAM flap breast reconstruction. postoperative period and to reassure the patient about the
In addition to autologous fat cell grafting by injection, nature of the firmness. As noted earlier, most of the
small contour deficits may be corrected by the placement smaller areas and cases in which there is a moderate firm-
of dermisfat grafts.28 These are small composites of adi- ness of the tissue will improve with the passage of time. It
pose tissue with overlying dermis that has been harvested is my experience that this will most often take about 1
from a distant site where there is an excess of skin and year. At that point, there will usually be no firm areas in
adipose tissue. This is most commonly noted in the lat- the breast. However, if the area of fat necrosis is more
eral-most extent of the IM incision, where a small dog ear extensive or very firm to hard in nature, most likely it will
is often present. The epidermal layer is removed in a stan- not soften. Occasionally it will be visible and rarely will it
dard de-epithelialization maneuver. The grafts can be be uncomfortable, especially when the patient lies on it. In
implanted beneath the skin overlying an area of contour this case it may be necessary to establish the diagnosis by
deficit. Here again it is important to harvest the grafts in needle aspiration cytology examination, and if the patient
an atraumatic manner and to achieve anesthesia and desires its excision revisional surgery can be done.
vasoconstriction in the recipient area with the use of an The following patient illustrates the typical presenta-
injection of local anesthetic containing epinephrine. The tion of fat necrosis after a TRAM flap breast reconstruc-
contour deformity is carefully marked on the overlying tion. This 55-year-old patient had undergone a left
skin before surgery. A precise pocket is created by careful mastectomy and desired reconstruction with her own tis-
dissection beneath the contour deficit to accept the graft. sue (Fig. 8-36A). The plan was for a single pedicle nonde-
Hemostasis in this pocket must be perfect. The graft is layed TRAM flap and a contralateral breast reduction. The
then inserted with the dermis side oriented superiorly. outcome at 6 weeks is seen (Fig. 8-36B). Unfortunately,
Generally it is not necessary to fix the graft in the pocket transmidline tissue (zone II) was placed in the IM fold dur-
with sutures. ing a vertical inset of this flap. She presented with a mass
in the center of the IM fold, along with poor definition of
the IM fold, which was lower than that of the opposite
FAT NECROSIS breast, and excess volume in the upper aspect of the TRAM
flap (Fig. 8-36C). The plan was to excise the fat necrosis
Fat necrosis is the most common complication of TRAM and reconstruct a more well-defined IM fold (Fig. 8-36C).
flap breast reconstruction.1 It is a process that results At surgery there was a localized area of fat necrosis in the
from the trauma of surgical dissection and some degree of deep adipose layer (or subscarpal fat layer; Fig. 8-36D).
ischemia in the adipose tissue of the TRAM flap that is This was excised without difficulty (Fig. 8-36E). The
being transferred. revision, nipple reconstruction, and subsequent intrader-
The circulatory dynamics of the adipose tissue layers of mal tattoo produced very satisfactory symmetry for this
the lower abdominal wall were discussed in Chapter 7, patient (see Fig. 8-36F).
and the importance of appropriate flap selection was As noted, fat necrosis most often occurs due to inap-
emphasized. I have found that strict adherence to the propriate procedure selection, i.e., relying on the circula-
guidelines discussed and the almost routine use of prelim- tion in a superiorly based unipedicle flap to provide
inary surgical delay procedure in unipedicle TRAM flap circulation to more than two zones of tissue.
reconstruction have significantly reduced the incidence of A more dramatic example of such a situation is noted
fat necrosis in my patients. Nevertheless, the fat necrosis in the following case (Fig. 8-37AE), in which this patient
rate is not zero. In my experience approximately 10% of with very large breasts preoperatively underwent immedi-
my patients undergoing unipedicle flap reconstruction ate postmastectomy reconstruction of the left breast with
exhibit some degree of fat necrosis. an undelayed unipedicle flap. This immediate reconstruc-
I believe that fat necrosis usually does not require sur- tion was done for local recurrence following a previous
gical intervention. Most often it is a localized area of firm- lumpectomy and radiation therapy (Fig. 8-37A). The
ness in the reconstructed breast that will soften over time. transmidline adipose tissue (zone II) was positioned in the
The problem is more likely to occur in the deeper or sub- medial aspect of her reconstruction. She developed a large
scarpal adipose layer in the zones of the flap that are adja- area of hardness in the medial aspect of her reconstructed
cent to the muscle pedicle (zones II and III). For this breast (Fig. 8-37B). An analysis of her appearance
reason I believe that it is generally a good strategy to revealed that her reconstructed breast was considerably
Ch08.qxd 11/28/05 9:26 PM Page 406
larger than the opposite breast and therefore some of the entire TRAM flap and medially translocated the flap to
fat necrosis problem may have been avoided by appropri- restore the medial fullness in the reconstructed breast
ately downsizing her TRAM flap at the time of the recon- (Fig. 8-37B). We then reduced the size of her skin paddle
struction. and tailored the skin envelope to optimize the aesthetics
This patients revisional surgery entailed opening her of the reconstructed breast mound. This produced a soft
inset incisions and resecting the hard area of fat necrosis breast mound with improved symmetry when compared
(Fig. 8-37C,D). We then performed a mobilization of her with the opposite breast (Fig. 8-36E).
FIGURE 8-36. A, Patient with left postmastectomy defect who

is seen before planned reconstruction with superiorly based sin-
gle pedicled TRAM flap. B, Appearance of left breast reconstruc-
tion with concomitant right breast reduction. Patient had a large
area of fat necrosis in the reconstructed left breast in the mid-
portion of the inferior onset of the flap. C, The surgical plan is
for revision with reconstruction of the IM fold, excision of fat
necrosis, and reduction of upper flap volume by liposuction.
(continued)
Ch08.qxd 11/28/05 9:26 PM Page 407
FIGURE 8-36. (CONTINUED) D, Fat necrosis in lower pole of

breast reconstruction seen in the deep (subscarpal) layer of adi-
pose tissue in the TRAM flap. E, The well-circumscribed area of
fat necrosis is resected. F, One year later a better IM fold by
internal suture has been established and good symmetry results
from this and NAC reconstruction with an infradermal tattoo.
FLAP LOSS FOLLOWING TRAM FLAP options. It is wise to take an aggressive approach of treat-
RECONSTRUCTION ing such flaps with early resection of nonviable tissue and
wound closure. This will avoid a prolonged period of addi-
Major flap loss following TRAM flap breast reconstruc- tional dressing changes and diminish the likelihood of
tion is, fortunately, an uncommon problem. Such losses extensive scarring.
do occasionally occur, however, and they can manifest Treatment of significant flap loss usually entails the
themselves as extensive fat necrosis with an intact overly- provision of additional flap tissue for salvage of the
ing skin envelope or, more commonly, there is a signifi- breast reconstruction. The most commonly employed
cant loss of both skin and adipose tissue in the TRAM flap reconstructive option is regional pedicle flaps, most often
resulting in a significant breast asymmetry. Total flap loss using the ipsilateral latissimus dorsi musculocutaneous
is rare, and when it occurs it is most likely the result of a flap29 or the scapular or parascapular flap.30 An addi-
failed free flap breast reconstruction. As noted previously, tional option is free tissue transfer, generally from the
the surgeon needs to carefully evaluate every breast recon- contralateral latissimus dorsi flap, the scapular flap, or
struction following surgery and be especially keyed in on the gluteus maximus flap.31 Additionally, use of the gra-
those reconstructions that show signs of potential cilis musculocutaneous flap32; the lateral thigh flap33; and
ischemia. Skin suture removal to relieve tension on the the Rubens,34 or deep circumflex iliac artery flap,35 have
closure and flap re-exploration are possible treatment been reported.
Ch08.qxd 11/28/05 9:27 PM Page 408
FIGURE 8-37. A, Plan for immediate breast reconstruction using single muscle TRAM flap designed
to carry 2.5 zones of tissue. B, A large area of fat necrosis developed medially in the reconstructed left
breast causing discomfort for the patient. The plan for revisional surgery procedure includes resection
of fat necrosis and medial mobilization of entire TRAM flap to reduce the size of the reconstructed
breast. C, The area of fat necrosis is dissected free from the surrounding TRAM flap tissue. D, The fat
necrotic TRAM tissue is excised. (continued)
Ch08.qxd 11/28/05 9:27 PM Page 409
the blood supply through this branch to the latissimus

dorsi so that this musculocutaneous flap may be used as a
salvage procedure in the rare event that the free tissue
transfer is unsuccessful.
The latissimus dorsi musculocutaneous flap was ini-
tially described by Tansini in 1906. It lay dormant in the
medical literature until the mid 1970s, when the latis-
simus flap became the most used musculocutaneous flap
for breast reconstruction. The point of rotation of the flap
is determined by the position of the vascular pedicle,
which is 8 to 10 cm below the axillary artery. When trans-
posing the flap to the chest for breast reconstruction, the
surgeon must pass it through a high axillary tunnel29 to
preserve an optimal lateral breast contour.
Knowing the position of the vascular pedicle and estab-
lishing this as the point of rotation, the surgeon can con-
struct a template of paper or cloth. The template consists
of both muscle, which tapers markedly toward its tendi-
nous insertion of the humerus, and the skin paddle and
will serve as an accurate guide for transpositioning the
flap to the chest area. As noted, the pedicled ipsilateral
FIGURE 8-37. (CONTINUED) E, The appearance of the breast
reconstruction following medial transposition of the TRAM flap latissimus dorsi musculocutaneous flap is especially use-
and reconstruction of the NAC. ful for laterally positioned defects. As previously men-
tioned, the most well-perfused portion of the TRAM flap
should be positioned superiorly and medially whenever
The ipsilateral latissimus dorsi musculocutaneous flap possible. This will ensure the best chance for preservation
is by far the most commonly used flap for salvage of a of the medial contour in the reconstructed breast, even in
severely compromised TRAM flap breast reconstruction. the event that some circulatory compromise in the TRAM
This flap is one that is familiar to virtually all reconstruc- flap occurs laterally. Tissue losses in such a situation most
tive surgeons. It includes a highly reliable skin paddle that often will be located laterally. Reconstruction of losses in
can be positioned almost anywhere on the muscle. This the lateral aspect of a breast flap is easily amenable to
permits exact replacement of skin deficits at various loca- treatment with the transposed latissimus dorsi flap.
tions on the compromised TRAM flap. This musculocuta- Although the latissimus flap can be used to reach the
neous flap has a vascular pedicle that is not only of good parasternal region quite readily when the tendon of inser-
caliber but also of substantial length. This permits an tion is released, the surgeon must tunnel through the
excellent arc of rotation and increases the flexibility and existing TRAM flap, which may present additional diffi-
utility of this musculocutaneous flap for salvaging a sub- culties in terms of producing fat necrosis and, addition-
optimal breast reconstruction. ally, abnormal contours in the reconstructed breast.
In performing flap elevation, it is my preference to Salvage of a major flap loss after TRAM flap breast
include both the thoracodorsal pedicle and the serratus reconstruction is illustrated by the following case (Fig. 8-
collateral vessels whenever possible. The blood flow in the 38AM). The TRAM flap proved to be a poor choice in this
serratus branch may be sufficient to carry the entire mus- significantly obese patient (Fig. 8-38C). She sustained
culocutaneous flap in the event that the thoracodorsal extensive flap loss despite the use of a split-muscle bipedi-
pedicle has been sacrificed. However, I have observed that cle flap (Fig. 8-38C). Tissue compromise occurred both
often the distal aspect of the skin paddle is compromised medially and laterally. This resulted in open wounds at
in this situation. When evaluating a patient preopera- both locations, a marked loss of flap tissue, and volume
tively, the surgeon must check the contractility of the latis- deficits and contour abnormalities in both the medial and
simus dorsi muscle. If the nerve supply to the latissimus is lateral aspects of the flap. The open wounds in these loca-
intact, then in most cases the vascular pedicle will also be tions were accompanied by marked loss of flap tissue.
intact. Serial dbridements resulted in severe contour deficits
When a breast reconstruction with a free microvascu- both medially and laterally in the reconstructed breast
lar TRAM flap is performed, the most common recipient (Fig. 8-38D). After complete healing of the wounds and
is the thoracodorsal artery and vein. I believe it is impor- scar maturation, the suboptimal reconstructive result was
tant to perform the anastomosis proximal to the take-off salvaged by resecting the scar tissue, with the plan being to
of the serratus collateral branch. This is done to preserve recreate the defect (Fig. 8-38D). The remaining TRAM flap
Ch08.qxd 11/28/05 9:27 PM Page 410
tissue was mobilized along with its underlying muscle As previously mentioned, medial flap loss with the obli-
pedicles by elevating the skin, fat, and muscle of the flap as gate scarring produces a deformity that is difficult to
one unit. This flap remnant was translocated medially reconstruct. The only hope of establishing a good breast
(Fig. 8-38f). A large lateral tissue deficit was envisioned contour is to resect the scar tissue and recreate the defect,
(Fig. 8-38E). With the use of a skin template the lateral and then replace the tissue deficit with vascularized flap
defect of skin in subcutaneous adipose tissue was carefully tissue. Potential strategies include mobilizing the TRAM
reconstructed by positioning the skin paddle on the latis- tissue and translocating it medially, if enough excess flap
simus in the precise location (Fig. 8-38G). The flap was ele- is present laterally. Alternatively, the surgeon may be
vated (Fig. 8-38H), transposed, and inset to the lateral forced to directly replace the medial tissue deficit by pro-
defect (Fig. 8-38I). The patient demonstrated a restoration viding a new and additional flap. Most often the latter
of excellent breast contour, and the latissimus flap pro- reconstructive plan is followed. In this situation free tis-
duced good symmetry with the opposite breast from the sue transfer becomes the modality of choice.
standpoint of volume restoration. Primary wound healing Donor flap options include the scapular, parascapular,
followed, and the patient recovered well (Fig. 8-38J,K). gluteus maximus, gracilis musculocutaneous, posterior
Subsequently, the patient underwent nipple areola recon- thigh or gluteal thigh flap, and the Rubens flap described
struction (Fig. 8-38L,M) and reconstruction of the by Elliot and Hartrampf.34 The surgeon must carefully
abdomen as finishing touches on her breast reconstruc- analyze the prospective flap donor sites for the amount
tion. and distribution of adipose tissue available and consider
FIGURE 8-38. A, Preoperative AP view of patient requesting right breast reconstruction with TRAM
flap. B, Oblique view demonstrating protuberance and obesity of abdomen. (continued)
Ch08.qxd 11/28/05 9:27 PM Page 411
FIGURE 8-38. (CONTINUED) C, The plan for right breast

reconstruction with split-muscle bipedicle TRAM is outlined. D,
Significant tissue loss noted medially and laterally with scarring
and abnormal contour. E, Revision will include resection of
medial and lateral scarred areas and medial transposition of
remaining TRAM flap remnant.
Ch08.qxd 11/28/05 9:27 PM Page 412
FIGURE 8-38. (CONTINUED) F, Intraoperative view following resection of lateral scar and medial
transposition of TRAM. G, Outline of latissimus dorsi musculocutaneous flap that will be used to recon-
struct. H, The lateral defect resulting from TRAM flap repositioning. I, Latissimus flap elevated and
about to be transposed through a high axillary tunnel. (continued)
Ch08.qxd 11/28/05 9:27 PM Page 413
FIGURE 8-38. (CONTINUED) J, Intraoperative appearance of latissimus flap following lat-

eral inset. K, Plan for revision of breast reconstruction includes NAC reconstruction and lipo-
suction of abdomen. L, Lateral preoperative view. M, Following revision a very satisfactory
symmetry is noted on AP and lateral views.
Ch08.qxd 11/28/05 9:27 PM Page 414
the prospects for concealing scars related to flap harvest ence when compared with the opposite buttock, and a
and transfer. The internal mammary artery and vein are lengthy scar results from its use. The flap can be trans-
readily available as recipient vessels for these flaps when ferred on either the superior gluteal artery or the inferior
defects in the medial breast region are to be recon- gluteal artery. When dissecting the latter, it is important to
structed. This vascular pedicle can be readily accessed in avoid injury to the inferior gluteal nerve. An example of a
the bed of the third and fourth costal cartilage. In this sit- patient who sustained a total TRAM flap loss and whose
uation it is very often necessary to extend the excisions on reconstruction was salvaged with a fee gluteus maximus
the breast mound medially to allow access to and prepara- flap is depicted (Fig. 8-39AI). The lateral thigh flap,
tion of this recipient pedicle for a microvascular anasto- which is based on the lateral femoral circumflex vessel, is
mosis. The artery is of consistent caliber, but the vein can another potential source for flap donor tissue. The dissec-
be somewhat thin, delicate, and at times friable. tion removes tissue in the lateral thigh area at the per-
As mentioned, total flap loss is exceedingly rare with itrochanteric region. This too can result in a local contour
pedicle TRAM flap breast reconstruction. I evaluated one deficit. The pedicle is quite lengthy and of sufficient cross-
patient who sustained complete flap loss after pedicle flap sectional diameter to nicely match the thoracodorsal or
transfer. Flap loss after free flap reconstruction is more internal mammary vessels. Because of the donor site
likely but still uncommon, with flap loss rates ranging deformity the lateral thigh flap is a flap of last resort in my
from 2% to 5% in most series. The gluteus maximus mus- practice.
culocutaneous flap and the Rubens flap34,35 appear to be
the flaps of choice for salvaging this situation. The con-
tralateral latissimus dorsi muscle is available in the event TRAM FLAP DONOR SITE PROBLEMS
that the pedicle to the ipsilateral latissimus has been dam-
aged or where the previous free flap procedure has made The abdominal wall defect following TRAM flap harvest
this pedicle unusable. must be carefully closed by reapproximating the medial
Once again, it is important to carefully estimate the fascial layer to two layers of lateral fascia36 (Fig. 8-40).
tissue requirements for such a salvage procedure before Despite all of the innovations and significant attention to
surgery. This will allow the selection of the appropriate detail in the abdominal wall closure after TRAM flap
flap donor site for the particular reconstructive effort. It is breast reconstruction, the hernia rate, although much
my experience that the flap tissue provided by the gluteus lower, has not been reduced to zero.1,37 Additional factors
maximus muscle is not as malleable as the TRAM flap tis- involved in the genesis of such hernias may be progressive
sues. The donor area can show a definite contour differ- postoperative attenuation of the abdominal wall tissue,
FIGURE 8-39. TRAM flap donor site requires closure of two layers of fascia laterally, the oblique fas-
cia and rectus fascia, which are sewn to the rectus abdominis fascia and linea alba. A, Complete TRAM
flap loss after attempted right breast reduction. B, Oblique view of breast area with scarred skin and
absent breast. (continued)
Ch08.qxd 11/28/05 9:27 PM Page 415
FIGURE 8-39. (CONTINUED) C, Salvage reconstruction of right breast planned using gluteus max-
imus musculocutaneous flap. D, Gluteus maximus free flap harvested and ready for transfer. E,
Appearance of right breast following salvage reconstruction with gluteus maximus free flap (AP view).
F, Lateral view of breasts demonstrates satisfactory symmetry in terms of volume and projection.
Ch08.qxd 11/28/05 9:27 PM Page 416
interruption of the intercostal nerve supply to the rectus Routinely, a patient who has sustained a hernia is care-
muscle remnants resulting in muscle imbalance, and fully assessed preoperatively to determine the location
other postoperative complications producing significant and size of the defect (Fig. 8-42A). This is done with the
stress in the abdominal wall repair such as forceful patient in a standing position. The exact dimensions of the
emphasis and pulmonary complications associated with bulge are then marked by placing dots on the patients
significant emesis following surgery. skin with a marking pen (Fig. 8-42B). As previously noted,
Abdominal wall hernia repair after TRAM flap breast there is most often a large area of attenuation of the lower
reconstruction has classically taken the form of attempt- abdominal wall musculature extending beyond the center
ing to reapproximate the abdominal wall fascia36 with or of the most prominent portion of the bulge. After the
without the onlay (Fig. 8-41) of synthetic mesh material dimensions are marked the patient is taken to surgery,
placed to reinforce the fascial repair. This method can be where the operation is performed using general endotra-
successful in many patients. Nevertheless, the reconstruc- cheal anesthesia. The technique includes reopening the
tive surgeon will encounter cases of significant abdominal lower abdominal incision and elevating the skin flap usu-
wall bulging with a large area of tissue attenuation or be ally to the level of the umbilicus or slightly beyond. It is
confronted with a hernia that has occurred or even often necessary to take down the umbilical stock. In this
recurred after an initial attempt at surgical correction way the defect in the abdominal wall fascia is usually eas-
using the technique in which the abdominal wall repair is ily identified. To confirm the dimensions of the defect, a
reinforced with an onlay of synthetic mesh. request is made of the anesthesiologist to provide a forced
Over the past 5 years I have treated more than 20 Valsalva maneuver with a sustained positive pressure ven-
patients who have presented with large, often painful, tilation delivered through the endotracheal tube (Fig. 8-
bulges in the lower abdominal region after TRAM flap 42C). This is helpful in demonstrating the precise extent
breast reconstruction. Each of the patients was treated of the abdominal wall defect. The defect dimension is
with abdominal wall exploration that included opening inscribed on the abdominal wall tissues using methylene
the weakened abdominal wall tissues by performing an blue (Fig. 8-42C).
exploratory laparotomy. This approach permits the place- A vertical incision in the attenuated abdominal fascial
ment of a large piece of reinforcing synthetic mesh mate- tissues is then created, allowing exposure of the abdominal
rial in an intraperitoneal location, with the mesh applied contents. Inspection is immediately made for any intra-
to the inner aspect of the parietal peritoneum on all sides abdominal pathology and careful evaluation of the omen-
of the defect in the lower abdominal wall. The omentum is tum is carried out. This is done to specifically note its size
then tacked over this mesh to isolate it from potential con- and the ability to bring it down to cover the intended mesh
tact with the abdominal viscera. Using this technique I repair. Most often a 10 10inch sheet of sterile Prolene
have been uniformly successful in correcting the defects mesh that has been soaked in antibiotic solution is used. It
in all of these patients. It is my technique of choice37 for is brought to the field and trimmed so that dimensions are
treating large defects and bulges in the lower abdomen larger than the hernia by approximately 4 cm on all sides
following TRAM flap breast reconstruction. of the defect (Fig. 8-42D). The mesh is then sewn onto the
onlay mesh
unfavorable tension
stress
FIGURE 8-40. The application of synthetic mesh to abdominal FIGURE 8-41. Intraperitoneal placement allows mesh to
wall following TRAM flap harvest. Mesh must absorb and negate absorb significant tension stress and convert it to a compression
a significant tension stress. stress.
Ch08.qxd 11/28/05 9:27 PM Page 417
intraperitoneal mesh
B
FIGURE 8-42. A, Patient who underwent left breast reconstruction using contralateral (right) rectus
muscle TRAM flap presents with 2-time recurrent hernia. B, Area of fascial attenuation noted with the
patient upright extends beyond the midline. C, Intraoperatively the area of fascial attenuation is out-
lined. Note that it extends significantly superiorly and laterally. D, Planned intraperitoneal placement of
Prolene mesh, which will be fixed to abdominal wall tissues on all sides of the defect. E, Intraoperative
view showing mesh being tacked into position with multiple mattress sutures through the entire wall
musculature peripheral to the defect. (continued)
Ch08.qxd 11/28/05 9:27 PM Page 418
FIGURE 8-42. (CONTINUED) F, The recalicitrant abdominal bulge in the patient in this operative
sequence is as pictured on the AP view. G, Postoperative appearance of patient following hernia repair.
Note restoration of normal lower abnormal contour. H, Note restoration of normal lower abdominal
contour with correction of the bulge.
parietal peritoneum surface of the abdominal wall using This improves the relationships of the abdominal wall
full-thickness suture placement through the abdominal musculature as the fascial defects become smaller. This
wall (Fig. 8-42E). Beginning externally, the needle is maneuver also often causes bunching of the tissue of the
passed through the entire thickness of the abdominal wall attenuated hernia on the surface of the abdominal wall. It
musculature (Fig. 8-42E). After catching the intraperi- then allows much of this tissue to be excised.
toneal mesh, the suture is then brought out through the In all cases it is most often possible to achieve an edge
abdominal musculature in a vertical mattress stitch tech- to edge closure of the abdominal wall fascia. This allows
nique. The mesh is first applied from the region superior to complete coverage of the intraperitoneal inclusion of the
the defect then brought to the areas lateral and, finally, synthetic mesh. Before the final sutures are placed, the
inferior to the defect. With the anesthesiologist providing omentum is brought down to the inferior-most aspect of
maximum muscle relaxation, the mesh is placed with a sig- the defect and tacked to the mesh. In this way the mesh is
nificant amount of tightness to make the defect smaller. excluded from having contact with the abdominal viscera.
Ch08.qxd 11/28/05 9:27 PM Page 419
Once the external fascial tissues are closed over the Reconstr Surg. June 2000;105(7):25832586; discussion
25872588.
mesh, two suction drains are placed and closure of the 14. Seroma catheter. Greer Medical Inc., Santa Barbara, Calif.
abdominal wound proceeds in standard fashion with the 15. Bilgen IG, Ustun EE, Memis A. Fat necrosis of the breast:
inferior advancement of the skin flap and repositioning clinical, mammographic and sonographic features. Eur J
Radiol. August 2001;39(2):9299.
of the umbilical stalk. Improved abdominal contours are 16. Kroll SS. Fat necrosis in free transverse rectus abdominis
noted immediately postoperatively after such a repair of myocutaneous and deep inferior epigastric perforator flaps.
these defects (Fig. 8-42H). Patients will have some ele- Plast Reconstr Surg. September 2000;106(3):576583.
17. Matarasso A. Suction mammaplasty: the use of suction lipec-
ment of discomfort related to tightening of the muscle. tomy alone to reduce large breasts. Clin Plast Surg. July
Generally an overnight stay in the hospital is required. 2002;29(3):433443.
Suction drains remain in place usually for 5 to 7 days. 18. Restifo RJ. Secondary use of the rectus muscle pedicle for
TRAM flap volume deficiencies. Ann Plast Surg. April
Recurrence of the laxity and bulges has been extremely 1998;40(4):343348.
rare. 19. McCraw JB, Maxwell GP. Early and late capsular deforma-
In some way this method of intraperitoneal mesh appli- tion as a cause of unsatisfactory results in the latissimus
dorsi breast reconstruction. Clin Plast Surg. October
cation provides a means of re-establishing normal 1988;15(4):717726.
anatomic relationships of the abdominal wall musculature. 20. Fagrell D, Berggren A, Tarpila E. Capsular contracture
I find it helpful in many patients who present with bulges around saline-filled fine textured and smooth mammary
implants: a prospective 7.5-year follow-up. Plast Reconstr
after TRAM flap breast reconstruction. It is especially help- Surg. December 2001;108(7):21082112; discussion 2113.
ful in patients with recurrent hernias. 21. Thorne CH, Beasley RW, Sherrell JA, et al. Grabb and Smiths
Plastic Surgery. Philadelphia, Pa: Lippincott Williams &
Wilkins; 2006.
22. Lassus C. A 30-year experience with vertical mammaplasty.
REFERENCES Plast Reconstr Surg. February 1996;97(2):373380.
23. Lejour M. Vertical mammaplasty: update and appraisal of
1. Watterson PA, Bostwick J III, Hester TR Jr, et al. TRAM flap late results. Plast Reconstr Surg. September
anatomy correlated with a 10-year clinical experience with 1999;104(3):771781; discussion 782784.
556 patients. Plast Reconstr Surg. June 1995 95(7) 11851194. 24. Bostwick J III Aesthetic and Reconstructive Breast Surgery. St.
2. Schusterman MA, Kroll SS, Miller MJ, et al. The free trans- Louis, Mo: Mosby; 1983.
verse rectus abdominis musculocutaneous flap for breast 25. Millard DR. The Principalization of Plastic Surgery. Boston,
reconstruction: one centers experience with 211 consecutive Mass: Little, Brown and Co; 1986.
cases. Ann Plast Surg. March 1994;32(3):234241; discussion 26. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast
241242. Surg. January 2001;28(1):111119.
3. Alderman AK, Wilkins EG, Kim HM, et al. Complications in 27. Mackay DR, Manders EK, Saggers GC, et al. The fate of der-
postmastectomy breast reconstruction: two-year results of mal and dermal-fat grafts. Ann Plast Surg. July
the Michigan Breast Reconstruction Outcome Study. Plast 1993l;31(1):4246.
Reconstr Surg. June 2002;109(7):22652274. 28. Bostwick J III. Latissimus dorsi flap: current applications.
4. Hultman CS, Daiza S. Skin-sparing mastectomy flap compli- Ann Plast Surg. November 1982;9(5):377380.
cations after breast reconstruction: review of incidence, man- 29. Siebert JW, Longaker MT, Angrigiani C. The inframammary
agement, and outcome. Ann Plast Surg. March 2003;50(3): extended circumflex scapular flap: an aesthetic improvement
249255; discussion 255. of the parascapular flap. Plast Reconstr Surg. January
5. Chang DW, Reece GP, Wang B, et al. Effect of smoking on 1997;99(1):7077.
complications in patients undergoing free TRAM flap breast 30. Shaw WW. Superior gluteal free flap breast reconstruction.
reconstruction. Plast Reconstr Surg. June 2000;105(7): Clin Plast Surg. April 1998;25(2):267274.
23742380. 31. Yousif NJ. The transverse gracilis musculocutaneous flap.
6. Krueger JK, Rohrich RJ. Clearing the smoke: the scientific Ann Plast Surg. October 1993;31(4):382.
rationale for tobacco abstention with plastic surgery. Plast 32. Elliott LF, Beegle PH, Hartrampf CR Jr. The lateral transverse
Reconstr Surg. September 15, 2001;108(4):10631073; dis- thigh free flap: an alternative for autogenous-tissue breast
cussion 10741077. reconstruction. Plast Reconstr Surg. February 1990;85(2):
7. Padubidri AN, Yetman R, Browne E, et al. Complications 169178; discussion 179181.
of postmastectomy breast reconstructions in smokers, ex- 33. Hartrampf CR Jr, Noel RT, Drazan L, et al. Rubens fat pad for
smokers, and nonsmokers. Plast Reconstr Surg. February breast reconstruction: a periiliac soft-tissue free flap. Plast
2001;107(2):342349; discussion 350351. Reconstr Surg. February 1994;93(2):402407.
8. Takeishi M, Shaw WW, Ahn CY, et al. TRAM flaps in patients 34. Elliott LF, Hartrampf CR Jr. The Rubens flap. The deep cir-
with abdominal scars. Plast Reconstr Surg. March 1997; cumflex iliac artery flap. Clin Plast Surg. April 1998;25(2):
99(3):713722. 283291.
9. Myers MB, Cherry G. Use of vital dyes in the evaluation of the 35. Kroll SS, Marchi M. Comparison of strategies for preventing
blood supply of the colon. Surg Gynecol Obstet. January abdominal-wall weakness after TRAM flap breast reconstruc-
1969;128(1):97102. tion. Plast Reconstr Surg. June 1992;89(6):10451051; discus-
10. Kroll SS, Khoo A, Singletary SE, et al. Local recurrence risk sion 10521053.
after skin-sparing and conventional mastectomy: a 6-year fol- 36. Shestak KC, Fedele GM, Restifo RJ. Treatment of difficult
low-up. Plast Reconstr Surg. August 1999;104(2):421425. TRAM flap hernias using intraperitoneal synthetic mesh
11. Pinedo HM. Thrombosis, prevalence and new evidence on application. Plast Reconstr Surg. January 2001;107(1):5562;
current perceptions of risk. Cancer Treat Rev. June 2003; discussion 6366.
29(suppl 2):35. 37. Zienowicz RJ, May JW Jr. Hernia prevention and aesthetic
12. DVT treatment. contouring of the abdomen following TRAM flap breast
13. Pollock H, Pollock T. Progressive tension sutures: a technique reconstruction by the use of polypropylene mesh. Plast
to reduce local complications in abdominoplasty. Plast Reconstr Surg. November 1995;96(6):13461350.
Ch09.qxd 28/11/05 2:59 AM Page 420
C h a p t e r 9
Reoperative Surgery Following

C h a p t e r 9
Lumpectomy and Radiation Therapy
Plastic Surgery Reconstruction of the The Postlumpectomy plus Radiation Deformity

Lumpectomy Defect 425 435
Reconstruction of Entire Breast Following Contour Abnormalities Treated with Implants 436
Completion Mastectomy 425
Surgical Modification of the Opposite Breast
The Postlumpectomy Defect 425 Following Lumpectomy and Radiation
Therapy 440
Scars Following Lumpectomy 429
Surgical Modification of Both Breasts Following
Breast Asymmetry Following Lumpectomy and Lumpectomy and Radiation Therapy 442
Radiation Therapy 429
Oncoplastic Surgical Treatment for the Post-
Correction of Small Contour DeficitsTissue Lumpectomy Patient 442
Shifts 429
Reconstruction of Postlumpectomy Defects with
Autologous Fat Transplantation for Contour Flaps 445
Correction 432
Reconstruction of the Partial Mastectomy Defect
Use of Combined DermisFat Grafts and with Autogenous Tissue 446
Autologous Fat Injection for Larger Deficits in
the Nonradiated Patient 433 Closing Thoughts 449
References 454
Breast-conserving therapy is currently the most common I have come to understand this surgery not only an
method of treating patients with breast cancer. The effi- oncologic surgical procedure but also as a cosmetic opera-
ciency and validity of such treatment have been estab- tion. That is to say, it is generally good to preserve a
lished by many large prospective studies [National womans breast when treating a breast cancer. However,
Surgical Adjuvant Breast and Bowel Project (NSABP) and this is only true if such treatment results in a breast that is
World Health Organization (WHO)] that have identified not deformed by such treatment and that a woman
the equivalence of survival in patients so treated when believes is worth keeping or preserving (Figs. 9-1 to 9-3).
compared with those treated with standard modified radi- Obviously any operation that removes tissue from the
cal mastectomy.13 The treatment entails removing a breast breast through a surgical incision with the subsequent
cancer with a surrounding rim of normal breast tissue addition of radiation therapy virtually always alters the
with the subsequent provision of adjuvant radiation to the breast. These changes involve every anatomic component
remaining breast parenchyma. This treatment preserves of the breast gland. There are changes in the skin pigmen-
most of the patients breast while accomplishing resection tation, elasticity, and thickness. In addition, there are
and local control of the patients breast cancer. This breast- often alterations of breast volume and contour and posi-
conserving treatment carries with it a 1% per year risk of tion of the nipple areolar complex (NAC; Figs. 9-4 to 9-8).
local recurrence, but the survival rates of patients treated As the prevalence of this technique has increased,
in this way are equivalent to those of patients treated with many experienced general and oncologic surgeons have
mastectomy over 15 years of follow-up.14 become increasingly aware of which breast cancer
420
Ch09.qxd 28/11/05 2:59 AM Page 421
Chapter 9 Reoperative Surgery Following Lumpectomy and Radiation Therapy 421
FIGURE 9-1. Postlumpectomy defect with excellent cosmesis

following tumor resection from upper outer aspect of right
breast with subsequent radiation therapy.
FIGURE 9-2. A, Anteroposterior (AP) view of postlumpectomy defect following resection of 2-cm
tumor from upper outer aspect of left breast. B, Note scar is convex upward and located in upper outer
aspect of the breast. The excellent cosmesis is because size of resection is relatively small compared
with size of residual breast tissue.
Ch09.qxd 28/11/05 2:59 AM Page 422
FIGURE 9-3. A, AP view of postlumpectomy defect in right breast with more significant asymmetry
after resection of larger tumor relative to the size of the breast. B, Lateral view with location of the scar.
This degree of asymmetry is still tolerated by most patients.
FIGURE 9-4. Subtle superior displacement of the NAC follow- FIGURE 9-5. More significant deformity following resection of
ing lumpectomy in upper aspect of the breast. lateral tumor in a relatively small breast.
Ch09.qxd 28/11/05 3:00 AM Page 423
FIGURE 9-6. Postlumpectomy deformity seen following resec-

tion of tumor in lower pole of left breast. This is bothersome to
the patient.
FIGURE 9-8. Hyperpigmentation of the breast skin and

hypopigmentation of the NAC are seen in this African-American
patient following lumpectomy and radiation for bilateral breast
cancers.
patients are candidates for such procedures and which are

not, from the standpoint of the resulting breast cosmesis.
I believe that it is critical to select this option only in those
patients who are likely to achieve a satisfactory cosmetic
outcome.
Factors that are predictive of poor results are a large
tumor size relative to total breast size (large tumor in
small breast) (Fig. 9-9) and tumor location relative to NAC
(tumors immediately superior to or inferior to the NAC
cause more displacement of the nipple following treat-
ment; Fig. 9-10). Additionally, patients who require re-
excision after the first attempt at resection and those
developing wound problems, most notably infection, very
often show a poor cosmetic outcome. Patients such as
these are many times better off undergoing a mastectomy
and having an immediate breast reconstruction.
An early question was whether the surgical tumor exci-
sion or the adjuvant radiation therapy was more of a fac-
tor in the production a poor outcome. This question was
analyzed by Matory et al.,5 who verified that it was the vol-
FIGURE 9-7. Significant volume asymmetry and displacement ume of breast parenchymal resection relative to total
of the NAC seen following lumpectomy to remove right breast breast volume that was the most influential determining
cancer that is bothersome to the patient. factor in the genesis of the significant postlumpectomy
Ch09.qxd 28/11/05 3:00 AM Page 424
and radiation deformity. Radiation plays a role due to its

qualitative effect on the breast skin and remaining breast
parenchyma, but its effect is less significant than that of
surgical excision. In that same review, a comparison was
made of patients, surgical oncologists, radiation thera-
pists, and plastic surgeons assessments of the overall
cosmesis using a scale of 1 to 10. The patients themselves
scored their own breast cosmesis most favorably. The cos-
metic outcome was scored with decreasing appeal by the
radiation therapists, surgical oncologists, and plastic sur-
geons, with the plastic surgeons issuing the lowest scores
for the quality of cosmetic outcome.
Several things are clear at the time of this writing. More
and more patients are being treated for breast cancer with
breast-conserving therapy (i.e., lumpectomy and radiation
therapy). As a consequence, more and more patients
are being seen by plastic surgeons for treatment of
postlumpectomy deformities that have resulted in objec-
tionable breast asymmetries. I personally continue to see
an ever increasing number of patients requesting correc-
tion of postlumpectomy deformities. Some of these
FIGURE 9-9. Significant deformity following lumpectomy
results from resection of a large tumor from a small breast. patients have presented after a second and sometimes even
There is marked contour abnormality, dislocation of the NAC, a third excision that has been done to obtain a tumor-free
and volume asymmetry.
FIGURE 9-10. A, Marked contour deformity has resulted from a large tissue resection from the lower
pole of the left breast in patient seen on AP view. It appears as if the lower hemisphere of the breast has
been removed. B, Note the marked dislocation of the NAC in an inferior direction and severe contour
deformity on lateral view.
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margin. Some patients probably were not optimal TABLE 9-1

candidates for the procedure in the first place but were dis- Postlumpectomy Deformitiesa Treatment Approach
inclined to have a mastectomy. From my discussions with I. Opposite breast adjustment surgery
these patients it appears that many of them had an unreal- a. Asymmetryopposite (contralateral) breast modification
istic expectation regarding the outcome of such treatment. b. Shapemastopexy
I believe that general surgeons with whom I work c. Volumebreast reduction
closely and who focus their practice on breast oncology do II. Reconstruction of the postlumpectomy defect (previously treated
a good job of selecting the patients who will not obtain a or ipsilateral breast) with or without opposite breast adjustment
good result from such treatment and steer such patients in a. Scarinvagination
the appropriate direction of mastectomy. Nevertheless, b. Redirect scars that are crossing contours
there are increasing numbers of patients who are present- c. Contour asymmetrytreatment of ipsilateral breast
d. Contour deformitylocal tissue shift, local flap
ing to plastic surgeons around the world with significant
e. Peripheral fat injection
deformities of their breasts following lumpectomy and f. Volume augmentationimplant
breast irradiation. Such problems vary both in their sever- g. Asymmetry of NACscorrection by relocation
ity and in their contributing components. Because of this III. Reconstruction of the postlumpectomy defect at the time of the
it follows that successful treatment from the standpoint of lumpectomyoncoplastic surgery with or without opposite breast
improving breast appearance requires a careful analysis adjustment
of each breast deformity with an individualized treatment a. Mammoplastyrearrangement of the ipsilateral breast at the
plan devised based on the patients chief complaint and time of tumor resection
the surgeons physical examination of the breast(s). b. Possible flap reconstruction
This chapter overviews treatment options for the most IV. Completion mastectomy and ipsilateral breast reconstruction with
or without opposite breast adjustment
commonly presenting breast problems following lumpec-
a. Recurrent tumorcompletion mastectomy
tomy and radiation therapy for breast cancer. The treat-
b. Severe deformity not amenable to partial reconstruction
ment options for postlumpectomy deformity are outlined c. Reconstructionvascularized tissue flap
in Table 9-1. d. Flaplatissimus dorsilateral defects, superior lateral
defects, some inferior defects
e. TRAMcentral defects, inferior pole defects, medial defects
PLASTIC SURGERY RECONSTRUCTION
TRAM, Transverse rectus abdominis myocutaneous; NAC, nipple areolar
OF THE LUMPECTOMY DEFECT complex.
Patients seek reoperative breast surgery following a previ-

ous lumpectomy because of either breast asymmetry, with
an acceptable appearance of the breast that has under-
gone a breast-conserving procedure, or a deformity of the
ipsilateral breast that has undergone the tumor removal reoperation are those who have opposite breast adjust-
and radiation therapy. Such deformities requiring surgical ments. Interestingly, patients who underwent a comple-
reoperation for reconstruction are either moderate to sig- tion mastectomy and reconstruction of their entire breast
nificant in their severity, and their correction may or may were far more pleased than patients who had attempted
not entail an adjustment of the opposite breast to opti- reconstruction of moderate defects of their ipsilateral
mize symmetry. Moderate defects require reconstruction breast. To address the deformities in this group, many
methods that entail local tissue rearrangements, occasion- authors have begun to enthusiastically support oncoplas-
ally the placement of an implant and often the provision tic surgery, or a tissue rearrangement of the breast under-
of a musculocutaneous flap or free tissue transfer. going lumpectomy at the time of that procedure and
Patients with an acceptable appearance of their ipsilateral before radiation.79 The initial analysis of such patients
breast are often best treated with an adjustment of the appears to show a benefit in terms of the cosmetic
opposite breast in the form of a mammoplasty procedure. outcome. Throughout the remainder of this chapter I
overview reoperation after lumpectomy and do not com-
ment on oncoplastic surgery.
RECONSTRUCTION OF ENTIRE BREAST
FOLLOWING COMPLETION
MASTECTOMY THE POSTLUMPECTOMY DEFECT
Clough et al.6 have studied the outcome of such treatment Postlumpectomy defects most often pose a significant
from the standpoint of patient satisfaction. Not surpris- challenge for the plastic surgeon. What makes them diffi-
ingly, the patients with the greatest satisfaction following cult is that there is almost always a tissue deficit with
Ch09.qxd 28/11/05 3:00 AM Page 426
varying degrees of intraparenchymal fibrosis or cicatrix the latissimus dorsi flaps as illustrated later in this
and skin scarring, along with a global hypovascularity of chapter. These flaps can provide variable amounts of new
breast due to radiation. The degree of quantitative skin tissue, and their use in breast reconstruction is standard-
deficiency varies, but there is always a qualitative skin ized. The latissimus is excellent for defects situated later-
abnormality. Very often there is an element of nipple are- ally, superolaterally, and inferolaterally, while the TRAM is
ola displacement or dislocation in cases of larger skin better suited for the reconstruction of inferior, central,
resection or significant parenchymal tissue resection, and medial defects. To reconstruct defects in these loca-
with a corresponding contour abnormality of the breast. tions with a latissimus flap, dissection through the breast
Surgery on the postlumpectomy defect, by definition, is is required to position the flap. Therefore its use has been
always revisional or reoperative in nature. limited in my hands to defects located in the outer half
The goals for treating postlumpectomy deformity are and occasionally the inferior pole of the breast. The
similar to those espoused in the previous chapters of this TRAM flap (whether free or pedicled) is also the most use-
text. They are restoring symmetry by reconstructing con- ful technique when there is a need for significant volume
tour deficits and correcting tissue deficits in kind, with the restoration or skin replacement.
overall goal of restoring breast appearance as much as I believe that the volume of resected tissue relative to
possible to what the eye would see and the brain would the total volume of the breast is the most important deter-
recognize as normal. There are additional constraints in minant in the genesis of the postlumpectomy deformity
treating postlumpectomy deformity that are imposed by (see Fig. 9-9). The next most critical factor is the location
the combination of radiation and scar effects from the of the resection. Tumor resections that are carried out
previous surgery(ies), and these must be outlined for each immediately above or immediately inferior to the NAC
patient by the surgeon preoperatively. are responsible for the large majority of postlumpectomy
The important principles at play in reoperative surgery deformities that require a major reconstruction, with the
in this group of patients are the same as those in the treat- resections in the inferior pole of the breast resulting in
ment of every secondary defect. These include recreating the worst cosmetic outcomes (Fig. 9-11A,B). Other pre-
the deformity by releasing and resecting all scars, and dictive factors for a poor outcome are reoperations for re-
then reconstructing the defect. The defect resulting from establishment of a tumor-free margin and intervening
the intraparenchymal scar almost always requires some infection in the lumpectomy wound. Finally, better out-
sort of reconstruction procedure. This may entail reposi- comes at the site of the excision from the standpoint of
tioning of the residual breast pedicle and/or reshaping the breast contour are seen in patients whose breast flaps are
skin envelope of the ipsilateral breast, a partial recon- kept thick as opposed to those patients whose skin flaps
struction of the breast with the addition of flap tissue, are thin.
completion of the mastectomy, and a reconstruction of an
entirely new breast.
It has been my experience that in most instances the
ideal reconstructive medium is vascularized tissue, which
brings in a new blood supply that can produce neovascu-
larization of the wound. Although the volume deficit is a
primary component in the genesis of the problem, an
implant alone is rarely the answer.5 Both modalities can
be used, as is illustrated later in this chapter, but my pref-
erence is for the addition of a well-vascularized tissue flap.
This has produced the best and most predictable outcome
over a wide range of patients and clinical situations.
Flap reconstruction of the postlumpectomy defor-
mity is complicated by the paucity of local flaps. Skin
rearrangements adjacent to the scar are suitable for only
the smallest and most superficial defects. There is a
paucity of local tissue. I have no experience with the lat-
eral thoracic skin flap because I believe that the donor
scar is prohibitive in most patients. This flap has been
described for postlumpectomy deficit reconstruction,
however. FIGURE 9-11. A, Erythema and induration of the left breast
The workhorses in my practice have been the trans- noted at the completion of radiation therapy after lumpectomy.
verse rectus abdominis myocutaneous (TRAM) flap and (continued)
Ch09.qxd 28/11/05 3:00 AM Page 427
The therapeutic radiation administered to the breast(s)

also plays a role in the etiology of the problems encoun-
tered by the reconstructive surgeon. It is has long been
accepted that radiation therapy produces effects on all tis-
sues subjected to it. These effects are indiscriminate (i.e.,
radiation therapy affects both the tumor cells and the sur-
rounding tissues), and they are permanent, continuous,
and progressive.
The injury produced by radiation therapy and the time
line of healing are generally understood as follows. The
acute phase of tissue repair following radiation therapy is
noted during and up to 6 weeks following such treatment.
It can be marked by redness, blisters, or frank ulceration
of the skin (Fig. 9-12A,B). After this time the skin exhibits
edema and definite induration. Clearly, advances in the
science of radiation therapy and refinements in the tech-
nology and instrumentation used for its administration
have dramatically decreased such acute radiation injury
FIGURE 9-11. (CONTINUED) B, Erythema, hyperpigmenta-
to the skin and have almost completely eliminated persist-
tion, and epidermolysis noted on right breast following mastec-
tomy with subsequent adjuvant radiation therapy. ent skin ulceration. However, such presentations are occa-
sionally still seen (Fig. 9-13AD).
The subacute phase of wound healing following such
treatment occurs over the ensuing 6 months and is
marked by hyperpigmentation and often a tactile quality
of woodiness in the breast tissues that is apparent to the
patient and the surgeon.
FIGURE 9-12. A, Radiation therapyinduced ulceration in the inferior pole of the breast skin of this
60-year-old obese patient with insulin-dependent diabetes who was seen and treated by me 18 years
ago. The wound showed no sign of healing after 4 weeks of serial dbridements and intensive wound
care. B, The wound was resected, including the NAC, in a fashion similar to an amputation breast
reduction.
Ch09.qxd 28/11/05 3:00 AM Page 428
FIGURE 9-13. A, Larger necrotic ulcer in the lower pole of the left breast of a 65-year-old obese
patient with insulin-dependent diabetes who has undergone a lumpectomy and radiation therapy for a
breast cancer. B, Appearance of the breast following resection of the entire lower pole in a fashion
resembling an amputation reduction mammoplasty. Patients wounds have healed and she is marked
for a contralateral breast reduction and a nipple reconstruction using a skate flap and full-thickness
skin graft on the left breast. The appearance of the breasts is noted 4 months after surgery (C) and 18
years after surgery (D).
Understanding the time line of wound repair is impor- they are best treated initially with the application of baci-
tant from a surgeons prospective. I almost never consider tracin ointment, which promotes the maintenance of a
operating in the setting of previous radiation therapy until moist, bacteriostatic environment that optimizes wound
at least 6 months has elapsed since the completion of the healing. In cases of a painful open wound I have found
therapy. This is important from both the standpoint of that the application of topical lidocaine (Xylocaine) gel
wound healing following any additional surgery and from (0.05%) may be helpful.
the vantage point of tissue equilibrium and pliability, Persistent skin ulceration following radiation therapy
which are necessary for the best cosmetic outcome follow- occurs rarely, but it may represent an indication for sur-
ing additional surgical intervention. gery. The common denominator in the pathogenesis of
Acute wound problems requiring surgical intervention such a problem is local tissue ischemia, often with coexist-
(i.e., radiation ulcers) are uncommon. When they occur ing subclinical wound infection and a medical comorbidity
Ch09.qxd 28/11/05 3:00 AM Page 429
such as diabetes mellitus or a vasculitis. To treat such a Such a patient presented with an invagination of a
problem typically two components are needed: an aggres- lumpectomy scar in the upper aspect of her right breast
sive surgical dbridement of the skin and the deep tissue (Fig. 9-14A). This had been present since her lumpectomy
injured by the radiation, most often with the simultaneous 1 year earlier. In her case, and in many others like it, the
provision of vascularized tissue to this ischemic wound appearance can be improved by resecting the scar tissue
environment. This combination of surgical treatment of the in the skin and tissues immediately beneath it and creat-
wound most often produces wound healing. Therapeutic ing small flaps, or tongues, of adipose tissue on either side
interventions consisting of vascularized tissue as therapy of the wound that can be advanced toward the center of
are the most reliable methods for achieving wound healing. the wound and interdigitated, or stacked, on one another.
When I have encountered problems with this schema they This surgical approach is possible if the tissues adjacent to
have usually been the result of inadequate surgical dbride- the wound have regained sufficient suppleness and mobil-
ment that has left marginally perfused and/or contami- ity to be advanced toward the center of the wound. In this
nated tissue behind in the wound. case the patient underwent a contralateral breast reduc-
I treated a patient with radiation-induced tissue loss tion (Fig. 9-14B) along with an excision of the scar and a
approximately 18 years ago. The patient, very obese with vertical stacking of the tissue in the wound. There was a
insulin-dependent diabetes, underwent a lumpectomy and marked improvement in the symmetry between the
radiation therapy as treatment for a lower pole breast breasts but only a minimal improvement of the scar on
tumor. She sustained a wound breakdown with ulceration the right breast (Fig. 9-14C). She subsequently underwent
of the surrounding skin (Fig. 9-13A). This wound showed a reoperation on the scar. This consisted of a precisely
no sign of healing despite serial dbridements in the office, done lysis of the scar at the interface of the dermis with
along with an intense regimen daily dressing changes done the adipose layer (Fig. 9-14D) and the harvest of a der-
over a 4-week period. Multiple true cut needle biopsies of misfat graft from the skin excess along the lateral chest
the wound were negative for tumor and the wound cul- wall from the previous breast reduction (Fig. 9-14E). This
tures did not grow any organisms. For this reason I excised was placed so that it precisely fit the wound (Fig. 9-14F).
the wound, including the NAC, in a fashion similar to an At a 2-month follow-up the patient demonstrates a much
amputation breast reduction and it healed without inci- improved appearance of the scar (Fig. 9-14G).
dent (Fig. 9-13B). There was no residual tumor in the
resected left breast tissue specimen. After wound healing
was ensured we proceeded with a contralateral breast BREAST ASYMMETRY FOLLOWING
reduction and left nipple reconstruction with a skate flap LUMPECTOMY AND RADIATION
and full-thickness skin graft from the groin (Fig. 9-13C). THERAPY
The patient has been without breast problems for the ensu-
ing 18 years (Fig. 9-13D), showing only loss of nipple pro- Breast asymmetry following lumpectomy and radiation
jection on the left breast and hypopigmentation of the skin therapy is the most common reason that such patients seek
graft used to reconstruct the left areolar complex. Our data consultation with the plastic surgeon. Asymmetry can result
indicate that patients with diabetes may be more predis- from contour deficits, breast volume discrepancies, differ-
posed to radiation-induced tissue injury in all areas of the ences in nipple areola position or appearance, and combi-
body than nondiabetic patients.10 nations of these. Different degrees of such deformity require
different surgical approaches and treatment options for
their surgical correction. As with many areas of breast revi-
SCARS FOLLOWING LUMPECTOMY sion discussed in this book, correction of postlumpectomy
and radiation deficits is always discussed with the patient in
Scar tissue formation resulting from the deposition of col- relative terms. That is to say, correction of these problems
lagen is the way the body heals all wounds. In the case of must be thought of in terms of improvement, not perfection.
lumpectomy there is often one common scar between the The concept of educating the patient as to what is possible
postresection wound cavity, which initially fills with and what is not possible is very relevant when treating
seroma fluid and then undergoes some degree of contrac- patients with postlumpectomy deformity.
tion, and the skin scar. Excessive contraction of this
underlying scar tissue/fluid space can be transmitted
throughout the depth of the wound, where contraction of CORRECTION OF SMALL CONTOUR
the scar mass may produce a depression of the contour DEFICITSTISSUE SHIFTS
with invagination of the skin scar itself. If this occurs the
appearance is very often objectionable to the patient. The Small or subtle discrepancies in contour can be objection-
extent of the resulting deformity may be increased by the able to the patient. This is especially true if they involve
effects of the subsequent radiation therapy. the NAC or the peripheral contours of the breast, either
Ch09.qxd 28/11/05 3:00 AM Page 430
FIGURE 9-14. A, Postlumpectomy appearance in a patient who is seen approximately 1 year follow-
ing treatment for a right breast cancer and exhibits two problems: an invaginated scar of the right
breast producing a contour deformity and a breast asymmetry related to a significant volume discrep-
ancy. B, The first procedure was a combination of a left breast reduction along with an excision of the
scar on the right breast, lysis of deep adhesions, and a vertical Z-plasty with overlap of multiple tissue
flaps in the right breast beneath the scar. C, This only partially corrected the contour deformity of the
right breast. D, Patient underwent a dermisfat graft of that area done with precise release of the cica-
trix beneath the scar. (continued)
Ch09.qxd 28/11/05 3:01 AM Page 431
FIGURE 9-14. (CONTINUED) E, Harvest of a dermisfat graft

from the tissue excess along lateral chest wall on left breast.
F, Graft was harvested and placed dermis side up to precisely fill
the created wound. G, Patient is seen with an improved appear-
ance of the scar and improved contour of right breast at 6 months
following surgery.
Ch09.qxd 28/11/05 3:01 AM Page 432
medially, laterally, inferiorly, superiorly, or the central part injecting this into the region of the adipose tissue to be
of the breast. harvested, I wait for at least 20 (and sometimes 30) min-
A small contour abnormality (most often an indenta- utes until there is a pronounced appearance of blanching
tion) at the junction of the areola and breast skin follow- of the skin, which is indicative of vasoconstriction in the
ing lumpectomy can produce a depression of the NAC. adipose layer. This usually means that the harvested adi-
This can be treated with the advancement of a de-epithe- pose cells will be almost completely devoid of blood con-
lialized flap of skin adjacent to the areola if there is some tamination. The fat is harvested into 10-cc plastic syringes
redundancy of skin and subcutaneous tissue in this loca- that are then inserted into a sterile centrifuging at 3,000
tion. This de-epithelialized advancement flap can be used rpm for 5 minutes, which makes it easy to separate the
as a foundation or a platform on top of which the NAC can cellular component from the infranatant fluid. This fluid,
be reseated after it has been elevated after the scar tissue which is composed of fatty oils, is then discarded and the
has been lysed. This contour correction requires lysis of adipose tissue is loaded into 1-cc glass tuberculin
the deep cicatrix in the breast beneath the scar in the skin. syringes, which are used to inject it into the recipient area
Advancing small or medium flaps to de-epithelialized (see Fig. 2-45).
skin to fill contour deformities is a common technique In the case of a deformity beneath a skin scar as small
that can be applied to correct contour deformities or step- as in this case, the skin scar must first be released. This is
offs in contour in many settings. It is illustrated in done by injecting the scar with a local anesthetic contain-
Chapter 2 (see Fig. 2-43). Often this can be done with only ing epinephrine, which is again allowed to set up in the
a minimal increase in the total length of the skin scar, tissue for 15 minutes. Next, a small sharp instrument is
especially in a location such as the periphery of the areola, passed immediately beneath the dermis along the scar to
where the curved incision often allows it to be concealed. release it from the deep tissues. This rarely results in any
bleeding. Then the adipose tissue is injected into the tis-
sue in strands, using the technique of lipostructuring as
AUTOLOGOUS FAT TRANSPLANTATION described by Coleman.11 The small access incisions
FOR CONTOUR CORRECTION needed to introduce the needles are created using a No. 11
blade scalpel to produce puncture wounds. It is important
Autologous fat transplantation is a modality that is gain- to place the fat in multiple layers, including in the breast
ing popularity among plastic surgeons to treat a myriad of tissue and subcutaneous space. It is very important to not
clinical problems. This is certainly true for contour abnor- inject the fat in clumps. The fat is injected using the 1-cc
malities in the breast. syringes through 14-gauge blunt-tipped needles. A slight
The use of autologous fat transplantation to treat overcorrection of the deficit should be achieved. The inci-
postlumpectomy deformity is illustrated in Chapter 2 (see sions used to inject adipose tissue are closed at the end of
Figs. 2-48 to 2-50) with regard to the treatment of a 55- the procedure using a 5-0 chromic suture. I then place a
year-old patient with diabetes who underwent a lumpec- piece of sterile nonstick topical foam over the area that
tomy and radiation therapy to treat a left breast deformity has been grafted. This is left in place for 5 days, during
that resulted in a depression over her laterally positioned which time the patient is maintained on oral antibiotics,
scar at the site of her tumor resection. This was bother- usually cephalexin [500 mg by mouth (PO) four times
some to her. In addition she was bothered by a depression daily (q.i.d.)]. If there is a history of penicillin allergy I will
in the superomedial aspect of the same breast that use erythromycin [333 mg PO three times daily (t.i.d.)] as
resulted from the placement and subsequent removal of a an alternative medication. Correction of such deformities
permanent intravenous (IV) access catheter or port used has been possible in most cases. I inform the patient that
for her chemotherapy. between 50% and 75% of the adipose tissue is likely to per-
The correction of these contour deformities was sist at the site of injection, but that a definite possibility of
achieved using autologous fat transplantation in two dif- having to retreat the contour deformity following an
ferent forms. The area beneath her depressed scar was autologous fat cell injection certainly exists. Such retreat-
corrected with the injection of autologous fat tissue that ments are usually spaced 6 months apart.
was harvested from the lower abdomen in the infraumbil- In this patient the depression at the site of the previous
ical area. I prefer to harvest such fat by aspirating it with a port used for her chemotherapy was reconstructed with a
1.5-mm blunt-tipped cannula (see Fig. 2-44). Alternatively, dermisfat graft. I have found that such grafts provide
the lateral thigh or medial aspect of the knee often har- more structural stability and resistance to compression in
bors excess fat that is a source for excellent quality adi- scarred areas as the healing of the fat graft proceeds.
pose tissue that can be transplanted. Regardless of the The technique of dermisfat graft harvest, removal of
donor area that is chosen, I believe it is important to inject the epidermis, and graft placement requires precision.
the adipose tissue with a local anesthetic agent that con- The area to be grafted is outlined and a template for the
tains epinephrine in a concentration of 1:400,000. After graft is made with sterile glove wrapper paper (from the
Ch09.qxd 28/11/05 3:01 AM Page 433
surgical gloves). The intended graft is outlined on the skin I have been impressed by the utility of both of these
and de-epithelialized. The graft is harvested and only the techniques for correcting small contour deficits. They
superficial layer of adipose tissue (the layer of fat above both achieved a very satisfactory correction of the deficits,
the superficial fascia) is used. I will occasionally harvest which is seen in this patient at 1 year following surgery
additional segments of the superficial fascia to use as sep- (see Figs. 2-58 to 2-60).
arate fingers of the graft in defects that are irregular and
where these additional strands of tissue can be used
to treat multiple recesses in a particular defect. The USE OF COMBINED DERMISFAT
dermisfat graft is placed with the dermal surface posi- GRAFTS AND AUTOLOGOUS FAT
tioned superficially against the overlying dermis. INJECTION FOR LARGER DEFICITS IN
When the recipient bed is prepared for such a graft the THE NONRADIATED PATIENT
surgical dissection must be precise from the standpoint of
hemostasis and dimension. Once again I prefer to use a Postlumpectomy defects can present themselves in various
local anesthetic containing epinephrine, and I will per- sizes or in various shapes and dimensions. Larger defects
form the dissection through one or two small incisions can sometimes require a combination of dermisfat graft-
using a scalpel. I will use a headlight with an appropriate ing to the central portion of such a defect with autologous
retractor (Senn, or cats paw) to achieve exacting hemosta- fat injection at the periphery.
sis in the wound. I will then insert the dermisfat graft, Such a case is illustrated by this 72-year-old patient
often using an attached pull-out suture at its lead edge to (Fig. 9-15), who underwent a lumpectomy for what turned
precisely position it. At times I will secure the graft using out to be a benign disease. She had tissue excised from the
three or four sutures brought through the skin, which are inferolateral quadrant of her breast that resulted in a very
tied over bolsters. When such fixation sutures are used noticeable and bothersome contour deformity for which
they are removed by the fifth postoperative day. In gen- she sought correction (Fig. 9-15A,B). She had not received
eral, the thickness of such grafts should not exceed 1 cm. radiation therapy to the breast.
There is normally a period of induration of these grafts We considered many options for correction but I felt
that lasts approximately 3 months, after which a tactile that the combination of a dermisfatfascia graft used in
sensation of softness returns to them. conjunction with autologous fat transplantation was the
FIGURE 9-15. Breast deformity in lower outer aspect of right breast following a resection of a benign
lesion on AP view (A) and lateral view (B). (continued)
Ch09.qxd 28/11/05 3:01 AM Page 434
FIGURE 9-15. (CONTINUED) C, The plan is for reconstruction with a combination of

a dermisfatfascia graft and autologous fat injection. Patient is marked for the insertion of the der-
misfatfascia graft. D, Additional marks are made for placement of the fat injections. E,
Dermisfatfascia graft is a composite harvested from the right lower abdomen through a previous scar
and includes a segment of the superficial fascia. F, Fat has been aspirated and centrifuged. (continued)
best option. The area to undergo the placement of the der- the suprapubic region was the site of the dermisfat graft
misfat graft was outlined first (Fig. 9-15C), and subse- harvest, and the autologous fat graft was obtained from
quently the sites of autologous fat injection and the sites the infraumbilical adipose tissue depot. We harvested the
of donor fat harvest were marked (Fig. 9-15D). In this case dermis with the superficial fat and segments of the super-
Ch09.qxd 28/11/05 3:01 AM Page 435
FIGURE 9-15. (CONTINUED) The fat is injected with 1-cc

syringes through a 14-gauge needle (G). The appearance at 2
months following surgery on AP view (H) and oblique view (I).
ficial fascial system. The fascial extensions (raised as a THE POSTLUMPECTOMY PLUS
composite with the dermisfat graft) were useful to fill RADIATION DEFORMITY
and reconstruct multiple recesses of her defect (Fig. 9-
15E,F). In addition, 30 cc of autologous fat was processed At the time of this writing I am acquiring experience using
(Fig. 9-15G) and injected peripheral to the major portion autologous fat injections in patients who have been
of the defect (Fig. 9-15H). She exhibited a very satisfactory treated with surgery and radiation. The best candidates
correction during a 3-month postoperative follow-up visit, are those patients with peripheral defects. The take of the
which was maintained (Fig. 9-15I). transplanted fat appears to be less reliable than the take in
Ch09.qxd 28/11/05 3:01 AM Page 436
nonradiated patients. This is because of the decreased sular contractures. Maintaining meticulous hemostasis and
vascularity in the area of the lumpectomy, but also using suction drains are routine.
because of the dense cicatrix. An unsuccessful take may An example of a favorable outcome following such
result in calcifications within the fat graft. When such treatment is illustrated by this patient (Fig. 9-16A,B), who
calcifications in the area of fat transplantation occur, underwent lumpectomy and radiation to treat a breast
they are usually easily distinguished by an experienced cancer superior to the NAC. Note that this patient had full
radiologist or surgeon from the calcifications that are B cupsized breast tissue even after the treatment with
worrisome for the suggestion or malignant disease. surgical resection and radiation. She was bothered by
Although the technique of fat injection shows promise both the volume difference in terms of breast size and the
for use in postlumpectomy defects, such patients must be deficit in contour of the superior and lateral aspect of her
advised of the increased possibilities of suboptimal sur- right breast adjacent to the NAC. She underwent recon-
vival and the fact that they will require special mammo- struction of this deformity with the submuscular place-
graphic surveillance to closely follow the treated area for ment of a smooth-walled round saline implant (9.6 cm,
the occurrence of calcifications. If at any time there is a 125 cc). The outline for precise pocket dissection is
question about the nature of such calcifications, addi- depicted (Fig. 9-16C). Postoperatively she demonstrates
tional biopsies of these areas may be needed. improved symmetry between the breasts with relatively
good softness of the breast implant (Fig. 9-16D,E). She
was noted to have Baker II capsular contracture, but the
CONTOUR ABNORMALITIES TREATED opposite breast exhibited a significant amount of firm
WITH IMPLANTS stromal tissue.
This result persisted for 2 years until she developed
More significant contour deficits in the breast require recurrent disease that required an additional lumpectomy
more aggressive methods of correction. For medium-sized and additional local radiation to the breast. She subse-
defects this most often means consideration of using an quently developed a deflation of her implant and required
implant. The major drawback of placing an implant to an implant exchange to a higher-profile implant with a
augment or reconstruct any breast is the predictable scar larger saline volume (9.6 cm, 230 cc; Fig. 9-16F). A resec-
tissue capsule that forms around every implant and the tion of the previous anterior periprosthetic capsular tissue
unpredictable tendency of such a capsule to contract. In was performed in an attempt to maximize implant projec-
most situations advanced forms of this capsular contraction directly beneath the upper aspect of the NAC but with
ture are uncommon. However, my experience has taught limited success. She remains pleased at a 14-month fol-
me that following previous radiation to the breast there is low-up, although the contour deficit with slight flattening
a definite increase in the tendency for advanced forms of the NAC persists (Fig. 9-16F,G). This is most apparent
(Baker III and IV) to occur. The resulting breast firmness in certain postures and is very visible when the patient
may be very bothersome to the patient. bends forward (Fig. 9-16H).
Nevertheless, in many cases of moderate to significant In this case the use of a saline implant was successful
contour (and volume) discrepancies following previous in improving volume asymmetry and correcting the con-
lumpectomy and radiation therapy to the breast, treat- tour deficit without significant capsular contracture. This
ment of these problems with an implant has appeal for is one of the better results that I have obtained from the
both patients and surgeons. This is because the procedure use of an implant in this setting. A major decrease in the
requires only a small incision on the breast, and there is quality of the breast appearance was produced by the sec-
no donor flap morbidity that would accompany a flap ond lumpectomy and additional radiation therapy.
procedure. Unfortunately capsular contracture of advanced degree
When implants are used for postlumpectomy recon- (Baker III, IV) is also quite common when using implants
struction, the best results are obtained in patients who have in this setting. Such an example is illustrated by this
significant residual breast tissue and relatively thick breast case wherein this 44-year-old patient underwent staged
flaps raised during the lumpectomy. Such implants should reconstruction of the left breast to correct both a volume
almost always be placed in the submuscular position. deficit and contour asymmetry following breast cancer
Generally, the smaller the defect, the better the result. When treatment with lumpectomy and radiation therapy (Fig. 9-
dissecting the recipient submuscular pocket the surgeon 17A). On the oblique view the extreme lateral dislocation of
should outline the specific contour deficit to be corrected the NAC is noted (Fig. 9-17B). We used a tissue expander
and precisely dissect the pocket in which the previously placed in the submuscular position that was overfilled (12
selected implant is to be placed. I use dimensional concepts cm, 525 cc) and maintained as such for 6 months. This was
for selecting such an implant, and in general I prefer saline carried out in conjunction with a right transaxillary breast
implants because I believe they confer an advantage in augmentation using a smooth-walled saline implant (11.9
terms of having a lesser tendency to develop advanced cap- cm, 330 cc) (Fig. 9-17C,D). This was exchanged for a
Ch09.qxd 28/11/05 3:01 AM Page 437
FIGURE 9-16. A, Postlumpectomy deformity in right breast of a young patient following resection
of a small tumor immediately above the NAC with subsequent radiation therapy. B, Oblique view.
C, Patient is marked for placement of a small subpectoral implant positioned to maximally correct vol-
ume and contour deficits. This option was chosen because patient has a significant amount of her own
breast tissue. DE, Improved symmetry and a better breast appearance are noted postoperatively at 8
months. (continued)
Ch09.qxd 28/11/05 3:02 AM Page 438
FIGURE 9-16. (CONTINUED) F, G, Patient underwent a second lumpectomy for recurrent disease
and has a nipple dislocation and flattening of the contour in the area of reresection and desires addi-
tional corrective surgery. High-profile implant with greater volume was placed, which improved her
appearance somewhat, but she has a contour defect that has not been completely corrected (H) and is
more visible in certain postures, especially when bending forward.
Ch09.qxd 28/11/05 3:02 AM Page 439
FIGURE 9-17. Another postlumpectomy deformity following treatment of a small, laterally located
left breast cancer. A, Note nipple displacement and asymmetry of lateral breast contour on AP view. B,
Oblique view shows nipple displacement. CD, First stage of reconstruction involved the placement of a
tissue expander (12 cm, 525 cc) to reconstruct the lateral breast contour. Radiated tissue was difficult to
expand. (continued)
Ch09.qxd 28/11/05 3:02 AM Page 440
FIGURE 9-17. (CONTINUED) EF, Subsequent implant placement (shaped textured saline, 13 cm, 490
cc) provides a suboptimal-appearing reconstruction and resulted in a Baker III capsular contracture.
shaped textured saline implant (base width 13 cm, height treated by the lumpectomy. The options for the contralat-
14 cm, volume 490 cc) at a second stage. The wider base eral breast are a mastopexy or a breast reduction.
width implant gives slightly more of an illusion that the lat- The vertical mastopexy procedure has been well suited
eral nipple dislocation is better corrected (Fig. 9-17E). After to this population of patients because breasts treated by
an initial satisfactory result the patient developed a Baker lumpectomy and radiation therapy often appear rounder
IV capsular contracture that was unresponsive to high dose and almost uplifted when compared with the opposite
of vitamin E (Fig. 9-17E,F). As of this writing she is consid- breast. Examples of this situation are illustrated by the
ering autogenous conversion using a TRAM flap. following two cases. The first is a 55-year-old patient who
underwent a left lumpectomy and radiation therapy for
breast cancer. She presented for correction of the result-
SURGICAL MODIFICATION OF THE ing breast asymmetry marked by a difference in volume,
OPPOSITE BREAST FOLLOWING nipple position, nipple areolar inclination, and degree of
LUMPECTOMY AND RADIATION ptosis (Fig. 9-18A). The asymmetry was addressed by per-
THERAPY forming a vertical mastopexy (Fig. 9-18B) on the opposite
right breast. At a 1-year follow-up examination after surgery
The treatment strategy that has the highest degree of the patient demonstrates markedly improved breast aes-
patient satisfaction is where only the opposite breast is thetics in terms of symmetry despite the persistent nipple
altered. This implies that the patient is satisfied or reason- areolar asymmetry due to the laterally displaced nipple on
ably satisfied with the appearance of the ipsilateral breast the left breast.
Ch09.qxd 28/11/05 3:02 AM Page 441
FIGURE 9-18. A, Postlumpectomy breast asymmetry on AP

view. B, Patient is marked for right vertical mastopexy. C,
Postoperative appearance at 1 year reveals much improved
symmetry.
Ch09.qxd 28/11/05 3:03 AM Page 442
SURGICAL MODIFICATION OF BOTH

BREASTS FOLLOWING LUMPECTOMY
AND RADIATION THERAPY
There is a circumstance in which it is propitious to per-

form surgery to alter the appearance of both breasts fol-
lowing a previous lumpectomy: when an ipsilateral breast
is deformed in the face of macromastia and a bilateral
breast reduction would facilitate symmetry. It is possible
to operate on most breasts that have undergone lumpec-
tomy, but with a marked increase in the risk for complica-
tions. Of course the greater the extent of local scarring or
radiation-induced tissue damage, the greater the risk for
complications.
This situation is illustrated by this 53-year-old patient
(Fig. 9-19), who had undergone a lumpectomy 5 years pre-
viously for a stage II breast cancer located superior to the
NAC at the 12 oclock position on the right breast. There
was a contour deformity present in the upper central
aspect of the right breast marked by an indentation in the
contour (Fig. 9-19A) that was especially apparent on lat-
eral view (Fig. 9-19B). The patient was 5 feet 4 inches tall
and the bra cup size of the left breast was DD. She desired
a breast reduction on the left side and a procedure on the
right side that would optimize the symmetry between
the breasts. Because of her surgery in the upper pole
of the right breast, I did not think it was prudent to per-
form a limited scar procedure and therefore we planned
for an inferior pedicle reduction on the left breast and an
inferior pedicle mastopexy on the right breast (Fig.
9-19C). The procedure established good symmetry
between the right and left breasts, both of which demon-
strated an attractive appearance (Fig. 9-19D).
Both unilateral modification of the opposite breast
following a previous lumpectomy and modification of
both breasts at the appropriate time after surgery are
the treatment options with the highest satisfaction rat-
ing across the board in the postlumpectomy patient
population.
ONCOPLASTIC SURGICAL TREATMENT

FOR THE POST-LUMPECTOMY PATIENT
Not infrequently following lumpectomy and radiation

therapy, the patient will exhibit a marked asymmetry
between the breasts and a definite deformity on the side
from which the tumor was resected. This deformity can
be quite severe as is seen in the following case. This 56-
year-old female presented for consultation 12 months fol- FIGURE 9-19. Postlumpectomy breast asymmetry 5 years fol-
lowing partial mastectomy and radiation done to treat a lowing previous surgery. Note contour deformity of right breast
right breast cancer in the lower outer aspect of the breast on AP view (A) and lateral view (B). (continued)
(Fig. 9-20A,B). This produced a marked contour abnor-
mality, nipple areola dislocation with the nipple pointing
inferiorly, and nipple retraction. There was a healed scar
Ch09.qxd 28/11/05 3:03 AM Page 443
in the lower outer quadrant of the breast. The patient had

macromastia, and the contralateral left breast was a DD
cup in size. She requested a procedure to improve the
symmetry between the breasts and to treat the abnormally
positioned NAC (Fig. 9-20C). The best operative plan was
that of a bilateral breast reduction.
Oncoplastic surgery is a discipline wherein the sur-
geon alters the breast affected by the cancer most often
by some combination of repositioning the nipple areola
complex and the adjacent breast parenchyma and skin
flaps so as to produce a better shape in the breast from
which the tumor was resected. This oncoplastic surgical
treatment can be performed at the time of tumor ablation
or at a much later time after the patient has undergone
radiation therapy to the affected breast. In general I pre-
fer to wait 9 to 12 months after the radiation is completed
before operating on such a breast. This will afford the tis-
sues the necessary time to recover and allow the wound
healing process to progress well into its chronic phase. It
is at this time when healing in these tissues is most pre-
dictable. It is important to enter into a discussion about
this time line with every patient seeking post-lumpec-
tomy reconstruction.
In all such cases the plastic surgeon must carefully
analyze the treated breast for the position of scars. Such
scars often determine the selection of the pedicle to be
used. The aesthetic plan for nipple transposition is then
outlined on both breasts (Fig. 9-20D). In this particular
case an inferior pedicle technique was planned. It was
apparent that a considerable release of scar tissue that
was tethering or holding the NAC in the abnormal
position was necessary. During the procedure the sur-
geon must release this cicatrix within the breast
parenchyma while a hook is placed on the nipple area
with traction in a direction so as to place the nipple in
an appropriate position. This must be (and usually can
be) done without compromising the circulation of the
NAC. I prefer to use the electrocautery device on the
cutting mode for this maneuver. In this case the internal
scar release allowed the dislocated and retracted nipple
to be repositioned in the appropriate location on the
affected breast. A contralateral breast reduction was
carried out, and this created good symmetry between
the breasts (Fig. 9-20E,F).
The option of surgically altering both breasts is the
most common strategy used in oncoplastic procedures to
treat post-lumpectomy deformities. I predict it will have
far greater impact in the treatment of such patients with
severe deformities in the near future.
FIGURE 9-19. (CONTINUED) C, Patient is treated with a right

mastopexy and left breast reduction. D, Immediate restoration of
better breast symmetry at the completion of surgery on AP view.
Ch09.qxd 28/11/05 3:03 AM Page 444
FIGURE 9-20. A, AP view of patient who has undergone a partial mastectomy to remove a breast can-
cer in the lower outer quadrant of the breast. B, Note the extreme dislocation of the NAC on lateral
view. C, Scar causing invagination of skin and dislocation of the NAC. D, The plan for the reduction is
marked on the skin including intended new nipple position. (continued)
Ch09.qxd 28/11/05 3:03 AM Page 445
reconstruction at the time of total mastectomy done to

treat a local recurrence in the previously operated and
radiated breast. The following two cases illustrate the use
of a TRAM flap and an autogenous latissimus flap in this
setting.
This 42-year-old patient (Figs. 9-21 and 9-22) presented
with a local recurrence 4 years after lumpectomy and
radiation therapy (5,000 cGy) to treat a breast cancer in
the upper outer quadrant of her left breast. She had a sig-
nificant deformity marked by an indentation in the upper
outer aspect of her breast, a dislocation of the NAC, and a
volume deficiency. The plan was for a completion mastec-
tomy and immediate breast reconstruction with a TRAM
flap (Fig. 9-21). In this case the flap was successful in
replacing the volume deficit and in restoring a normal
contour. A secondary nipple reconstruction provided an
excellent finishing touch in terms of producing symmetry
with the opposite breast (Fig. 9-22).
This next patient had a significant deformity of the left
breast following a previous lumpectomy and radiation for
breast cancer (Fig. 9-23A). She developed a local recur-
rence whose treatment required a mastectomy. She had
undergone five previous intra-abdominal procedures with
incisions in both the upper and lower abdomen that con-
traindicated the use of a TRAM flap (Fig. 9-23A,B). She
was moderately obese with excess adipose tissue in the
back region, including the axilla and lateral chest (Fig. 9-
22C). The plan for breast reconstruction included an auto-
genous latissimus dorsi flap with harvest of a significant
amount of adipose tissue with the latissimus dorsi muscle
(Fig. 9-23C) and a contralateral (right) mastopexy for
symmetry. In a patient of this body habitus it is possible to
harvest a significant amount of adipose tissue with the
FIGURE 9-20. (CONTINUED) EF, At 2 months following sur-
gery marked improvement in the appearance of the breasts is
muscle (Fig. 9-23D). Her reconstruction and contralateral
seen. The symmetry is good and the appearance of the right NAC mastopexy resulted in an excellent appearance of her
is dramatically improved. breasts in terms of symmetry (Fig. 9-23E). She also
demonstrates the extreme extent of a back deformity that
RECONSTRUCTION OF can result from an abundant harvest of adipose tissue
POSTLUMPECTOMY DEFECTS WITH from the back (Fig. 9-23F).
FLAPS Such contour deficits in the back wound from a latis-
simus dorsi flap donor site can improve with the accumu-
There are two settings in which flaps have been used to lation of a small seroma, or they may be benefited by the
treat a postlumpectomy deformity. The first, and classically injection of autologous fat grafts. In any event, in patients
the most common, setting is breast reconstruction follow- for whom such a flap is planned, the reality of substantial
ing mastectomy to treat a local recurrence where a comple- depression at the latissimus flap donor site should be
tion mastectomy is indicated and a breast reconstruction reviewed preoperatively. Patients such as this one, who
using a flap is then performed. The second is reconstruc- are at a high risk for a suboptimal outcome, and in reality
tion of a partial mastectomy defect marked by a significant for a myriad of complications using any method, are often
deformity of the breast remnant. The breast remnant is well served by a latissimus dorsi flap reconstruction with-
reconstructed preserving the NAC and the majority of the out the use of an implant. When harvesting such a flap the
remaining breast tissue. This latter situation represents the surgeon should maintain all of the adipose tissue above
most difficult type of breast reconstruction from the stand- the dorsal thoracic fascia on the skin flaps of the back. In
point of achieving consistently good results. addition, the adipose tissue anterior to the muscle, espe-
The most common scenario in my practice is that of cially that proximally in the region of the axilla, can be
using a musculocutaneous flap for immediate breast and must often beharvested with the muscle tissue. The
Ch09.qxd 28/11/05 3:03 AM Page 446
flap is best designed so that the skin closure can be

achieved without undue tension.
RECONSTRUCTION OF THE PARTIAL

MASTECTOMY DEFECT WITH
AUTOGENOUS TISSUE
Philosophically I have always been in favor of using flap

tissue to perform an entire breast reconstruction, i.e.,
after all of the remaining tissue has been removed with a
completion mastectomy. However, Slavin12 and others6
have demonstrated the oncologic safety of reconstructing
such deficits from the standpoint that long-term surveil-
lance of such a breast is possible by both a physical exam-
ination and x-ray studies. Therefore, I am more and more
often performing partial breast reconstruction in patients
who have undergone a lumpectomy that has resulted in a
significant deformity but who nevertheless wish to keep
their native breast.
This first patient underwent a lumpectomy with
removal of tissue in the upper central portion of her breast
to excise her tumor. This, combined with the subsequent
radiation therapy, resulted in a significant volume asym-
FIGURE 9-21. AP view of a 34-year-old patient who has been pre- metry and contour depression in her central and
viously treated with a left lumpectomy and radiation therapy. lateral breast regions with upward displacement of the
Patient has dislocation of the NAC and a significant contour NAC (Fig. 9-24A,B). She requested reconstruction but
deformity of the left breast. She has developed a recurrent breast
cancer, and the plan now is for completion mastectomy and expressed a desire to maintain her native breast.
immediate breast reconstruction with a single pedicle TRAM flap.
FIGURE 9-22. Preoperative and postoperative appearance of the breast after subsequent nipple
reconstruction and intradermal tattoo.
Ch09.qxd 28/11/05 3:03 AM Page 447
FIGURE 9-23. A significant postlumpectomy deformity of left

breast on AP view (A) and lateral view (B). C, Patient has recur-
rent left breast cancer and requires a mastectomy. The plan is for
an autogenous latissimus dorsi flap reconstruction. (continued)
Ch09.qxd 28/11/05 3:04 AM Page 448
FIGURE 9-23. (CONTINUED) D, The latissimus flap is har-

vested with a segment of de-epithelialized skin, and the entire
deep adipose layer overlying the muscle is kept with the skin. E,
Patient shows an excellent cosmetic outcome from the combina-
tion of the latissimus flap reconstruct and a contralateral inferior
pedicle mastopexy. F, The flap donor defect is seen at 1 year post-
operative.
Ch09.qxd 28/11/05 3:04 AM Page 449
The plan was for a staged reconstruction with the She had a mild excess of lower abdominal skin and
placement of a tissue expander (Fig. 9-24C) in the subg- subcutaneous adipose tissue. There was no history of pre-
landular position to stretch both the breast parenchyma vious abdominal surgery. The plan was a surgically
and skin so that there would be an ample space for the delayed ipsilateral TRAM flap. Following the delay she
latissimus dorsi flap. The space was overexpanded slightly underwent careful templating of the defect (Fig. 9-25D,E).
(Fig. 9-24D). At the completion of her course of tissue Only minimal new skin was required. The TRAM flap pro-
expansion the affected breast was slightly larger than the duced a restoration of the contour of the lower pole of the
opposite breast in its appearance (Fig. 9-24D). The latis- breast, and she is extremely please with the restoration of
simus muscle with a small de-epithelialized skin paddle her previous breast shape, contour, and volume. The
harvested through a bra line incision was harvested and patient is shown 6 months postoperatively with excellent
transferred (Fig. 9-24E) simultaneously with the removal correction of her contour abnormality and a relatively
of the tissue expander. This produced good symmetry with normal breast appearance in terms of nipple symmetry
the opposite breast (Fig. 9-24F,G) and an acceptable (Fig. 9-25FH).
donor site scar (Fig. 9-24H), both noted at 6 weeks follow- In summary, correction of moderate to significant
ing surgery. The patient was very satisfied with the correc- deformities following partial mastectomy or lumpectomy
tion of the abnormal contour and with the fact that the with subsequent radiation therapy is most often best
breast was soft to the touch. achieved by the addition of flap tissue. The most com-
It is not usually necessary to employ an intermediate monly used tissue composites are the rectus abdominis
phase of tissue expansion in cases where the latissimus and latissimus dorsi musculocutaneous flaps. Free tissue
dorsi flap is used to reconstruct partial mastectomy transfer is also an option for the particularly adept
defects. However, because of the anticipated parenchy- microvascular surgeon.
mal scar and that we would be burying the entire flap, I
choose to create a space into which to place the de-
epithelialized latissimus dorsi musculocutaneous flap CLOSING THOUGHTS
that would minimally constrict the flap during the early
phases of healing. Reconstruction of partial mastectomy defects will
This final patient illustrates the use of the TRAM flap become much more common in the near future. This is
for correction of severe deformities of the lower breast because so many patients with breast cancer are being
pole following lumpectomy procedures in which too treated with breast conservation therapy, and the sur-
much breast tissue was resected. This 52-year-old patient geons performing the procedure continue to push the
presented with a marked deformity following the exci- envelope. This is a challenging and rewarding area of
sion of a tumor in the lower pole of the left breast. This plastic surgery. The popularity of oncoplastic surgery is
resulted in a marked contour deformity with an inferior increasing, and many patients who have larger tissue
displacement of the NAC (Fig. 9-25AC) and a volume resections will undergo breast tissue rearrangements at
asymmetry. She expressed a desire to maintain her the time of their breast tumor removal and before radia-
native breast and sought correction of her deformity. The tion therapy. I have found that the principles outlined in
only real option was the transfer of autologous tissue to this chapter have helped me in approaching these
reconstruct this scarred, irradiated, substantial defect. patients.
Ch09.qxd 28/11/05 3:04 AM Page 450
FIGURE 9-24. AP view (A) and oblique view (B) of postlumpectomy defect of the right breast. C, The
plan is for reconstruction in stages with placement of a tissue expander in the subglandular position
through the old lumpectomy scar. D, Tissue expansion is completed. (continued)
Ch09.qxd 28/11/05 3:04 AM Page 451
FIGURE 9-24. (CONTINUED) E, Tissue expander has been removed and the latissimus flap is ready
for transfer. FG, Postoperative appearance at 6 months following surgery showing symmetry of
breasts. H, Appearance of flap donor area on patients back.
Ch09.qxd 28/11/05 3:04 AM Page 452
FIGURE 9-25. AC, Significant deformity of left breast following lumpectomy for resection of a
tumor from the inferior pole of the breast and subsequent radiation therapy. DE, The plan is for a sin-
gle pedicle TRAM flap after releasing the scar and recreating the defect. FH, Dramatic improvement in
the contour and symmetry of left breast following TRAM flap reconstruction.
Ch09.qxd 28/11/05 3:04 AM Page 453

Ch09.qxd 28/11/05 3:04 AM Page 454
REFERENCES 6. Clough KB, Cuminet J, Fitoussi A, et al. Cosmetic sequelae

after conservative treatment for breast cancer: classification
1. Fisher B, Bauer M, Margolese R, et al. Five-year results of a and results of surgical correction. Ann Plast Surg. 1998;
randomized clinical trial comparing total mastectomy and 41(5):471481.
segmental mastectomy with or without radiation in the treat- 7. Clough KB, Kroll SS, Audretsch W. An approach to the repair
ment of breast cancer. N Engl J Med. March 14, 1985;312(11): of partial mastectomy defects. Plast Reconstr Surg.
665673. 1999;104(2):409420.
2. Jacobson JA, Danforth DN, Cowan KH., et al. Ten-year 8. Audretsch WP, Rezai M, Kolotas C, et al. Tumor-specific
results of a comparison of conservation with mastectomy in immediate reconstruction (TSIR) in breast cancer patients.
the treatment of stage I and II breast cancer. N Engl J Med. Perspect Plast Surg. 11:71, 1998.
April 6, 1995;332(14):907911. 9. Kroll SS, Singletary SE. Repair of partial mastectomy
3. Fisher B, Anderson S, Redmond CK, et al. Reanalysis and defects. Clin Plast Surg. April 25, 1998;25(2):303310.
results after 12 years of follow-up in a randomized clinical 10. Shestak KC. The definitive treatment of radiation ulcers.
trial comparing total mastectomy with lumpectomy or with- Presented at: The 2004 Plastic Surgery Educational
out irradiation in the treatment of breast cancer. N Engl J Foundation Perspectives and Advances in Plastic Surgery;
Med. November 30, 1995;333(22):14561461. March 2004; Vail, Co.
4. Dooley WC. Breast Cancer: Surgical Therapy. In: Cameron 11. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast
JL, ed. Current Surgical Therapy. 3rd ed. St. Louis, Mo: Surg. January 2001;28(1):111119.
Mosby; 1995. 12. Slavin SA, Love SM, Sadowsky NL. Reconstruction of the
5. Matory WE Jr, Wertheimer M, Fitzgerald TJ, et al. Aesthetic radiated partial mastectomy defect with autogenous
results following partial mastectomy and radiation therapy. tissues. Plast Reconstr Surg. 1992;90(5):854865; discussion
Plast Reconstr Surg. May 1990;85(5):739746. 866869.
Ch10.qxd 11/28/05 12:10 PM Page 455
C h a p t e r 1 0
Revision of Nipple Areola

Reconstruction
Nipple Reconstruction Options 459 Revision and Salvage of the Suboptimal

Nipple Reconstruction 471
Commonly Encountered Problems with
Reconstructed Nipples 461 Subtotal and Total Nipple Loss 472
Avoiding Problems During the Primary Redo Nipple Reconstruction with a

ProcedurePlanning and Patient Double-Opposing Sliding Periareolar
Marking 462 Flap 477
Surgical Technique 464 Redo Nipple Reconstruction with

AlloDerm 477
Planning in the Difficult Case 465
Incorrect Nipple Position 477
Nipple Reconstruction Techniques 468
Incorrect Nipple Inclination 484
The Modified Star Flap 468
Problems with Tattooing 485
The Skate Flap 469
Nipple Loss Following Breast Reduction
The Double-Opposing Tab Flap 469 or Mastopexy 486
References 488
The nipple is a unique structure that in its natural state specialized muscle elements. The nipple is surrounded by
has an important physiologic function in terms of breast- areola tissue, which is a darkly pigmented epithelium that
feeding. It also confers to the breast both an aesthetic and has a small number of ducts opening into it. In addition,
sexual dimension. Reconstruction of the nipple following this areola tissue contains Montgomery glands or tuber-
mastectomy visually transforms the newly created breast cles and lanugo hairs (Fig. 10-2A). The areola skin is visu-
mound into a breast, and subsequent areola color patch ally darker than the surrounding breast skin but is slightly
duplication gives to the reconstructed breast the maxi- lighter in pigmentation than the nipple.1 The nipple is
mum amount of realism that any breast reconstruction most aesthetically positioned at the point of maximal pro-
can ever achieve (Fig. 10-1A,B). jection on the breast mound.1 It can be located by the
The nipple is an essential aesthetic feature of the breast transposition of the inframammary (IM) fold (done rou-
(Fig. 10-2A) and it is the hub around which the rest of the tinely in planning a breast reduction) or by measurements
gland emanates. Anatomically the nipple represents the from fixed points of reference on the anterior chest (done
terminus of the multiple lactiferous ducts1 (usually 20 to in most nipple reconstructions following a previous breast
30) that run through the breast (Fig. 10-2B). These ducts reconstruction). The distance from the nipple to the
are clustered in the nipple and functionally they allow suprasternal notch and the IM fold varies from patient to
egress of mothers milk. They contain fibrous tissue and patient (Fig. 10-2C,D). In the absence of previous surgery
455
Ch10.qxd 11/28/05 12:10 PM Page 456
FIGURE 10-1. A, Preoperative AP view of a patient who has undergone a left breast reconstruction
with an implant. B, Postoperative appearance of same breast reconstruction following nipple recon-
struction and areola tattoo. Note vivid dimension of realism.
or an obvious developmental asymmetry the nipple posi- This situation was rescued by a well-done intradermal tat-
tions are roughly symmetric. too, which produced an excellent aesthetic outcome.
When nipple areola reconstruction is performed the (Fig. 10-3AD).
optimal visual appearance of the reconstructed nipple is
achieved by simulating the best possible color match with
the opposite areola. In the past this was accomplished
with the transplantation of a darkly pigmented full-thickness
skin graft (vulva or proximal medial thigh skin). Currently,
however, this is best done with an intradermal tattoo,
which can produce the most predictable symmetry with
the opposite areola in a wide variety of colors.1
Symmetrically reproducing the size, shape, and color
of the opposite areola must be the surgeons goal in every
nipple areola reconstruction. In my opinion the most
important characteristics of successful nipple areola
reconstruction are pigmentation, position, and projec-
tionin that order.
Visual symmetry between the color and location of the
nipple areolar complex (NAC) on the opposite breast and
its position on the reconstructed breast mound is para-
mount for the optimal visual appearance of the recon-
structed nipple. This symmetry can be most ideally
enhanced and most consistently reproduced using an
intradermal tattoo, with which the surgeon can best simu-
late the color patch of areola skin on the opposite breast.
As stated, the color of the areola around the reconstructed
nipple is more important than either the position or the
projection of the areola. Indeed, color patch symmetry
can compensate for partial or even significant loss of nip-
ple projection or slight abnormalities in position. This is FIGURE 10-2. A, Photograph of distinctive color and position
of the NAC, which ideally is located at the highest point of the
illustrated in this patient (Fig. 10-3), who sustained a sig- breast mound. B, Schematic illustrating ducts draining the lob-
nificant loss of nipple projection, marring what was other- ules and emanating through the nipple. CD, Typical position of
wise a good left breast reconstruction with a TRAM flap. nipple relative to topographic landmarks on the chest wall.
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Chapter 10 Revision of Nipple Areola Reconstruction 457

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FIGURE 10-3. A, Suboptimal nipple reconstruction with significant loss of projection resulting in a
major asymmetry. B, The areola tattoo transforms this suboptimally projecting nipple into a nipple
with an aesthetically pleasing appearance. C, Pre-operative oblique view. D, Post-operative oblique
view. This is a 7-year postoperative view.
In terms of timing, I believe that nipple areola reconstruction is most often combined with a procedure to
struction is best done at a second stage rather than during revise and reshape the reconstructed breast. In cases
the primary breast reconstruction procedure. This allows where the reconstruction is performed with tissue expan-
the breast mound to mature in terms of evolution of shape sion followed by secondary placement of an implant,
and gravitational settling. In my practice nipple recon- I perform the nipple reconstruction as a third stage,
Ch10.qxd 11/28/05 12:10 PM Page 459
although others2,3 will perform the procedure at the time An intradermal tattoo alone for nipple reconstruction
of subsequent implant placement. Performing a simulta- may be sufficient in the elderly, high-risk patient who
neous nipple reconstruction at the time of exchanging the desires a semblance of visual symmetry15 but in whom it
expander for an implant carries with it a small but definite may not be wise to have a formal nipple reconstruction
increased risk of losing the implant due to problems with due to local tissue conditions (i.e., scarring of skin, atro-
wound healing and subsequent exposure and/or infection phy of dermis, and subcutaneous adipose tissue).
at the site of nipple reconstruction.2,3
NIPPLE RECONSTRUCTION OPTIONS TABLE 10-1 Nipple Reconstruction Options

I. Tattoo only
Historically, the options for nipple areola reconstruction
II. Composite grafts
have been tattoo alone; the use of composite grafts such as a. Toe pulp
toe pulp,4 earlobe,5 labia minora6; or most commonly a b. Earlobe
composite graft of a portion of the contralateral nipple7 c. Labia minora
from the opposite breast (in patients with extremely large d. Opposite nipple
nipples). Over the past twenty years pullout skin flaps III. Pullout skin flaps
raised at the desired nipple position have represented the a. Skate
state of the art812 in nipple reconstruction. The most com- b. Star
monly used flaps are listed in Table 10-1. Reconstruction c. Modified star
of the areolar region is then performed using either a full- d. Fishtail
e. Mushroom
thickness skin graft with darkly pigmented skin13 or, as
f. Double-opposing tab flaps
noted earlier, an intradermal tattoo,14,15 which is the best
g. Areola tattoo
way to create symmetry of areola color.
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With the exception of nipple sharing,7 composite nipple, which in some cases may be a benefit. It also results
grafts, which were important in the early days of nipple in a scar on the donor nipple. However, when such compos-
reconstruction (e.g., earlobe, toe pulp), are largely rele- ite grafts are placed in the appropriate location and sur-
gated to the role of historic significance alone. I believe rounded by an intradermal tattoo, they can produce a good
that there is still a place, albeit rarely, for nipple sharing. simulation of the patients opposite nipple (Fig. 10-4D).
This technique is applicable in special circumstances of Currently the most popular technique for nipple recon-
primary reconstruction where there are extremely thin struction involves the use of a pullout flap810 of skin and
and attenuated tissues or scarring in the desired position subcutaneous adipose tissue at the ideal site on the recon-
of nipple reconstruction in the patient who has a large structed breast mound with the application of an intrader-
opposite nipple that might serve as donor tissue for nipple mal tattoo for the areola reconstruction. Many designs are
reconstruction (Fig. 10-4AD). In addition, a composite possible and these are outlined in Figure 10-5. Varying
graft of the nipple is also helpful in a difficult secondary degrees of success can be achieved with pullout flap
case to treat the complication of loss of nipple projection reconstructions based on their design. That is to say, the
in selected instances where the option of local flap recon- design of the specific nipple flap may indeed play a role in
struction is unavailable. Such a case is illustrated in the ultimate projection. I believe that some flap designs
Figure 10-4. are inherently better than others.
Nipple sharing involves removal of either the distal or For example, I have found that the quadripod design16
most anterior aspect (Fig. 10-4A) of the nipple or excision (Fig. 10-6), which employs a direct elevation of the tissue
of a pie-shaped portion of the nipple on its undersurface with closure of flaps at the base of the nipple, is unreliable
(Fig. 10-4B). It obviously decreases the size of the donor in terms of producing and maintaining long-term nipple
FIGURE 10-4. A, Nipple-sharing technique of nipple reconstruction with harvest of the most anterior
aspect of the wedge of the nipple, which is ready for transfer as a composite graft. B, Alternatively a
wedge of the inferior aspect of the opposite nipple can be harvested for transfer as a composite graft.
C, Composite graft of nipple placed on recipient bed. D, Healed appearance of composite nipple graft.
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A Quadripod flap
FIGURE 10-5. Pullout flaps. These are the most commonly

C
used skin designs for skin and subcutaneous adipose flaps used
for nipple reconstruction.
projection. This technique often produces a nipple that

looks excellent on the operating table but it loses most of
its projection with time (by 1 year postoperatively). To the
surgeon who studies this design and analyzes the tech- D
nique of elevation, this loss of projection would seem to be
almost intuitive. The forces of wound contraction would
act to directly pull this tissue back down to the plane of
the breast surface, thereby predisposing it to and potenti-
ating loss of projection.
In contrast, the flap techniques that elevate skin and adi-
pose tissue off of the reconstructed breast, detaching it at FIGURE 10-6. AD, The quadripod flap. This is a type of pull-
all areas but the base of the flap and then reconfiguring it out flap that does not involve separation and reconfiguring of
into the desired nipple shape, are more successful in terms the nipple. Inherently it allows the forces of wound contraction
to pull the nipple back down to the base.
of maintaining their projection.811,1720 The elements in the
flap responsible for the nipple projection are adipose tissue
and the thickness of the dermis. The more reliable designs
are those in which the flap tissue used for reconstruction of COMMONLY ENCOUNTERED
the new nipple is elevated, or pulled out, to at least a 90- PROBLEMS WITH RECONSTRUCTED
degreen angle from the surface of the breast mound. Such NIPPLES
procedures are variations of the skate design originally pro-
posed by Hartrampf,11 which were subsequently modified Problems associated with nipple reconstruction include
and refined by Little and Spear (Fig. 10-7).17,18 asymmetries of position or a slight tilt of the nipple to one
It has been my observation that the modified star side or the other, or in a superior or inferior direction; differ-
design19 can reliably produce small to moderately project- ences in skin pigmentation, and the most commonly noted
ing nipples (Fig. 10-8; 5 mm). For the reconstruction of problem, projection loss. Loss of projection is multifactor-
larger nipples, my choice is the skate design18 (Fig. 10-7). ial. It is related certainly to the natural processes inherent
The fishtail flap developed by McCraw20 (Fig. 10-9) also with wound healing, most notably contraction. Additionally,
has the ability to produce a nipple with very marked pro- loss of projection can be attributed to ischemia of the skin
jection. Such designs may allow the maintenance of and adipose tissue in the nipple flap itself. This is most often
greater long-term projection. Of particular advantage is a marginal ischemia of the skin flap used for the nipple recon-
modification of the fishtail flap design that is used when struction at the point of inset. The latter can result in an
there is a transversely oriented scar slightly above or open wound, which accentuates the problem of wound con-
slightly below the desired nipple position (Fig. 10-10). traction and increases the loss of nipple projection. To learn
This design makes it possible to reconstruct the nipple about the natural history of nipple reconstruction, we have
without placing any new scars on the reconstructed recently completed a prospective analysis of projection loss
breast. It may be based either superiorly or inferiorly, studied every 3 months for 1 year following nipple recon-
depending on the desired nipple position. struction. Our data indicates a loss of projection of 40%
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The Skate flap

A
B
FIGURE 10-7. AE, The skate flap is the classic pullout flap. This entails elevating a composite of skin
and fat out of the breast to a 90-degree angle and configuring the nipple with closure of the donor site in
a way to support the projection of the nipple.
with all types of flaps, and the majority of this loss occurs contralateral breast. This must be visually assessed, and
within the first 6 months of surgery.9 then careful measurements from a fixed point, most often
the suprasternal notch, are made. The next reference point
is the distance from the midline on the horizontal plane to
AVOIDING PROBLEMS DURING THE the position from the suprasternal notch, and this is also an
PRIMARY PROCEDUREPLANNING important parameter. These measurements are then cross-
AND PATIENT MARKING referenced with the patients opinion as to where the nipple
should be created (Fig. 10-11A,B). At this time the aesthetic
In planning nipple reconstruction the surgeon must study judgment of the surgeon comes very much into play.
the opposite breast carefully. It is important to note the The projection of the opposite nipple, its base width,
position of the nipple relative to the breast mound on the and the shape and position of the areola all need to be
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The Modified star flap

base width of
opposite nipple
lateral flap
A 1.5cm
B
2cm 1.5 cm
C
4mm adipose tissue
Note distal tip of flap

is past midline to
permit "stacking"
increasing projection
FIGURE 10-8. AE, The modified star flap. Very useful in primary and secondary reconstruction of
the nipple. A derivative of the skate flap. (continued)
carefully assessed and considered in the preoperative The surgeon next focuses his or her gaze on the recon-
plan for nipple reconstruction, in conjunction with its structed breast and must analyze its shape and degree of
planned position relative to existing scars on the recon- projection and visually assess where the nipple might best
structed breast (Fig. 10-11A,B). The base width of the be aesthetically placed. Ultimate placement is performed
normal nipple on the contralateral breast determines using a combination of this assessment, patient desires,
the base dimensions of the flap used for the new nipple and aesthetics. I believe that when possible the nipple
and is an important guide no matter what technique should be placed at the highest point of the breast mound,
is selected. These features are outlined in the illustra- but definitely not above this point. It is acceptable to place
tions (see Figs. 10-7 and 10-8) for the skate flap and mod- it slightly below this point should the patient have ptosis
ified star flap. of the opposite breast and not request or refuse surgery to
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delicate flaps. They must be handled with extreme care

using skin hooks or fine forceps employed primarily with
sharp dissection with a scalpel or sharp scissors for flap
elevation. In configuring and suturing the flaps, the sur-
geon must be careful not to excessively twist or bend the
flaps. Flap loss due to ischemia is may result from over-
tightening the skin, excessively bending the flap(s), or
using too many sutures. Any element of flap compromise
must be recognized at the time of the nipple reconstruction,
and necessary sutures must be removed or flap transposi-
tions altered to immediately reverse any flap ischemia dur-
ing folding and configuring the nipple. Generally only one or
two sutures need to be removed to avoid such a problem.
Achieving primary wound healing is key. The surgeon
must avoid ischemia of these delicate flaps, which most
often will lead to flap separation and open wounds. This
condition results in increased wound contraction, often
dramatically decreasing nipple projection or altering the
shape, inclination, and even position of the reconstructed
nipple.
Following nipple areola reconstruction, I feel it is nec-
essary to protect the nipple from external compressive
forces. I do this by placing a foam rubber donut around
the nipple. I ask patients to wear this inside their bra for
approximately 1 month as a means of protecting the
newly reconstructed nipple. I believe that such a device
may play a role in preventing loss of projection due to
early mechanical compression of the reconstructed nipple
(Fig. 10-13).
correct the ptosis (Fig. 10-11C). The relevant factors most If a skin graft is used for the areola reconstruction, a
commonly considered and important planning measure- bolster-type dressing is placed to ensure maximum con-
ments before a primary nipple reconstruction are illus- tact of the graft with the underlying graft bed. This bolster
trated in this patient, who will undergo nipple areola is left in place for a minimum of 5 days. When skin grafts
reconstruction and mound revision following a TRAM are needed, full-thickness skin grafts are my preference.
flap breast reconstruction (Fig. 10-12). I do not feel that it is necessary or advisable to harvest pig-
The procedure of nipple reconstruction can almost mented skin from the area of the proximal inner thigh or
always be done in an outpatient setting under local labial region. Harvesting skin from these donor sites can
anesthesia with sedation. In the situation of previous auto- be uncomfortable or painful for the patient. Almost all
genous tissue breast reconstruction, the nipple reconstruc- full-thickness skin grafts will undergo hypopigmentation
tion need not be performed in the hospital operating with the passage of time. An intradermal tattoo is usually
environment because it can be safely done in an office oper- the best way to optimize the color match between the nor-
ating room or even in a treatment room. However, in cases mal areola and areolar tissue around the new nipple.
where an implant breast reconstruction has been per- A skate flap requires a small or large skin graft to close
formed, I believe that the maintenance of the best possible the flap donor area. The traditional skate involved a donut
sterility in terms of the operating room environment and or washer-shaped skin graft, whereas more recent designs
surgical technique is essential. Therefore the nipple recon- have employed smaller rectangular skin grafts at the base
struction procedure following an implant breast recon- of the nipple. It is important to oppose the edges of the
struction requires the use of an operating room where dermis to close the donor area of the fat component on the
sterility can be maximally preserved. deep surface of the skate flap (Fig. 10-7D,E).
The use of the star flap (Fig. 10-8AE) includes primary
closure of the donor area and does not require a skin graft.
SURGICAL TECHNIQUE The donor area in this technique is closed directly by edge
to edge skin approximation (Fig. 10-8D). This is done in
In performing nipple reconstruction the surgeon must two layers. It is important to realize that with this tech-
realize that no matter what technique is used, these are nique the sutures that have been used to configure the
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Fishtail Flaps
FIGURE 10-9. AE, The design and elevation of the fishtail flap.
nipple must be left in for at least 3 weeks (Fig. 10-8E). mon circumstances be treacherous, and it is fraught with
A subsequent areola tattoo can camouflage the scars from problems related to the natural forces of wound healing;
the flap donor closure areas, which extend radially away the type of previous breast reconstruction; the quality,
from the nipple base (Fig. 10-8D,E). Direct closure of the thickness, and degree of attenuation of the local tis-
donor area flattens the contour of the reconstructed sues, most importantly the thickness of the dermis and
breast slightly. subcutaneous adipose tissue layers at the site of the pro-
posed reconstruction.
When assessing a patient for nipple reconstruction, the
PLANNING IN THE DIFFICULT CASE surgeon must be especially wary of tissues that are exces-
sively thin. This situation is common following the use of
Although seemingly very simple in concept, creation of tissue expansion for the breast reconstruction (Fig. 10-
consistently successful nipple areola reconstructions with 14). Because tissue expansion definitely results in thin-
long-term projection that simulates the opposite NAC is ning of the subcutaneous fat layer and dermis, at the time
an art. This straightforward operation can in some com- of exchange of the expander for the chosen implant
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Alternative Design of Fishtail Flaps
Healed Transverse
Mastectomy
Incision
Fishtail flaps designed 1808

to each other
FIGURE 10-11. A, Plan for positioning of the nipple on the

reconstructed breast. Ideally the nipple is placed at the highest
point of the breast mound. It can be positioned according to
dimensions derived from fixed points on the torso, including the
FIGURE 10-10. AC, An alternative and very useful design of suprasternal notch, and the distance from the midline. The base
the fishtail flap that can be used when a transverse scar is pres- (here lateral) of the new nipple should not be encroached on by
ent on the breast. existing scars on the breast. B, Outline for modified star flap
reconstruction with 15-mm flap base width. C, Nipple placed in
dependent position on left breast reconstruction to match right
nipple, which is in a dependent position.
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FIGURE 10-12. Planning for combination of lipocontouring

of breast and modified star flap reconstruction.
I always make special note of the thickness of the muscle
layer, subcutaneous adipose tissue, and dermis, specifi-
cally noting any significant atrophy that exists in the sub-
cutaneous adipose layer. As previously mentioned,
I believe that it is helpful to perform the nipple recon-
struction at a third stage in individuals who are undergo-
ing implant reconstruction following the placement of a
tissue expander.
The presence of scars (Fig. 10-14) on the breast is often
a significant factor in selecting the type of nipple recon-
struction. Their position and width, as well as the quality
of the surrounding skin and deep tissue, must be carefully
assessed, and a reconstructive plan must be developed to
minimize any negative impact these scars might have on
the nipple reconstruction.
Scars from previous biopsies or the mastectomy can be
very problematic. They do influence the choice of tech-
nique, and this is especially true if the scar runs right
through the area of the planned base of a new nipple
reconstruction. In this situation it is often advisable to use
a technique that straddles2125 the scar (Fig. 10-15). The
technique that best accomplishes this is the double-
opposing tab flap described by Knoll.25 Scars can be a par- FIGURE 10-13. Sterile foam rubber donut used to be placed
ticularly important factor, especially when they lie right around reconstructed nipple at the time of surgery to protect it
where the nipple is to be centered. Previous radiation from compression over the first 3 weeks of healing.
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NIPPLE RECONSTRUCTION
TECHNIQUES
My choice of nipple reconstruction technique depends on

the projection of the nipple I am attempting to match on the
contralateral breast. For nipples with 5 mm of projection or
less I favor the modified star flap (see Fig. 10-8AE). For
nipples with greater projection I sometimes use a skate flap
(see Fig. 10-7AF). Another indication for the skate flap is
the situation where I do not wish to produce any flattening
of the anterior contour of the breast. Here a skate flap and a
skin graft may be preferable. Finally, I will consider the use
of a double-opposing tab flap (Fig. 10-15AE) when
the mastectomy scar runs directly through the site where
the base of the nipple would be ideally located. The follow-
ing section outlines how I perform each of these techniques.
FIGURE 10-14. A: Patient with significant scar and atrophy of

subcutaneous tissue following a right breast reconstruction with THE MODIFIED STAR FLAP
tissue expander and implant.
The design of the flap in a particular case is dependent on the
base width and projection of the opposite nipple. The base
therapy causes fibrosis of the skin and dermis and confers width is created to match that of the nipple of the opposite
to the skin flaps a stiff quality that makes folding and con- side. The width of the lateral limbs determines the ultimate
figuring them difficult. There is also decreased circulation nipple projection. When planning this dimension it is impor-
in such flaps. A history of smoking further complicates tant to realize that approximately a 30% to 40% loss of pro-
these conditions and poses special problems. Therefore I jection will occur over time. Therefore I usually make the
urge all patients who smoke to quit completely for at least lateral limbs a minimum of 1.5 cm wide and 2 cm in length
4 weeks before surgery.26 (see Fig. 10-8A). The total height of the nipple is planned for
In summary, I believe that it is essential to alter the at least 1 cm. By making the distance from the base of the
design of the nipple reconstruction procedure so that the lateral flap to the tip 2 cm, the flap will fold around the cen-
blood supply to the flaps is minimally affected by the exist- tral core of the nipple, allowing skin closure without tension.
ing scar tissue. Radiation therapy poses its own set of diffi- These flaps are elevated with 2 to 4 mm of adipose tissue (see
culties, especially if multiple skin scars are also present. Fig. 10-8B) on their deep surface (deep to the dermis), which
Patients who smoke also appear to have more problems allows folding of the flaps without tension.
related to circulation in the skin of the breast. As mentioned, After injection of 1% lidocaine (Xylocaine) without epi-
this must be pointed out to the patient preoperatively and a nephrine, the lateral flaps, or wings, are elevated first fol-
plea made for temporary cessation of smoking.26 lowed by the central flap. The dissection proceeds toward
Combinations of these risk factors for nipple recon- the central portion of the design. As the central core of the
struction can often lead to problems. As previously noted, nipple is approached, it is important to access a deeper
an open wound anywhere in the area of a nipple recon- plane in the adipose layer. In a primary nipple reconstruc-
struction will in my opinion definitely predispose the tion the dissection proceeds unencumbered. In the second-
patient to experience accelerated contraction and loss of ary case the surgeon will be elevating scarred elements of
projection in the reconstructed nipple. the previous unsuccessful nipple and so it is important to
Major loss of projection following nipple areola recon- preserve the maximum amount of blood supply to the adi-
struction is very disappointing for both the patient and pose tissue and skin arising deep within the flap. For this
the surgeon. This outcome results in an asymmetry that reason I elevate the most proximal portion of the flap at its
detracts from the overall appearance of the reconstruc- base, delicately with blunt dissection, using either teno-
tion. In addition, it places scar tissue directly at the site tomy scissors or in some cases the handle of the scalpel
where the nipple should be positioned. Therefore the pri- blade. This tends to optimally preserve the blood supply to
mary nipple reconstruction must be carefully planned and the central core of adipose tissue and skin of the new nip-
executed in a precise manner because secondary recon- ple. The donor area is closed primarily and in layers, with
structions are more difficult. For this reason a few com- the deep dermis closed first with coated polyglycolic acid
ments about the planning and technique of primary suture [3-0 Maxon (Sherwood-Davis & Geck, St. Louis,
nipple reconstruction are in order. Mo) or 3-0 PDS (Ethicon, Inc., Somerville, NJ)], followed
Ch10.qxd 11/28/05 12:11 PM Page 469
by a skin closure with interrupted 5-0 nylon. The nipple through the dermis into the adipose tissue, thereby raising
elements are then assembled starting with the lateral flaps. a core or finger-like projection of adipose tissue in conti-
These flaps are advanced past the midline to achieve stack- nuity with the skin in the central portion of the flap. This
ing in the portion of the nipple opposite the base to maxi- central core of adipose tissue is gently raised with a
mally increase the projection (Fig. 10-8D). scalpel, leaving behind a deep V-shaped trough defect in
The 5-0 nylon sutures used for configuration of the nip- the subcutaneous adipose tissue. The width of this core
ple with these flaps are left in place for 3 weeks to ensure progressively increases as the dissection moves toward
good healing and to prevent unfurling of these folded the base of the flap. As the base of the flap is reached, it is
flaps. Removal of these sutures before 3 weeks has in sev- important to preserve as much blood flow to the fat as
eral cases resulted in wound separation of the flaps used possible. This blood flow is derived from vertically ori-
to create the nipple. Finally, the newly reconstructed nip- ented blood vessels running in the fat, and to spare them
ple is protected from direct compression by a foam rubber I will gently spread or stretch this tissue with either the
donut (Fig. 10-13), which can be inserted into the bra dur- dissecting scissors or handle of the scalpel. The dermis on
ing the first month of postoperative healing. either side is incised to the nipple base to permit a full
90-degree elevation of the flap. When the elevated flap is
held perpendicular to the plane of the breast, it resembles
THE SKATE FLAP a sunfish or skatehence its name, the skate flap.
The V-shaped donor area in the center (see Fig. 10-7D)
The skate flap (see Fig. 10-7AF) can produce a large nip- is then closed with 4-0 chromic sutures that bring dermis
ple with significant projection, and it is my choice when edge to dermis edge, with care taken to bury the knots.
the existing contralateral nipple has a projection of 7 mm This closed wound will create a platform on which to
or greater. The nipple is located according to patient assemble the new nipple. The nipple is reconstructed by
wishes and aesthetic concerns. It is optimally positioned configuring the lateral wings around the central core by
at the highest point of the breast mound. starting at its base and working toward the apex. The lat-
I will often give the patient an electrocardiogram lead to eral-most tip of each lateral wing is sewn to its counter-
place on her reconstructed breast. In this way she chooses part with interrupted 5-0 chromic suture. The flaps are
the position for the nipple to be created. The design of the closed without excessive tension.
skate flap is variable and the dimensions are dependent on The donor area of the skate flap is most often closed
the projection of the opposite nipple. The base width is with a full-thickness skin graft that is harvested from any
planned to match that of the opposite nipple, with approx- area of skin excess. It need not be taken from an area of
imately an equal distance of skin on either side to com- skin with increased pigmentation, such as the inner thigh
prise the lateral wing. The distance from the base of the or labia. The full-thickness graft is thoroughly defatted
nipple to the portion of the areola furthest from it is and sutured to the periphery of the defect. It is preferable
approximately twice the projection of the opposite nipple to raise a skin graft rather than to close the wounds under
(see Fig. 10-7A). This 2 to 1 dimension of the central axis of excess tension. Closure under tension will almost invari-
nipple allows for loss of projection occurring from the nor- ably produce a spread scar that will be unsightly and that
mal processes of contraction and wound healing. The does not take tattoo pigment well.
patient should be informed preoperatively of the discrep- A tie-over bolster dressing is used to maximize graft to
ancy in nipple height that will be present immediately after the recipient bed contact. The bolster is usually left in
surgery, with the reconstructed nipple much larger than place for a minimum of 5 days. The reconstructed nipple
the opposite nipple. This central axis is also the region is again protected from compression by clothing it with a
from which the core of fat that will comprise the main sub- foam rubber donut that is worn for 1 month.
stance of the nipple will be elevated. The central core of the The optimal time for areola reconstruction with an
flap is adjoined on either side by extensions of skin that intradermal tattoo is approximately 3 to 4 months follow-
elevated together leave a circular outline (see Fig. 10-7D,E). ing healing of the skin graft. This skate flap method per-
The position of the nipple and design of the flap are mits the reconstruction of a nipple of virtually any size,
checked just before taking the patient to surgery. and it is my technique of choice when the projection of the
The skin markings of the flap are injected with local contralateral nipple exceeds 6 mm.
anesthetic (1% lidocaine) without epinephrine. The out-
line of the design is incised peripherally on all sides. Next,
the lateral flaps are elevated from peripheral to central at THE DOUBLE-OPPOSING TAB FLAP
the deepest dermal level. Yellow adipose tissue should not
be visible at this point. As the point of transition between As previously mentioned, a potential problem situation
the lateral elements and the central core of the flap is for nipple reconstruction results when the scar from the
reached, the dissection is deepened by incising completely mastectomy runs directly through the intended site of the
Ch10.qxd 11/28/05 12:11 PM Page 470
nipple reconstruction. This scar position can cause prob- mound at this point. This remains an unsolved problem.
lems with the vascularity of the flap(s) used for the nipple Nevertheless, the double-opposing tab flap remains a use-
reconstruction and reduces the amount of subcutaneous ful technique for nipple reconstruction when the mastec-
adipose tissue available on the deep surface of the skin tomy scar runs directly though the ideal position for
flaps. This situation can be addressed with the use of flaps nipple creation.
raised on either side of the scar. Such a technique is that It is important to realize that no matter what technique
of the double-opposing tab flap, as proposed by Kroll21,25 is selected, contraction will occur as part of the wound
(Fig. 10-15A,E). healing process and therefore the nipple needs to be made
If this double-opposing design is used, it is essential for larger than the opposite nipple at the time of the nipple
the surgeon to make the base width of these flaps consid- reconstruction surgery. Before the study9 noted earlier
erably wide (minimum of 15 mm). This will help ensure was done, we had the strong clinical impression that the
adequate blood supply to the flaps as they are elevated. shrinkage rate was somewhere between 40% and 60%.
Unfortunately, closure of the created donor defect does This was based on evaluation of projection as a function
confer a definite flatness to the reconstructed breast of time from surgery, with projection carefully studied for
Double opposing tab flaps
A
B
FIGURE 10-15. AE, The double-opposing tab flap. This is a nipple reconstruction based on flaps that
are elevated and wrapped around each other. It has utility when the scar from the mastectomy runs
directly through the site of intended nipple reconstruction. It is important to make the base of these
flaps sufficiently wide (18 mm) to ensure vascularity to the reconstructed nipple.
Ch10.qxd 11/28/05 12:11 PM Page 471
1 year. As corroborated in our study,9 most of the projec-

tion is lost within the first 6 months. Projection loss does
continue up to 1 year, but it seems to be stable after that.
This is an important concept for the surgeon to be cog-
nizant of when trying to achieve long-term nipple symme-
try from the standpoint of projection.
REVISION AND SALVAGE OF THE

SUBOPTIMAL NIPPLE
RECONSTRUCTION
Cases of minor nipple projection loss may be compen-

sated for with an intradermal tattoo procedure (see
Fig. 10-3AC). This tends to produce color patch symme-
try, giving the appearance of a normal breast and nipple
symmetry on casual glance. I believe that a well-done tat-
too can salvage a suboptimal nipple reconstruction in
many cases (see Fig. 10-3).
Major loss of projection following nipple areola recon-
struction is disappointing for both the patient and the sur-
geon. This outcome results in an asymmetry that detracts
from the overall appearance of the reconstruction. This
situation can be addressed in several ways. An uncommon
but helpful technique is to use a composite graft of nipple
from the opposite breastif the nipple is of sufficient size
and the patient is willing to permit a surgical procedure
on it with the placement of incisions. The utility of this
technique is illustrated in the following case.
The patient in question had undergone a previous nip-
ple reconstruction following breast reconstruction with a
tissue expander and subsequent implant. The recon-
structed nipple had suboptimal projection (Fig. 10-
16A,B). Because the patient had a wide thin scar at the
intended site of nipple reconstruction only, with attrition
of the skin and subcutaneous fat from the tissue expan-
sion process and a very large contralateral nipple, we
addressed this problem by de-epithelializing the skin over-
lying the suboptimal nipple reconstruction and placing a
composite graft from the opposite nipple (Fig. 10-16C).
This remedied the deficient projection and enhanced sym-
metry between the nipples (Fig. 10-16D,E).
More commonly a modified star flap19 is very helpful
as a booster tissue substrate (Fig. 10-17AD) for the sub-
optimal nipple reconstruction. This flap can be elevated
at the site of the original nipple reconstruction as long as
it is oriented such that the base is not encroached on or
compromised by existing scar tissue. The use of this
modified star flap to augment nipple projection in a
patient who had previously undergone nipple recon-
struction with a modified star procedure is illustrated in
(Fig. 10-18AF). This was a young female who had an
FIGURE 10-16. A, Partial loss of previous left nipple recon-
immediate left breast reconstruction with a TRAM flap. struction following tissue expander and implant noted on AP
Eight months following surgery she underwent nipple view. B, Lateral view of same patient. Note lack of projection in
areola reconstruction with a superiorly based modified the reconstructed nipple. (continued)
Ch10.qxd 11/28/05 12:11 PM Page 472
star flap to increase her nipple projection (Fig. 10-

18B,C). This was done by orienting the flap in the exact
same direction as the original flap, elevating most of the
previous flap with the new modified star flap (Fig. 10-
18D). This produced a very satisfactory outcome from
the standpoint of symmetry with the contralateral nipple
(Fig. 10-18E,F).
SUBTOTAL AND TOTAL NIPPLE LOSS
Failure of nipple reconstruction is extremely disappoint-

ing for the patient and the surgeon. Fortunately it is rare.
The foregoing section highlights the conditions most
often responsible for excessive or complete loss of nipple
projection. It is obviously critical for the surgeon to care-
fully assess each patient for the presence of these factors
and to make adjustments in the surgical plan to compen-
sate for scars or tissue atrophy.
What do you do when the patient sustains either sig-
nificant or complete loss of nipple projection? My
approach has been to first allow wound conditions to
equilibrate. The acute inflammation, tissue edema, and
stiffness in the wound must be allowed to resolve com-
pletely. This means waiting the appropriate time for tis-
sue equilibrium to occur. The patient must be informed
of the critical importance of this healing period, which is
at minimum a period of 3 months, but it may be consider-
ably longer.
When this point of tissue equilibrium is reached, usu-
ally my approach is to use a pullout flap in the same loca-
tion, most often oriented in the same way as the original
flap design. The optimal orientation of the flap is deter-
mined by dermal blood supply and the presence of previ-
ous scars. When possible, the base of the flap should be
positioned in such a way as to avoid encroachment by pre-
vious skin scars. There is some evidence to show that
there is blood flow across a scarred dermal bed when 3
months has been allowed to elapse. However, it is most
prudent not to orient a new flap such that scars will trans-
gress on the blood supply at its base.
In virtually all cases of redo nipple areola reconstruc-
tion I use a modification of the skate design, namely the
modified star flap (Fig. 10-8). I have found this to be very
FIGURE 10-16. (CONTINUED) C, Composite nipple graft har- reliable because it has the advantage of direct closure of
vested from opposite nipple. D, Postoperative result of redo nip- the donor area. The only disadvantage is slight flattening
ple reconstruction seen at 9 months following surgery on AP of the anterior contour of the breast if the lateral limbs are
view. E, Lateral view of composite nipple reconstruction 9 made too wide. The design of the flap has been previously
described.
In summary, it is important to realize that the tissue of
the previously unsuccessful nipple reconstruction can be
star flap. She sustained wound separation at the site of elevated as part of a new or secondary skate flap that is
flap inset, which resulted in excessive wound contraction being used to treat the problem of the suboptimal projec-
and a 70% loss of nipple projection. Five months follow- tion. The following two cases illustrate the use of this
ing complete healing we performed another modified technique after unacceptable loss of nipple projection fol-
Ch10.qxd 11/28/05 12:11 PM Page 473
A B
design of modified star flap

in bed of previous mipple
reconstruction
redo nipple reconstruction

with modified star flap
modified star flap on-table nipple projection

incisional closure following redo nipple
FIGURE 10-17. AD, Outline of redo nipple reconstructed with modified star flap. Note that the flap is
designed such that the base (blood supply) is oriented in the same direction as the previous reconstruction.
lowing primary reconstruction with a skate flap, a BELL increase nipple projection. We addressed this problem by
flap, and a previous modified star flap. performing a modified star flap with the base oriented
The first patient underwent a left breast reconstruction superiorly (Fig. 10-19C). The nipple reconstruction star
with a free microvascular TRAM flap. She had a subse- flap was elevated as described earlier, incorporating por-
quent nipple areola reconstruction with a skate flap. The tions of the previously placed skin graft as part of both lat-
areola was reconstructed with a full-thickness skin graft. eral flaps and the central flap. She healed without
The patient experienced separation at the suture line difficulty and demonstrates stable projection that is sym-
between the skate flap and skin graft that produced excess metric with the opposite nipple at a 2-year postoperative
wound contraction This resulted in loss of nipple projec- follow-up (Fig. 10-19D,E).
tion such that there was less projection on the recon- The next patient had undergone a BELL flap27 (Fig.
structed side (Fig. 10-19A,B). She desired a procedure to 10-20AF) for bilateral nipple areola reconstruction
Ch10.qxd 11/28/05 12:11 PM Page 474
FIGURE 10-18. Modified star flap used as a boost to inadequate previous nipple reconstruction.
A, Inadequate projection of reconstructed nipple when compared with significant projection of the nip-
ple on the patients opposite breast. B, Design of redo nipple reconstruction with the modified star flap
used as a boost to address the inadequate projection of the previous nipple reconstruction. CD, Surgical
elevation of the flap. Gentle handling of the tissue is accomplished with skin hook. E, Flap tissue being
configured into the shape of a nipple. F, Enhanced projection noted postoperatively on lateral view.
following a tissue expander (synthetic implant breast However, both the areolar projection and nipple projec-
reconstruction for her bilateral mastectomy reconstruction are short lived in most cases so I no longer use this
tions. The BELL flap was selected because of the signifi- flap. The patient had normal primary healing but experi-
cant areola projection of the contralateral nipple. At one enced total loss of nipple projection of both nipples over
time I felt that the purse string closure (Fig. 10-20E) of the the ensuing 9 months (Fig. 10-21A). There was good vas-
donor area of this flap could produce a projecting areola. cularity of the nipple flap but a diminished thickness in
Ch10.qxd 11/28/05 12:11 PM Page 475
both the dermis and the subdermal adipose layer noted at

the initial procedure.
This loss of nipple projection was addressed using a
modified star flap (Fig. 10-21B), in which a portion of the
underlying pectoralis major muscle (PMM) was elevated
(Fig. 10-21C). Incorporating the PMM in this manner can
increase the tissue bulk (Fig. 10-21D) available and prob-
ably provides increased circulation to the skin of the nip-
ple flap. When elevating the PMM (Fig. 10-21C) it is
important not to violate the periprosthetic capsule to
minimize danger to the implant. If the capsule is inadver-
tently opened it may be closed with a 4-0 chromic suture.
In this patient and others I have seen with similar defi-
ciency of subcutaneous fat at the site of planned nipple
reconstruction, raising the PMM as part of the nipple recon-
struction has resulted in excellent long-term nipple pro-
jection following the previously suboptimal outcome
(Fig. 10-21E,F).
FIGURE 10-19. Modified star flap used to rescue subtotal loss

of nipple projection following skate flap nipple reconstruction
FIGURE 10-18. (CONTINUED) done in patient who underwent an immediate reconstruction of
the left breast with a free microvascular TRAM flap Nipple pro-
jection was lost as a result of contraction of wound at base of
skate flap following skin graft loss. A, Preoperative AP view.
(continued)
Ch10.qxd 11/28/05 12:11 PM Page 476
FIGURE 10-19. (CONTINUED) B, Oblique view. C, Surgical

plan for an inferiorly based modified star flap. D, On table view
of increased nipple projection provided by the modified star
flap. E, Follow-up view after redo nipple reconstruction seen 2
years postoperatively on AP view. F, Lateral view of same
patient.
Ch10.qxd 11/28/05 12:11 PM Page 477
incision is made just into the subcutaneous adipose tis-

sue so that the skin of the base of the nipple flap and the
opposite crescent flap can slide toward each other (Fig.
10-22D). This central donor site is closed with interrupted
5-0 nylon suture. The peripheral or peri-areolar donor
area is closed with a purse-string suture of 2-0 PDS (Fig.
10-22E), which is used to shrink the size of the circular
defect and establish a new areolar diameter that will
match the areolar diameter of the opposite breast (Fig. 10-
22E). The cloure of the periareolar wound is completed
with 5-0 chromic suture (Fig. 10-22F) and the post-opera-
tive appearance is shown in Figure 10-22G.
The advantages of this flap are that its blood supply is
robust, the nipple has stable projection after the first 8
months when only 30% is lost, and, most importantly,
there is a circular scar at the periphery of the nipple that
can be completely camouflaged by a subsequent tattoo
procedure. It is useful in both primary and secondary
cases of nipple reconstruction.
REDO NIPPLE RECONSTRUCTION WITH

ALLODERM
I have had experience with the use of AlloDerm (LifeCell

Corp., Branchburg, NJ) to salvage a partially failed nipple
reconstructions in four patients. This acellular dermal
matrix material28 can be implanted beneath the skin at the
site of a suboptimal nipple reconstruction. It is important
that there be sufficient unscarred skin to permit draping
FIGURE 10-19. (CONTINUED) over this material without excessive tension. A tightly con-
stricting scar covering tends to flatten out this graft and
REDO NIPPLE RECONSTRUCTION WITH limits its effectiveness. The illustrated case (Fig. 10-23)
A DOUBLE-OPPOSING SLIDING shows the design and creation of skin flaps that will cover
PERIAREOLAR FLAP the AlloDerm graft. The patient is shown with a 4-month
postoperative result (Fig. 10-23AH).
A flap that I have used over the past year (and now I have not found the injection of collagen, the use of
strongly favor) for both primary and secondary nipple autologous fat injections, or dermis fat grafts to be useful,
reconstructions is a derivative of the skate flap design that and I have no experience with the use of stacked cartilage
incorporates features of the BELL flap. It is a flap with a grafts, which require incisions and a deformity at a sepa-
circular incision peripherally, whose diameter is made rate donor site and therefore have limited appeal for this
30% larger than the opposite areola (Fig. 10-22A). Within indication. Finally, I have not implanted silicone nipple-
this circular design a modification of the skate flap is shaped implants into the tissues at the site of a previously
drawn. The base diameter of the nipple matches that of failed nipple reconstruction. In such cases the existing
the opposite breast, and the horizontal flaps extending on scar tissue would not drape well over this type of implant.
either side of this are at least 1.5 cm in length and 1 to 1.4
cm in width, depending on the height of the opposite nip-
ple (Fig. 10-22B). The flap is then raised by making full INCORRECT NIPPLE POSITION
thickness incisions on all sides of the nipple flap without
traversing the base and elevating 1 to 2 mm of adipose tis- When a reconstructed nipple comes to lay in the incorrect
sue with the wings. The nipple is then configured using position, it can be moved, but usually only a short dis-
the same method as seen with a skate or modified star flap tance. This may take the form of re-elevating the nipple by
with the wings curled toward the center and the cap com- dissecting toward its base and beyond its base, taking care
ing over the top of them (Fig. 10-22C). This creates a cen- to preserve its blood supply. The resulting defect or
tral donor area (Fig. 10-22C). At the same time the circular extended donor area of the flap must be closed by a direct
Ch10.qxd 11/28/05 12:11 PM Page 478
BELL flap
base width of nipple = 1/2r
radius of areola = r
B
A
elevation of superiorly D
based flap
flap folded on itself and donor

area closed with transfer of
E
adjacent flaps
FIGURE 10-20. The BELL flap. This reconstruction can potentially produce a projecting
areola. Because of my own problems with maintenance of nipple projection I no longer recommend
its use.
advancement closure, a V to Y closure, or a full-thickness case is usually closed using a purse string suture or V to Y
skin graft. Scars and skin grafts that are maintained closure technique (Fig. 10-24AD).
within 2 cm of the nipple that has been relocated can be If the nipple is significantly displaced the challenge is
camouflaged by an areola tattoo. more formidable. The options are to transfer the nipple as
If the nipple has been reconstructed on top of a skin a rotation flap or on a subcutaneous pedicle. The resulting
paddle from a musculocutaneous flap, a change in loca- open wound where the nipple was located must be closed
tion can often be achieved by moving the skin paddle a with a direct advancement closure, a V to Y technique, or
short distance in any direction. The donor area in such a a skin graft. When such wounds are located superior to
Ch10.qxd 11/28/05 12:12 PM Page 479
FIGURE 10-21. A, Complete loss of bilateral nipple projection in patient previously reconstructed with bilateral BELL flaps. There
is thinning of the dermis and subcutaneous adipose layer following the tissue expanderimplant breast reconstruction. B, Reoperative
nipple reconstruction is to be performed with bilateral modified star flaps where PMM will be raised with the skin. C, The PMM can
be raised with the skin of the modified star flaps to provide additional tissue bulk for the nipple reconstructions. D, On table view illus-
trating excellent projection in these redo nipple reconstructions. E, AP view at 2 years after redo nipple reconstruction in this patient
demonstrates maintenance of nipple projection. F, Oblique view at 2 years in the same patient.
Ch10.qxd 11/28/05 12:12 PM Page 480
FIGURE 10-22. A, Design of the double opposing periareolar flap. The areolar diameter is usually
30% larger than the opposite areola. The base width of the flap matches the base width of the opposite
nipple. The length of the wings is variable (1.5-2.0 cm) and the width varies between 1.0 and 1.4 cm. B,
The nipple flap is elevated with 2 mm of adipose tissue on the deep side of each wing and more adipose
in the center. C, The nipple is assembled by curling the wings in toward the center and bringing the cap
over them, D, An incision is made in the periareolar outline into the subcutaneous tissue until there is a
definite give when centrally direct traction is exerted on the flaps, indicating that they can slide
toward each other. The central donor area is closed with interrupted 5-0 nylon sutures. (continued)
Ch10.qxd 11/28/05 12:12 PM Page 481
FIGURE 10-22 (CONTINUED) E, The peripheral donor area is closed with a 2-0 PDS purse-string
suture, which creates an areolar dimension equal to that of the opposite breast. F, The peripheral skin
incision is closed with interrupted 5-0 chromic suture. G, The typical appearance of the nipple recon-
struction at 6 weeks following surgery.
Ch10.qxd 11/28/05 12:12 PM Page 482
FIGURE 10-23. A, Total loss of nipple projection following tissue expanderimplant reconstruction.
The patient has completely absent thickness in the subcutaneous fat layer due to attrition produced by
the tissue expansion process. B, The plan for reconstruction with AlloDerm includes elevation of skin
flap with which to wrap the AlloDerm. C, AlloDerm substrate after it is removed from package and rehy-
drated. D, AlloDerm strip rolled around a sterile toothpick like a bale of hay. E, The AlloDerm is put into
position and is about to be wrapped by the skin flaps. F, Appearance of redo nipple reconstruction after
redraping the skin flaps. GH, Appearance of reconstructed nipple 4 months following redo with
AlloDerm graft on AP view (G) and oblique view (H). (continued)
Ch10.qxd 11/28/05 12:12 PM Page 483

Ch10.qxd 11/28/05 12:12 PM Page 484
FIGURE 10-24. AE, Partial dermal excision to correct downward inclination of previously recon-
structed nipple.
the new location of the nipple, the outcome is usually less nipple. This is needed when either the nipple is very large
than aesthetically ideal. In such cases it may be best to and gravity causes it to tilt inferiorly or there is excess
excise the reconstructed nipple with the shortest possible contraction from scar tissue. Either of these problems
scar and redo the nipple reconstruction in the more can be corrected. The former is simple and involves an
appropriate position. excision of skin from the base of the nipple. This is done
in a way that preserves the deep dermis to preserve maxi-
mal blood supply to the nipple (Fig. 10-25A,B). In the lat-
INCORRECT NIPPLE INCLINATION ter situation, where scar contracture has resulted in an
abnormal inclination, the scar must be released (excised)
If the inclination of the nipple is incorrect, this can be and adjacent tissue advanced to form a new platform
corrected by excising skin into the very superficial dermal onto which to position the corrected nipple construct
level at the base of the nipple and the inclination of the (Fig. 10-25A,B).
Ch10.qxd 11/28/05 12:12 PM Page 485
B
A
nipple
inclined C
inferiorly
nipple lifted
D
off scar
superiorly
De epithelialized
crescent
FIGURE 10-25 AG, Re-establishment of base skin by advancement of skin flaps and de-epithelializa-
tion so that the nipple can be seated on a better foundation.
A more difficult situation is when the tattoo is too dark.

PROBLEMS WITH TATTOOING It may be possible use a lighter pigment and tattoo over a
darker area. However, this procedure is not successful in
As mentioned many times in this chapter, the intrader- most cases. In this situation it may be necessary to depig-
mal tattoo provides a critical visual dimension to the ment the area. The most common maneuvers involve der-
reconstructed nipple. Every reconstructive surgeon will mabrasion of the hyperpigmented area. On rare occasions
acknowledge that the best nipple reconstructions in his the area is excised and skin is grafted to the open wound,
or her practice exhibit excellent tattoos. Most medical with a redo tattoo planned for a later time.
tattoos fade with time, and usually they must be redone Fortunately this is a rare situation, and it is better to
at least once. This is not a problem, and each patient use a slightly lighter tattoo pigment at the primary tattoo
must be informed of this possibility before the initial procedure if there is any question about the shade of the
procedure. pigment to be used.
Ch10.qxd 11/28/05 12:12 PM Page 486
NIPPLE LOSS FOLLOWING BREAST This allows augmentation of the remaining nipple. The
REDUCTION OR MASTOPEXY costs of such a maneuver are the additional scars within
the areola and a narrower areola shape. The altered areola
Loss of the nippleeither complete or partial, with combi- can be adjusted using an intradermal tattoo. As previously
nations of NAC lossis uncommon, but it is a potential mentioned, this can be done to treat areas of hypopigmen-
risk that accompanies every breast reduction or mastopexy tation, as well as to restore symmetry to the areola in
procedure. This is true for mammoplasty procedures in terms of shape. An example of this combination is illus-
which a pedicle is used to carry the nipple to a new posi- trated in Figure 10-26.
tion, and also in procedures where the nipple is removed Loss of nipple projection in the setting of a previous
and repositioned as a full-thickness skin graft. The occur- breast reduction can be treated in the same ways as loss
rence of nipple areola loss is between 1% and 2%. following a postmastectomy nipple reconstruction. This is
Nipple necrosis is the result of ischemia that produces illustrated by this 42-year-old patient (Fig 10-26), who sus-
an open wound. These wounds heal by a combination of tained loss of projection of the right nipple following an
contraction and epithelialization. The scar tissue contrac- inferior pedicle breast reduction. After 9 months had
tion occurring in the wound may further diminish nipple elapsed and softness had returned to her tissues, we pro-
projection that results from tissue necrosis. In addition, ceeded with a superiorly based modified star flap (Fig. 10-
areas of hypopigmentation involving either the nipple and 26AE) and subsequent intradermal tattoo. This resulted
or the areola commonly occur. in a very good appearance of the NAC noted at a 2-year
Loss of nipple projection following breast reduction follow-up.
can be very disturbing for some patients. In such cases it Areolar hypopigmentation can be treated and often
is most often possible to increase nipple projection with a improved by an intradermal tattoo procedure. I have found
modified star flap designed right over the existing nipple. that the uptake of the tattoo pigments is often more diffi-
FIGURE 10-26. Loss of nipple projection following breast reduction reconstructed with modified star
flap. A, AP view showing suboptimal appearance and projection of right nipple with hypopigmentation
following previous breast reduction. B, Outline for reconstruction with modified star flap. C, Nipple
substance elevated to include previous ductal tissue at site of scarred nipple. D, Flaps configured into
the shape of a nipple using the stacking technique described earlier. E, Appearance of nipple recon-
struction 9 months following completion of modified star flap reconstruction and intradermal tattoo to
re-establish normal appearance of areola. (continued)
Ch10.qxd 11/28/05 12:13 PM Page 487
cult due to scar tissue resulting from the ischemia and the If the resulting areolar pigment is dark following a tat-
wound contraction. The NAC pigmentation on the opposite too, it is best to wait and allow sufficient time for it to
breast serves as a template for selecting the most appropri- lighten. If lightening does not take place, then the darker
ate pigment. Often it is necessary to blend various pigments pigment can be addressed using a YAG laser, dermabra-
to obtain the correct shade. All tattoos are done to increase sion, or excision of the skin with replacement using a full-
areolar color fade. Often these have to be redone. It is best thickness skin graft. It is uncommon to resort to the latter
to inform the patient of this preoperatively. The temptation option, but if it is chosen at least 2 months should be
to use a slightly darker color of dye must be avoided. This allowed to elapse before pursuing a redo of the tattoo
may result in an areola tattoo that is too dark. procedure.

Ch10.qxd 11/28/05 12:13 PM Page 488
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Index.qxd 11/30/05 1:14 AM Page 489
I N D E X
A Autogenous tissue conversion, Contd. Bra

Abdominal donor site, seroma and, 356 following suboptimal breast recon- cup size, 9
Abdominal wall closure, TRAM flap and, struction, 180, 180f, 181f hypertrophy and, 42
337338, 338f following suboptimal implant-based medial implant malposition and, 128
Abdominal wall hernia reconstruction, 180, 181f subglandular pocket dissection and, 79
prolene mesh and, 416, 416f, 418, TRAM flap and, 297, 297f298f Breast aesthetics, 382. See also
418f, 419 Autogenous tissue reconstruction, post- Symmetry of breast(s); Tubular
TRAM flap breast reconstruction and, mastectomy defect and, 384f breast deformity
416, 416f Autologous fat creating breast mount, 321, 322f323f,
Acute complications, breast augmenta- injection, 405 323, 324f, 325327
tion and, 8688 sites for, 432f433f, 434 determinants of, 20
Acute fat necrosis, TRAM flaps and, transplantation, contour of breast and, fat necrosis and, 406, 406f407f
358, 359f 432433 folds and, 287289
Acute wounds, 428 Autologous fat grafts, contour deficit nonoperated breast and, reoperated
Adipose tissue reconstruction and, 404405 breast and, 1764
aspiration, 363 Autologous tissue, pedicled TRAM flap, postoperative, 385f
contour abnormalities, skin scar, 432 399, 404 revision surgery and, 51f52f
contour defects and, 404 Axillary incision, 7576 skin paddle and, 379, 382
excision, volume reduction by, subpectoral pocket dissection and, 81 skin scars and, 379, 382
366, 367f Breast asymmetry, 100101, 396,
flap techniques for, 461 B 398f
tissue expander placement and, Bacitracin disfigurement and, 9
252, 253f subglandular pocket dissection and, 79, expander malposition, 265, 267f268f
TRAM flap breast reconstruction and, 80f multifactorial, 101102, 103f
303, 307, 308f, 313 subpectoral pocket dissection and, 82 postoperative view, 106f
volume excess, flap and, 362 Baker Classification Score, 149, 151t pre existing, 102, 105f
Adjacent contour adjustment, liposuc- Baker III capsular contracture, 111, 295 preoperative view, 105f, 108f
tion and, 368, 368f369f silicone augmentation and, 168f radiation and, 429
Adjustab implant, 102 Baker IV capsular contracture, 111, 138f, reoperative view, 107f
Aesthetic analysis. See also Cosmetic 166, 168f superior skin flaps and, 298299,
outcome autogenous conversion, 297, 297f 299f, 301
breast and, 19f silicone implant and, 164, 164f TRAM flap Breast reconstruction
Age, breast changes and, 21f Balloon dissector, subpectoral pocket and, 302
AlloDerm dissection and, 82 treatment plan, 378f
nipple projection loss with, 482f483f Base dimension vertical mastopexy and, 440, 441f
redo nipple reconstruction, 477, 482f breast augmentation and, 71, 71f Breast augmentation. See also Skin
skin wrinkling and, 134 breast reconstruction and, 371f envelope; Transaxillary breast
Anaphylaxis, fluorescein and, 342 problems with, contour and, 50, augmentation
Ancef. See Cefazolin 51f52f acute complications of, 8688
Anesthesia. See also General anesthesia tissue expander and, 243, 244f breast size reduction after, 97, 100
abdominal wall closure and, 337338, TRAM flap and, 370 complications of, 8586, 85f
338f Base width of breast informed consent and, 93
hernia and, 416, 416f, 417f implant choice and, 68, 70f, 243 larger cup size
reoperative surgery and, 4 TRAM flap and, 323, 324f postoperatively, 119f
Angiosomes, TRAM flap and, 311, 313f Becker expander/implant, 245f preoperatively, 118f
Antibiotic therapy Bell flap, nipple areola reconstruction, litigation and, 8
fat transplantation and, 432 473474, 478f malpractice insurance companies
infection and, 91, 259, 259f Bilateral breast reduction, 443 and, 5
TRAM flap breast reconstruction Biofilm, breast augmentation and, 88 medial malposition and, 125
and, 353 Biopsy, intraductal carcinoma of breast patient evaluation and, 6768
Applied aesthetics, 2224 and, 333 reoperative
Areola tissue, 455, 456f Bipedicle TRAM flap reconstruction overview of, 84t
Areolar hypopigmentation, intradermal rectus muscle and, 320f, 327, 327f reasons for, after saline implant, 97t
tattoo procedure and, 486, 487 synthetic mesh and, 321f six months postoperative, 127f
Areolar tattoo. See Tattooing technique for, 319 revisional surgery following, 67
Arterial insufficiency, TRAM flap BLAKE drain, seroma and, 163 reasons for, 66
and, 335 Bleeding, transaxillary breast augmenta- transaxillary approach to, 7576
Aspirin, breast augmentation and, 86 tion and, 76 volume asymmetries and, 56f, 5859
Augmentation mastopexy, vertical scar Bleeding points, TRAM flap breast worksheet, 70f
technique and, 41 reconstruction and, 353 wrong size, malpractice insurance
Autogenous latissimus dorsi flap, 445 Blood supply companies and, 5
Autogenous tissue breast reconstruction, breast parenchyma and, 74f Breast bud, 19
464, 467f double-opposing sliding periareolar Breast cancer. See also Mastectomy
Autogenous tissue conversion, 291 flap, 477 breast-conserving therapy and, 420
advanced capsular contracture and, nipple reconstruction and, 468 partial mastectomy for, 444f445f
297, 297f Body habitus, breast aesthetics and, periareolar incision, 332f, 333
following breast augmentation, 178, 3233, 34f, 3537 post-lumpectomy deformity and,
178f, 179f Bovie, capsulectomy and, 159 445, 447f
489
490 Index
Breast deformities. See also Combination Breast volume, Contd Cigarette smoking
breast deformity internal adipose flap and, 399, explantation with mastopexy alone
combined, reoperation and, 6263 402f403f and, 170
tumor resection and, 432 post-lumpectomy deformity and, mastectomy flap necrosis and,
Breast gland. See also Ptosis of breast 424, 445, 446 341, 341t
anatomy, 1820, 18f projection of breast, 399, 404 reoperative surgery and, 4
deformities, 30, 31f tissue volume and, lower abdomen TRAM flap breast reconstruction, 306
development, anatomic distribution and, 370, 370f, 372, 375 Circulation, fat necrosis and, 405406,
and, 1820, 18f discrepancies, nipple position and, 406f407f
dimensions, breast aesthetics and, 33 6263 Cleavage, wide-set, 101f
puberty and, 1920, 21f excess, 384f Closed capsulotomy, 108, 112f
radiation and, 420 flap insertion for, 171f Color patch symmetry, 456
supporting structures of, 2426, 27f, implant choice and, 243 Combination breast deformity, autoge-
2830, 31f post-lumpectomy deformity and, nous conversion and, 291, 292f
Breast hypoplasia, 89f, 100, 101f 426, 426f Combination dermis-fat grafts and autol-
Breast implantation multifactorial, skin reduction, adipose tissue excision and, ogous fat injection, nonradiated
wrinkling, etiology of, 132t 366, 367f patient and, 433435, 433f435f
Breast implants. See Implant(s) TRAM flap Breast reconstruction Combination saline silicone tissue
Breast malposition, TRAM flap and, and, 303 expander, 244, 245f
63, 63f Breast-conserving therapy, breast cancer Communication, reoperative surgery
Breast mound and, 420 and, 12
breast aesthetics and, 379, 382 Complete capsulectomy, implant removal
nipple and, 455 C and, 155158
Breast mount, creating, flap inset and, Calcification, periprosthetic capsule and, Completion mastectomy, reconstruction
321, 322f323f, 323, 324f, 325327 158f of breast following, 425
Breast orientation, breast asymmetries Capsular contracture Complications, 9
and, 101102, 103f advanced, 111, 112f Composite grafts
Breast parenchyma breast augmentation and, 89 contralateral nipple and, 472
blood supply to, 74f breast implant and, 66 nipple reconstruction and, 460
mastopexy and, 183 breast reconstruction and, 372, Connective tissue, IM fold and, 26, 28f
pregnancy and, 20, 21f 373f374f Consent form, reoperative surgery
vascularity, implant effect on, 4748 causes of, 375 and, 76
Breast projection. See Projection classification of, 138t Constricted breast deformity, 29f, 30, 87,
Breast ptosis. See Ptosis of breast early, 138 89f, 90f
Breast reconstruction. See also Breast established, 138139, 141 IM fold asymmetries and, 104
augmentation; Delayed breast infra-areolar incision and, 172f periareolar incision and, 75f
reconstruction; TRAM flap pre v. post-treatment, 140f Consultation
skin replacement in, 370 saline implant and, 137 informed consent and, 7
volume requirements in, 370, 370f therapeutic approaches, 294 notes, patient documentation and, 8
Breast reconstruction tissue expander. Capsular flaps, lateral implant malposi- Contour abnormalities, 44, 45f, 46,
See Tissue expander tion and, 280 429, 432
Breast reduction Capsular fluid, infection and, 91 adjacent tissue and, muscle pedicle
inverted T incision and, 60 Capsular space, suture capsulorrhaphy and, 399, 404
litigation and, 8, 9 and, 100f autologous fat transplantation for,
malpractice insurance companies Capsular suture technique, raising IM, 432433
and, 5 272, 273f, 274f correction of, tissue shifts and,
nipple loss following, 486487, Capsulectomy, technique of, 159160 429, 432
486f487f Capsulotomy, implant malposition and, dermis fat graft and, 50f
revision surgery following, 183235 117, 121 dimension problems and, shape prob-
skin loss, 53, 53f Cefazolin (Ancef) lems and, 50, 51f52f
volume asymmetries and, 56f, 5859 subglandular pocket dissection and, implants for, 430, 434, 436, 436f,
Breast remnant, deformity of, 445 79, 80f 437f438f
Breast shape. See Shape of breast subpectoral pocket dissection and, 82 TRAM flap reconstruction, malposi-
Breast skin. See also Native breast skin Cellulitis tioned volume and, 389390, 395
flap necrosis breast augmentation and, 88 TRAM flap volume redistribution and,
asymmetry, 41, 41f periprosthetic capsulectomy and, 92f 396, 399
sensation of, 9 Cephalaxin, fat transplantation and, 432 Contour deficit reconstruction, autolo-
Breast skin flaps, skin scars and, 44f Cephalosporin gous fat grafts and, 404405
Breast sonography. See Sonography infection and, 91 Contour deformity, 60f, 6263, 299,
Breast surgery. See Surgery TRAM flap breast reconstruction and, 299f300f
Breast symmetry. See Symmetry of 353 Contour lines, skin scar and, 43
breast Chart(s) Contour of breast
Breast tissue, stretched, 39f breast distances and, 23 autologous fat transplantation for,
Breast volume, 36 implants and, surface dimensions 432433
asymmetries, 55f, 5859, 101 for, 72f breast cancer treatment and, 420,
lumpectomy and, 60f, 6263 Chest dimension, wide, 32, 32f 421f, 422f
TRAM flap and, 376f Chief complaint, reoperative breast post-lumpectomy, 449, 452f453f
breast aesthetics and, 20, 21f augmentation and, 84 Contralateral breast
breast asymmetries and, 101102, 103f Chromic sutures, implant removal breast aesthetics of, 382, 383f
breast cancer treatment and, 420, and, 133f TRAM flap and, 308, 311, 313314
421f, 422f Cicatrix, post-lumpectomy deformity IM fold lowering and, 389, 391f
deficiency, 391f and, 426 NAC and, visual symmetry and, 456
Index 491
Contralateral breast Contd Dual plane technique, capsular contrac- Fishtail flap design, 466f
reduction, TRAM flap reconstruction ture and, 142f nipple reconstruction and, 461
and, 395 Ductal carcinoma in situ (DCIS) Fixation sutures, dermis-fat harvest, 433
Coopers ligaments, breast and, 24, 25f expander malposition, 265, 267f Flap skin. See Skin flap
Cosmetic outcome, breast cancer treat- skin loss, TRAM flap and, 345 Fluid accumulation, breast augmenta-
ment and, 420, 421f, 422f, 423f, total mastectomy and, 332f, 333 tion and, 88
424 Fluorescein, perfused skin and, 342
Criticisms, previous surgery and, 2 E Focal capsule excision, raising IM and,
Cytosarcoma, breast reconstruction, pre Ecchymosis, 87, 87f 273276, 277
and post operative views, 239f Ectopic breast tissue, 19, 20f Forced Valsalva maneuver, hernia and,
Edema, postoperative, 102 416, 416f, 417f
D Elastic wrapping, breast reconstruction
DCIS.See Ductal carcinoma in situ and, 116f G
Debridement, 346, 347f Elasticity, 26f, 28f, 38f General anesthesia, procedures requir-
fat necrosis and, 358, 360f361f breast shape and, 24, 25 ing, 4
skin loss and, TRAM flap reconstruc- Electrocautery device Gentamicin
tion and, 344 capsulectomy and, 159, 163 subglandular pocket dissection and,
TRAM flap breast reconstruction and, IM fold lowering and, 389, 391f 79, 80f
348, 349f350f, 351 implant breast reconstruction and, 284, subpectoral pocket dissection and, 82
Deep inferior epigastric artery (DIEA) 285f286f Gluteus maximus musculocutaeous flap,
dissection of, 319f inferior capsulotomy incision and, 414, 414f415f
TRAM flap and, 315f, 318f, 335 267f268f TRAM flap loss and, 414, 414f415f
Delayed breast reconstruction post-lumpectomy patient and, 443 Graft template, dermis-fat harvest,
immediate breast reconstruction v., 333 Embryologic breast, 19 432433
with low-height tissue expander, pre Epidermolysis, post-lumpectomy defor-
and post operative views, 240f mity and, 427f H
mastectomy and, 328, 328f, 329, 329f Epinephrine Harvested fat. See Fat
mastectomy flap and, 333, 334335, dermis-fat harvest, 433 Hematoma
334f fat cell grafting and, 405 breast augmentation and, 8688, 87f
planning of, 333 fat donor site and, 404 implant and, 256
skin envelope and, 333335 Erythema, post-lumpectomy deformity surgical drainage of, 90f
with tissue expander placement, and, 426, 426f, 427f tissue expander and, 256
255, 255f Erythromycin, fat transplantation TRAM flap breast reconstruction
Dermis fat grafts and, 432 and, 353
contour abnormalities, 44, 45f, 50f Established capsular contracture. See Hematoma evacuation surgery, 8788,
harvest of, 431f Capsular contracture 90f
Dermis-fat harvest, technique of, Exercise. See also Implant displacement Hernia. See also Abdominal wall hernia
432433 exercises abdominal wall closure and, 338
Developmental breast asymmetry, 39, 40f subpectoral pocket dissection and, 83, TRAM flap breast reconstruction and,
Diabetes mellitus, radiation therapy 83f 416, 416f, 417f
and, 429 Explantation High-profile implants, 73, 285
DIEA. See Deep inferior epigastric artery with augmentation mastopexy, malposition and, 274f276f
Digital imaging, reoperative surgery 176177, 176f, 177f Horizontal dimension, breast and,
and, 5 with autogenous tissue conversion, 178 1820, 18f
Dimension. See Base dimension implant reinsertion and, 162164 Hyperpigmentation, post-lumpectomy
Direct capsular suture technique, indications for, implant removal and, deformity and, 427f
273, 273f 153154, 154t Hypopigmentation
Disfigurement, malpractice insurance with mastopexy alone, 168, 170f, areola construction and, 464
companies and, 5 171, 171f skin scar and, 43
Doctors Company data, litigation and, 8 Explantation alone
Dog ears, 44, 396, 400f breast implant removal, 160161, 161f I
reoperative surgery and, 298 treatment options following, 160t IM fold. See Inframammary fold
Donor fat harvest, sites for, 431, Extracapsular rupture, silicone gel Immediate breast reconstruction
432f, 434 implant and, 166, 166f delayed reconstruction v., 333
Double bubble deformity, 28, 29f, skin envelope preservation in, 331, 332f
129, 132 F skin-sparing mastectomy and,
treating, 132 Fascia closure, flap donor site and, 414 343, 343f
Double capsular flap technique, 282 Fascia intermedialis, tissue expander Implant(s). See also Inferior implant
implant too low, 115 placement and, 251, 251f malposition; Lateral implant mal-
medial implant malposition and, Fat. See also Adipose tissue; Donor fat position; Specific type Implants
129, 133f harvest i.e. High-profile implants
periprosthetic capsular space and, 123f harvested, 46f, 404 choosing, 68, 69f, 71
Double opposing periareolar flap, design Fat graft, 299, 299f300f. See also contour abnormalities and, 434, 435f,
of, 480f481f Autologous fat grafts; Dermis fat 436, 436f, 437f438f
Double opposing tab flap, technique for, grafts deflation, 142, 143f, 144f
469471, 470f Fat necrosis, 399. See also Acute fat saline implant and, 291
Double-opposing sliding periareolar flap, necrosis edge palpability, thin patient
nipple reconstruction and, 477, skin loss and, 358, 360, 360f and, 135f
480f TRAM flap and, 357f358f, 405406, encapsulation, malpractice insurance
Drains. See also Jackson-Pratt drain 406f407f companies and, 5
seroma and, 163 Fibrosis, hematoma and, 256 failure, 142, 143f, 144f, 154
Dual chamber saline tissue expander Finger dissection, periprosthetic treatment of, 154155
(PMT), 244, 245f capsule, 159f hematoma, 256
492 Index
Implant(s) Contd Incisions Contd Intradermal tattoo, Contd

imaging modalities for, 149, 151153, skin-sparing mastectomy and, 332f, areolar hypopigmentation and, 486,
151f, 152f 333 487
infection and, 91, 259, 259f subpectoral pocket dissection, 7982 for areolar pigmentation, 282,
integrity, evaluation, 147182 transaxillary breast augmentation and, 283f284f
malposition, 79, 108, 110111, 111f, 76, 76f nipple projection loss and, 471
112f Infection nipple areola construction and, 456
migration, Prolene sutures and, 271f breast augmentation and, 88, 91, 92f, options, 459, 459t
pocket, medial implant malposition, 93, 94f Intraductal carcinoma of breast
125 implant and, 259, 260f open incisional biopsy, 333
position of, 71, 73, 77, 77f nipple reconstruction and, 459 TRAM flap breast reconstruction and,
postoperative complications of, 256, TRAM flap breast reconstruction and, 353, 354f356f
257f, 258f, 259, 260f, 261f, 262f, 353, 355f Intraparenchymal fibrosis, post-lumpec-
263f Inferior capsulorrhaphy, implant too low, tomy deformity and, 426
postoperative view, 131f 115 Inverted T incision, 155156
preoperative v. correction, 124f Inferior capsulotomy incision, electro- breast reduction and, 60
previous surgery, 46 cautery device and, 267f268f explantation with mastopexy alone
reconstruction, folds following, 289, Inferior implant malposition, 125f126f, and, 170
290f 274f276f, 282 fat necrosis and, 358, 360f361f
removal, suture closure after, 126f maneuvers for, 117, 121, 122f Inverted T mastopexy, 156
reoperative surgery and, 4 saline implant and, 114 Ischemia
replacement, 162 Inferior pedical breast reduction, nipple of breast skin flaps, 346, 347f, 348
round, measurements and, 71, 71f loss and, 486487, 486f487f TRAM flap breast reconstruction
rupture, 142, 148f Inferior pedicle mastopexy, skin mark- and, 302
silicone gel implant, breast recon- ings for, 177f nipple reconstruction and, 464
struction with, 291 Inferior pedicle technique, 40f, 41 radiation therapy and, 428
size, upper pole fullness and, 115, 118f Inferior pole of breast, post-lumpectomy
sizer, 79 deformity and, 426 J
saline, 79 Inferior-medial capsulotomy, 130f Jackson-Pratt drain
surface dimensions for, charts for, 72f Information gathering, 2 capsulectomy and, 159
suture placement and, 100f Informed consent hematoma and, 87
tissue loss in TRAM flap and, 377378 breast augmentation and, 93 medial implant malposition and, 128
too high, 111, 113, 114115 obtaining, 68 seroma and, 163
too low, 272 surgical procedures and, 5
frank inferior malposition, 115, 117, Infra-areolar incision, 75 K
122f capsular contracture and, 172f Kerlix roll application, 79
too small, patient desiring larger size Inframammary (IM) fold, 20
and, 95, 97, 98f abnormality in, 360, 360f361f L
Implant displacement exercises, subpec- asymmetries, 102, 104, 108, 109f, 386, Laparotomy, exploratory, TRAM flap
toral pocket dissection and, 83, 392f393f breast reconstruction and, 416,
83f TRAM flap Breast reconstruction 416f
Implant-based breast reconstruction, 32, and, 302 Lateral breast contour, adipose excess in,
284, 285f286f breast aesthetics and, 22, 22f, 23, 23f, 363
difficult patients for, 246, 247f248f 26, 27f, 28 Lateral capsular recess, closing, 130f
implant selection for, 242 breast augmentation and, 77, 77f Lateral implant malposition, 111f, 112f,
large volume implants and, 38 deformities in, 30, 31f 121, 124, 125, 129f, 273, 280, 282
preoperative evaluation for, 238241, establishing definition of, 277, Lateral implant subluxation, marking
243245 278f279f patient for, 128f
projection and, 284285, 285f implant and, 277 Lateral pocket dissection, limiting, 78
skin folds with, etiology of, 287289, internal reconstruction of, 390, 392f Lateral thigh flap, 414
288t nipple position to, 455, 456f457f Latissimus dorsi flaps, post-lumpectomy
upper pole of breast, 244f raising, capsular suture technique, 272, deformity and, 426, 426f
INAMED tissue expander, 244, 245, 245f 273f, 274f Latissimus dorsi muscle, 449, 451f
Incisions. See also Axillary incision; scars in, 41, 42f, 49 flap reconstruction, radiation-induced
Electrocautery device; Inferior tightness in, 28f capsular contracture and, 294,
capsulotomy incision; Infra-areo- tissue expander and, correction of, 264, 295f296f, 296
lar incision; Inframammary inci- 265, 266f Lidocaine, fat donor site and, 404
sion; Inverted T incision; too high, 386, 389, 390f Lipocontouring, 382, 384f
McBurney-type oblique abdominal too low, 389, 392f breast volume reduction and, 365f, 366
midline incision; Open incisional TRAM flap and, 323, 324f, 327328, planning, 467f
biopsy; Periareolar incision; 327f Liposuction
Transaxillary incision; Vertical Inframammary incision adipose volume reduction and, 56f, 59
incision capsulectomy and, 159 adjacent contour adjustment and, 368,
approaches, breast augmentation and, implant removal and, 155, 155f 368f
71f Total periprosthetic capsulectomy, 142f superior skin flap and, 299, 299f
breast aesthetics and, 35f36f Initial visit, revisional surgery and, 2 TRAM flap and, 362, 362f
implant malposition, 124, 124f Injection, fat cell grafting and, 405 Litigation. See also Medical malpractice
implant too low, 115 Internal adipose flap, obese patient and, breast surgery and, specifics of, 89
previous, TRAM flap breast reconstruc- 399, 402f403f Lumpectomy, 396, 398f. See also Post-
tion, 307 Internal flaps, 396, 399 lumpectomy deformity
revisional breast surgery and, 48 Intracapsular rupture, TPPC and, 155 both breasts, surgical modification of,
selection of, 7576 Intradermal tattoo, 299, 299f 442, 443f444f
skin scar and, 43 areolar area and, 291 breast asymmetries and, 429
Index 493
Lumpectomy, Contd Modified star flap nipple reconstruction, Nipple projection, Contd
combined deformities and, 6263 360, 360f361f, 461f, 463f464f, loss, modified star flap and, 475,
contralateral breast, surgical modifica- 468469, 471, 472, 473f, 474f, 483f 475f476f, 479f
tion of, 440, 441f planning, 467f Nipple reconstruction, 291, 292f293f,
defect Mondors disease, 9495 299, 299f300f, 382
breast cancer and, 420, 421f, 422f Multiple capsulotomy technique, capsu- double-opposing sliding periareolar
plastic surgery reconstruction and, lar contracture, 141f flap and, 477
425 Multiple focal capsulectomy, 284 options, 459461, 459t
deformity, 424f Multiple reconstructive modalities, sub- planning, 462464, 466f
reoperative surgery following, optimal result revision with, 396, skin marking and, 462464, 466f
420453 400f skin-sparing mastectomy and, 57f, 61
scars following, 429, 430f431f Muscle pedicle atrophy, treatment, 386 suboptimal, revision of, 471
skin loss and, 259, 263f Musculocutaneous flap, total mastec- surgical technique for, 464465
tomy and, 445 techniques, 468471
M Nipple retraction, oncoplastic surgical
Macromastia, 442 N treatment for, 442, 443f
Magnetic resonance imaging (MRI), NAC. See Nipple areolar complex Nipple sharing, nipple reconstruction
breast implants and, 149, 153 Native breast skin, loss, immediate and, 460, 460f
Malpractice insurance companies, 5 reconstruction and, 341343 Nipple symmetries, post-lumpectomy,
Mammary ptosis. See Ptosis of breast Native breast skin flap necrosis, con- 449, 452f453f
Mammary ridge, 19, 19f tributing factors, mastectomy and, Nonsteroidal anti-inflammatory drugs
Mammography, breast implants and, 341t (NSAIDs), Mondors disease and,
149, 151f Nipple 95
Marking. See Skin marking breast reconstruction and, 455, 456f NSAID. See Nonsteroidal anti-inflamma-
Mastectomy. See also Completion mas- dislocation, 391f tory drugs
tectomy lumpectomy and, 60f, 6263
breast reconstruction and, 287f, 384 incorrect inclination, 484, 485f O
IM fold asymmetry and, 394f395f loss, 9 Obese patient
IM fold in, 328, 328f mastopexy, 486487 internal adipose flap and, 399
previous incision and, 43 post breast reduction, 486487 superior implant malposition and, 280
skin envelope and, 331, 332f subtotal, 472475 TRAM flap breast reconstruction and,
skin loss and, 259, 263f total, 472475 307, 308f, 321
skin template for, 329, 329f positioning, 23, 24f Office chart, informed consent and, 7
Mastectomy flap necrosis, 343 sensation, 9 Oncology, breast, 424, 425
cigarette smoking and, 341, 341t Nipple areola reconstruction Oncoplastic surgery, post-lumpectomy,
Mastectomy skin flap difficult case, planning, 465, 467, 468 442443, 444f
delayed breast reconstruction, 333, interdermal tattoo and, 456 Open incisional biopsy, intraductal carci-
334335, 334f TRAM flap and, 357f358f noma of breast and, 333
resection, 342 Nipple areolar blood supply Open wounds. See Wound(s)
seroma fluid and, 256 implant effect on, 4748, 47f Operating room notes, patient documen-
Mastopexy, 9. See also Augmentation subglandlular implant, 170f tation and, 8
mastopexy; Vertical mastopexy Nipple areolar complex (NAC) Operative plan
breast cancer and, 445, 447f asymmetry and, 62, 63f communication and, 2
malpractice insurance companies blood supply, 48 implant reconstruction and, 289, 290f
and, 5 breast aesthetics and, 20, 21f, 33, Opsite dressing, 79, 80f
nipple loss following, 486487 5962, 379, 382 infection and, 91
revision surgery following, 183235 contour abnormalities in, 429, 432 Oxicillin, TRAM flap breast reconstruc-
skin marking for, 174f contralateral breast and, visual symme- tion and, 353, 354f356f
McBurney-type oblique abdominal mid- try and, 456
line incision, TRAM flap breast dislocation, post-lumpectomy defor- P
reconstruction and, 307 mity and, 441f, 445, 446 Pain, breast augmentation and, 9
Medial breast constriction deformity, 30, downsizing, 6162 Partial dermal excision, downward nip-
31f malpositioned, 443 ple inclination and, 484, 484f
Medial dissection, 77, 78f orientation, breast asymmetries and, Partial flap loss, TRAM flap and, 377
Medial implant malposition, 125, 101102, 103f Partial mastectomy defects, reconstruc-
128129, 282, 282f position tion of, 449
correction schematic for, 133f breast asymmetries and, 101102, Partial retropectoral position, 166, 169f
Medial inferior capsulotomy, 130f 103f Patient. See also Physical examination
Medical malpractice breast cancer treatment and, 420, documentation, operating room notes
risk minimization of, 6 421f, 422f, 423f and, 8
scope of, 56 postoperative appearance of, 37, 37f education, 3
Medical records, operative plan and, 2 reconstruction, revision of, 455488 evaluation, 6
Mesh. See also Prolene mesh; Synthetic tumor location v., 423, 424f breast augmentation and, 6768
mesh tumor resection and, 426 expectations, 23
bipedicle TRAM flap reconstruction Nipple position history
and, 321f estimating, patient height and, 171t implant integrity and, 147148
Midabdominal TRAM flap reconstruc- implant too low, 117f reoperative breast augmentation
tion, technique for, 319, 320f, 321 incorrect, 477478 and, 8385, 84t
Modified fishtail flaps, 282, 284f nipple areola construction and, 456 informed consent and, 7
Modified radical mastectomy, early plan for, 466f467f surgeon and, reoperative plastic sur-
debridement and, 351, 351f352f volume discrepancies and, 6263 gery and, 12
Modified skin-sparing mastectomy, 282, Nipple projection, 456, 458f, 473, 479f Pectoralis major muscle (PMM)
284f flap and, 461 breast aesthetics and, 28, 29f
494 Index
Pectoralis major muscle (PMM) Contd Postlumpectomy plus radiation defor- Radiation therapy, Contd
physical examination and, 149 mity, 435436 reoperative surgery following, 420453
subpectoral pocket dissection and, Postlumpectomy reconstruction, skin loss and, 259, 263f
7980, 81f, 82, 82f implants for, 435f436f, 436, 436f, staged tissue expander-implant recon-
tissue expander placement and, 437f438f struction and, 296
251252, 252f Postoperative management, subpectoral tissue expander and, 240f
Pectus excavatum, 32, 33f pocket dissection and, 83 Radiation-induced capsular contracture,
Pedical flap transfer, flap loss after, 414 Post-radiation, latissimus dorsi flap and, autogenous tissue supplementa-
Pedicled TRAM flap, 321, 322f323f, 294, 295f296f, 296 tion, 294, 295f, 296
377 PPCS. See Periprosthetic capsular space Radiation-induced tissue loss, 429
autogenous conversion and, 179f, 180, Pregnancy Recalcitrant capsular contracture, TRAM
181f breast parenchyma and, 20, 21f flap and, 288
suboptimal projection and, 399, 404 mammary ptosis and, 38 Reconstructive plan, TRAM flap, 280f
Periareolar incision, 75f Preoperative evaluation, implant breast Rectus abdominis muscle fascia
breast cancer and, 332f, 333 reconstruction and, 238241 abdominal wall closure and, 337338
constricted breast deformity and, 75f Preoperative imagery, breast aesthetics excision, inferior medial bulge correc-
implant removal and, 155, 155f and, 18 tion and, 368
skin-sparing mastectomy and, 332f Preoperative marking, breast augmenta- flap procedures and, 325327, 325f,
Periprosthetic capsular space tion and, 121 326f
double capsular flap technique for, Preoperative planning tissue expander placement and,
123f errors in, TRAM flap Breast recon- 251252, 252f
hematoma and, 87 struction and, 302, 303t TRAM flap and, 404, 404f
implant disproportion and, 289, 290f factors in, implant choice and, 68 Reoperation breast surgery. See
plication sutures and, 273f, 276 immediate breast reconstruction, Revisional breast surgery
revision, device dimension and, 269, 364f366f Revision Breast Augmentation Consent
269f270f inadequate, problems in, 95 Form, 11
suture capsulorrhaphy closure and, nipple reconstruction, 462464, 466f Revision Breast Reconstruction with
133f TRAM flap Breast reconstruction and, Synthetic Implant Consent Form,
Periprosthetic capsular surgery, 4647 302 12
Periprosthetic capsule Procedure selection, fat necrosis and, Revision of Augmentation Mastopexy
finger dissection and, 159f 405 Consent Form, 14
management of, 155158 Projection loss Revision of Breast Reduction Consent
suture placement, 273f double opposing tab flap and, 471 Form, 16
Periprosthetic capsulectomy, cellulitis nipple reconstruction and, 461, 468 Revision of Mastopexy Consent Form, 13
and, 92f Projection of breast Revision of TRAM Flap Breast
Permanent monofilament suture, implant breast reconstruction and, Reconstruction Consent Form, 15
implant and, 272, 273f 284285, 285f Revisional breast surgery
Photographic documentation nipple areola construction and, 456 aesthetic priorities in, 4862
patient documentation and, 8 TRAM flap revision, 395 anatomic considerations with, 184
reoperative surgery and, 45 malpositioned volume and, 390 breast reduction and, 183235
Photographs, implant choice and, 69f TRAM flap tissue and, 389 deciding against, 34
Physical examination volume deficit and, 399, 404 following lumpectomy, 420453
implant integrity and, 148149 Prolene mesh, abdominal wall hernia following radiation therapy, 420453
reoperative breast augmentation and, and, 416, 416f, 418, 418f, 419 mastopexy and, 183235
8385, 84t Prolene sutures, Implant migration and, overview of, 84t
Pigmentation, nipple areola construction 271f post-lumpectomy deformity and, 426
and, 456 Prosthetic infections, 91 primary surgery v., 1, 910
Pinch test Ptosis of breast, 24, 38, 396, 397f proceeding with, 4
breast parenchyma and, 74f age and, 21f reasons for, 48t
implants and, 162f weight gain and, 388f, 395 Ripples, ridges and folds. See Skin wrin-
Plastic surgeon, post-lumpectomy defor- Puberty, breast gland at, 1920, 21f kling
mity and, 425429 Pullout skin flaps, nipple reconstruction Rotational deformity of chest wall,
Plastic surgery reconstruction, lumpec- and, 459, 460, 460f, 461f breast aesthetics and, 33, 34f
tomy defect and, 425 Purse string closure, 474, 478f Round implants, 287
PMM. See Pectoralis major muscle double-opposing sliding periareolar Rubens flap, 414
PMT. See Dual chamber saline tissue flap, 477
expander S
Pocket dissection, 77, 77f Q Saline implant, 110
implant insertion and, 79, 80f Quadripod flap, nipple reconstruction capsular contracture and, 137
implant too high with, 111 and, 460, 461f implant deflation and, 291
Pocket reassignment, medial implant postoperative view, 113f, 114f
malposition and, 128, 133f R studies, 108
Polyurethan-covered implants, TPPC Radiation therapy, 396, 398f. See also subpectoral position for, 73
and, 157 Post-radiation Scar hypertrophy, 4243, 42f, 49, 49f
Post-lumpectomy both breasts, surgical modification of, Scar tissue, 9, 48
both breasts, surgical modification of, 442, 443f444f breast aesthetics, 379, 382
442, 443f breast asymmetries and, 429 contour abnormalities, adipose tissue
oncoplastic surgical treatment for, contralateral breast, surgical modifica- and, 432
442443, 444f tion of, 440, 441f double opposing tab flap and, 470
Post-lumpectomy deformity, 419f, 420, poor outcome and, 423 flap site and, 414
422f, 423f, 425429 post-lumpectomy deformity and, 440f, IM region, 49
flaps and, 445446 445, 446 immediate breast reconstruction v., 333
treatment approach, 425t postoperative breast with, 391f invagination of, 49
Index 495
Scar tissue, Contd Skin. See also Abdominal donor site; Skin marking Contd
invagination of skin and, 444f Breast skin; Scar tissue; Skin graft template, 432433
lumpectomy and, 429, 430f431f deficit measurement hernia and, 416, 416f, 417f
malpractice insurance companies and, 5 breast and, 2425 inferior pedicle mastopexy and, 177f
nipple reconstruction and, 460, 460f, necrosis, 43, 351, 351f352f lateral implant subluxation, 128f
467, 468f split-muscle bipedicle TRAM flap malposition and, 274f276f
position, breast reconstruction and, 35, and, 345 mastopexy and, 174f
35f radiation and, 424 nipple reconstruction and, 462464,
post-lumpectomy deformity and, 426 radiation therapy injury, 240f 466f
post-lumpectomy patient and, 443 reoperative surgery and, 298 silicone granuloma and, 167f
reoperation and, 4143, 41f, 42f, 298 stretching, breast reconstruction tissue skate design flap and, 469
revisions, 4 expansion and, 248 tissue expander placement and, 250,
shape of, revisional breast surgery, 382 TPPC and, 157, 158, 158f 251f
transaxillary approach and, 7576 volume loss of, debridement and, 377, Skin paddle, 384, 406
Scarps fascia. See Superficial fascia sys- 377f breast aesthetics and, 379, 382
tem Skin deficit measurement, TRAM flap breast reconstruction and, 329,
Scoliosis, breast asymmetry and, 32, 34f Breast reconstruction and, 303, 330f
Secondary nipple reconstruction, 445, 304f305f reduction, 386, 387f
446 Skin dimensions, asymmetries and, 39, Skin pigmentation, loss of, 9
Selective cerebration, 7 40f Skin scars. See Scar tissue
Sensory nerve damage, malpractice Skin envelope, 406 Skin template
insurance companies and, 5 asymmetry, 3941, 382, 384, 386, 387f mastectomy and, 329, 329f
Seroma breast aesthetics and, 20 TRAM flap breast reconstruction and,
breast augmentation and, 88 breast volume adjustment, by excision, 311, 312f
textured implants and, 141 386, 388f Skin tissue deficiency, breast asymmetry
tissue expander and, 256, 258f contralateral breast and, 333 and, 39, 41
TRAM flap breast reconstruction and, immediate breast reconstruction and, Skin ulceration. See Ulceration
356 331, 332f Skin wrinkling, 287
Seroma fluid, mastectomy flaps and, 256 reduction, 335, 336f breast implantation multifactorial and,
SFS. See Superficial fascia system TRAM flap breast reconstruction and, etiology of, 132t
Shape of breast 328330, 329f etiology of, 132
elasticity and, 24 Skin excision, template of, 384, 386f theories on, 132, 134
explantation and mastopexy only and, Skin flap. See also Breast skin flaps; frequency of, 134
173f Specific type Skin flap i.e. Bell implant edge palpability and, 135f
internal sutures and, 390 flap minimizing, 134
problems with, contour and, 50, breast reconstruction and, 35, 35f, 36f surgery and, 134, 136
51f52f donor site, 414 Skin-sparing mastectomy, 351,
revisional breast surgery, 382 explantation with mastopexy alone, 351f352f, 382, 383f, 387, 388f
TRAM flap and, 310f, 311f, 323, 324f 171f immediate breast reconstruction and,
visual aesthetics and, 3738 loss, TRAM flap revision and, 407, 343, 343f
Sharps fascia. See Superficial fascia sys- 409410, 414 incision designs, 332f, 333
tem necrosis, 343 intraductal carcinoma of breast and,
Short skin flap, lateral implant malposi- reconstruction, post-lumpectomy 333
tion and, 280 deformity and, 426 TRAM flap and, 57f, 61
Short-height tissue expanders, 253, 254f selection, improper, 346, 347f Smooth-walled breast implants
lower pole and, 253 skin loss at, 53, 54f55f postoperatively, 137f
superior capsulotomies and, 249f vascular perfusion assessment, 342 rippling and, 288
tissue expansion and, first-stage recon- Skin folds SNN. See Suprasternal notch
struction with, 248250, 248f implant breast reconstruction and, Snowstorm
SIEA. See Superficial inferior epigastric 287289, 288t breast implants and, 149
artery implant reconstruction and, 289, 290f intracapsular rupture and, 153f
Silicone gel implant Skin graft, areola construction and, 464 Soft tissue
intracapsular rupture of, 153 Skin hooks, nipple reconstruction, 464 padding, skin wrinkling and, 289
leak, capsulectomy and, 159 Skin loss tissue expander placement and, 250
rupture, 155 breast incisions and, 348 Sonography, breast implants and, 149,
breast reconstruction with, 291 fat necrosis and, 358, 360f 152f
safety of, 66 immediate breast reconstruction with Spine, bony anatomy of, 32, 33f
skin wrinkling, 132 TRAM flap and, 343 Split-muscle bipedicled TRAM flap
Silicone granuloma, skin markings pre- implant and, 259 contralateral breast and, 349f
operatively and, 167f malpractice insurance companies and, 5 elevation, 320f
Single chamber saline tissue expander, management of, TRAM flap recon- skin necrosis and, 345
244, 245f struction and, 344346, 344f345f Stacked TRAM flap, 366, 367f
Single pedicle TRAM flap, 364f366f scar spreading and, 53, 53f, 54f55f, 56 Staged reconstruction with tissue
tissue area and, 306f TRAM flap and, nonoperative manage- expander, TRAM salvage and,
Size change ment of, 345t implant for, 378379, 379f
minimizing operations for, 97 Skin marking Staged tissue expander-implant recon-
patient desiring larger size and, 95, 97, adipose tissue volume excess, 362, 362f struction, soft tissue envelope and,
98f, 99f post surgical, 363f 271
Skate flap, 473 capsular modifications and, 250 Standard profile implant, 73f
areola construction and, 464 contour deficit and, 404 Staphylococcus aureus, breast augmenta-
nipple reconstruction, 461, 462f, delayed breast reconstruction with tion and, 88, 91
463f464f, 468 tissue expander placement and, Staphylococcus epidermidis, capsular
technique for, 469 255, 255f contracture and, 375
496 Index
Star flap Surgical debridement. See Debridement Tissue expander. Contd

donor area and, 463f, 464 Surgical excision, radiation v., 424 hematoma, 256, 257f
nipple reconstruction, 463f464f, 464 Surgical technique, nipple reconstruc- implant breast reconstruction and, 242,
Stepladder sign, intracapsular rupture tion and, 464465 243
and, 153f Survival, breast-conserving therapy and, lower pole, correction of, 264
Step-off deformity, 102f 420 malposition, 264265, 264f, 266f
Sterile foam donut, reconstructed nipple Suture(s). See also Chromic sutures; nipple loss and, 471, 471f
and, 467f Fixation sutures placement, postoperative complications
Sterile needle aspiration, seromas and, closure, implant removal and, 126f of, 256, 257f, 258f, 259, 260f, 261f,
256, 257f IM fold, 393f 262f, 263f
Steroid injections, skin scar and, 43 implant malposition, 124, 124f placement techniques for, 250253
Streptococcus, infection and, 259, 259f internal, breast shape, 390, 393f, 395f position, 251f
Striae, ptosis and, 25 medial implant malposition, 282, 282f reinsertion, inadequate implant recon-
Subglandlular implant, NAC and, blood nipple reconstruction and, 464 struction and, 269, 269f270f
supply to, 170f periprosthetic capsular space, 289, 290f seroma and, 256, 258f
Subglandular pocket dissection, 79, 80f placement, implant malposition and, skin stretching and, 248
Subglandular silicone gel implants, pre- 100f too low, 272
operative, 161f plication, periprosthetic capsule, 273f types of, 244, 245f
Subglandular space subglandluar space and, 163f Tissue expander-implant reconstruction,
implant position and, 71, 73, 73f superficial fascia and, 110f nipple projection loss with,
suturing, 163f Suture capsulorrhaphy closure 482f483f
Subglandular to subpectoral space con- capsular space and, 100f Tissue expansion, 280f
version, 128 implant too low, 117, 120f breast reconstruction and, 285f
Submuscular space, implant position lateral implant malposition and, 280, Tissue loss in TRAM flap, implant for,
and, 71, 73, 73f 282 377378
Subpectoral pocket dissection, 7982 Symmastia, 125, 136, 137f, 282, 284f Tissue zones, adipose fat and, 405
postoperative management of, 83 Symmetry of breast(s), 3637, 299f300f, Total breast size, tumor size v., 423, 424f
Subpectoral space, pocket dissection 300, 381f382f Total capsulectomy, capsular contrac-
and, 79, 80, 81 breast reconstruction and, 372, ture, 141, 141f
Suction drain, seroma and, 356 373f374f Total mastectomy, musculocutaneous
Suction-assisted liposuction with syringe IM fold and, 389 flap and, 445
aspiration, adipose tissue reduc- post-lumpectomy patient and, 443, Total periprosthetic capsulectomy
tion and, 362 443f, 445f (TPPC)
Superficial fascia of chest, suture and, procedures for, 366, 367f IM incision for, 142f
110f silicone implant and, 164, 164f, 165f incisions for, 155
Superficial fascia system (SFS or Scarps TRAM flap and, 353, 354f356f intracapsular rupture and, 155
fascia), peri-prosthetic capsule Synthetic implant-based reconstruction, medial implant malposition and, 128
and, 277, 278f279f donor tissue for, 246 TRAM flap (Transverse rectus abdomi-
Superficial inferior epigastric artery Synthetic mesh, abdominal wall closure, nus muscle flap). See also Pedicled
(SIEA), TRAM flap and, 314, 315f 337338, 338f TRAM flap
Superior capsulotomies, short-height tis- post-lumpectomy deformity and, 55f,
sue expanders and, 249, 249f T 58, 60f, 62f, 63, 178, 298, 382, 426,
Superior implant malposition, 112f T skin excisional pattern, 395 426f
of expander, 271, 272f Tactile sense, breast aesthetics and, 18 abdominal wall hernia and, 416,
obese patient and, 280, 281f Tailor tacking technique, 157f 416f
Superior incision, internal adipose flap breast reshaping and, 36, 37f acute complications following, 341
and, 399, 402f403f mastopexy and, 172f adipose tissue
Superior pedicle mastopexy technique, scar and, 41f reduction and, 362
170 Tattooing. See also Intradermal tattoo volume in, 370
Superior pole rippling, correction, 291, areola construction and, 465, 465f autogenous tissue conversion, 291,
292f293f problems with, 485 292f, 297, 297f298f
Superior skin flap, liposuction of, 299, TEPID system, 110 following suboptimal implant-
299f Textured shaped implants, 244 based reconstruction and, 180,
Supermedial translocation of flap, 382, Textured silicone gel implants, tissue 181f
384f expansion and, 287, 288f avoiding complications in, 302339
Supranumerary nipple, 19, 19f Textured-surface implants circulation to, 314t
Suprasternal notch (SNN), breast aes- medial implant malposition and, 134 complications following, 341, 341t
thetics and, 22, 2324 seroma and, 141 donor site problems for, 414, 414f,
Surface dimensions, implants and, Thin patient, TRAM flap breast recon- 415f, 416, 417f, 418419
charts for, 72f struction and, 308, 309f310f fat necrosis and, 405406, 406,
Surgeon. See also Plastic surgeon Thoracic adipose tissue, thick, superior 406f407f
patient and, reoperative plastic surgery implant malposition and, 280 final assessment of, 335
and, 12 Thoracodorsal vessels, TRAM flap and, flap loss following, 407, 409410,
Surgery. See also Periprosthetic capsular 317f318f 414
surgery; Postoperative manage- Thorax, bony anatomy of, 32, 33f harvest, 414
ment; Preoperative planning; Thrombophlebitis of axillary veins, mesh in, 337
Revisional breast surgery; Specific NSAIDs and, 85f, 95 synthetic mesh application in,
type Surgery i.e. Periprosthetic Timing, reoperative surgery and, 4 416, 416f
capsular surgery Tissue expander. See also Short-height hematoma and, 353
litigation and, specifics of, 89 tissue expanders IM fold in, 327328, 327f
planning and technique, breast aug- breast cancer and, 449, 450f infection and, 259, 259f
mentation and, 7779, 77f, 78f, 79 breast reconstruction and, 372, loss, gluteus maximus musculocu-
skin wrinkling and, 134, 136 373f374f taeous flap and, 414, 414f415f
Index 497
TRAM flap Contd U W

midabdominal, 315f Ulceration, 428f, 429 Weight
patient selection in, 303t, 306308 necrotic, radiation therapy and, 427, mammary ptosis and, 38
planning, 323 428f skin changes and, 25, 27f
post-lumpectomy, 449, 452f453f Unipedicle superiorly based flap, TRAM Whole muscle harvest, flap procedures
procedure selection, 303, 303t, 305 flap as, 305, 305f and, 325, 325f
projection and, 395 Upper breast pole, TRAM flap and, Wise incisional pattern. See Inverted T
recalcitrant capsular contracture 389 incision
and, 288 Woods lamp, vascular perfusion assess-
recurrent hernia and, 419 V ment and, 342
skin paddle, autogenous conversion V to Y closure method, 377, 377f Worksheet, breast evaluation and, 148,
and, 291, 292f293f nipple position and, 478 150f
skin-sparing mastectomy and, 57f, Vascular insufficiency, TRAM flap Breast Wound(s). See also Acute wounds
61 reconstruction and, 302 abscess, TRAM flap breast reconstruc-
staged tissue expander-implant Vascular ischemia, mastectomy flap tion and, 353, 355f
reconstruction and, 296 necrosis and, 341, 341t contraction, 472
tissue, projection of, 389 Vascularized tissue, post-lumpectomy nipple reconstruction and, 461, 464
volume excess and, 362363, 366 deformity and, 426 debridement, 353
zones, 305, 305f Vasculitis, radiation therapy and, 429 dehiscence, 96f
TRAM flap (Transverse rectus abdomi- Venous circulation, TRAM flap and, 313, breast augmentation and, 9394, 96f
nus muscle flap) revision, projec- 314f, 314t dressing, skin loss, TRAM flap recon-
tion and, lower TRAM flap pole, Vertical breast shape, TRAM flap breast struction and, 344
404f reconstruction and, 310f healing, 346, 347f
TRAM flap (Transverse rectus abdomi- Vertical incision double opposing tab flap and, 470
nus muscle flap) volume abdominal wall hernia and, 416, 416f radiation therapy and, 427, 427f
augmenting, adjacent tissue and, 396, mastopexy and, 172f reoperative surgery and, 4
400f TPPC and, 156f, 157f management, 351
deficiencies with, 378 Vertical inset, flap and, 323, 326f skin loss and, 259, 262f
insuffiicency and, 372, 375, 375f Vertical mammoplasty technique, native skin flap necrosis and, 342
TRAM skin paddle inset, 343, 343f projection of TRAM flap with, nipple reconstruction and, 459, 461
Transaxillary breast augmentation, 396, 397f open
bleeding and, 76 Vertical mastopexy, 440, 441f debridement of, TRAM flap breast
Transaxillary incision, subpectoral contra lateral breast and, 241, reconstruction, 348, 349f350f,
pocket dissection and, 82, 82f 241f242f 351
Transmidline tissue, 346, 347f postoperative, 175f, 440, 441f nipple position and, 478
TRANS flap and, 346, 347f Vertical oblique shape, TRAM flap breast reconstructed breast and, 351
Transverse rectus abdominis muscle reconstruction and, 310f split-muscle bipedicle TRAM flap
flaps. See TRAM flap Vertical scar mammoplasty, 171, 173f and, 345
Tubular breast deformity, 30, 31f Vertical scar technique, augmentation reclosure, skin loss and, TRAM flap
Tumor mastopexy and, 41 reconstruction and, 344
excision, poor outcome and, 423 Visual aesthetics, breast shape and, repair, timeline of, 428
resection, NAC and, 426 3738 Wound care, skin loss and, TRAM flap,
size, breast-conserving therapy and, Visual sense, breast aesthetics and, 18, 346
423, 424f 18f

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Illustrations by William R. Filer

Acquisitions Editor: Brain Brown

Reoperative Plastic Surgery of the Breast

Copyright 2006 by Lippincott Williams & Wilkins, a Wolter Kluwer business

Library of Congress Cataloging-in-Publication Data

Printed in the United States of America.

Last digit is the print number: 9 8 7 6 5 4 3 2 1

I dedicate this book to my wife Cindy

2 Breast Aesthetics in the Nonoperated and Reoperative Breast 17

3 Revising the Unsatisfactory Breast Augmentation 64

4 Evaluating Implant Integrity and Explantation Options and Techniques 146

5 Revision Surgery Following Breast Reduction and Mastopexy 183

6 Revision of Implant Breast Reconstruction 237

8 Revision and Salvage of the Suboptimal TRAM Flap 340

9 Reoperative Surgery Following Lumpectomy and Radiation Therapy 420

10 Revision of Nipple Areola Reconstruction 455

Introduction to Reoperative Plastic

The Patient and the Surgeon 1 The Scope of Medical Malpractice 5

Patient Expectations 3 Minimizing the Risk of Medical Malpractice 6

Patient Education 3 Obtaining Informed Consent 7

The Decision Not to Operate 4 Patient DocumentationConsultation and

Photographic Documentation 5 Conclusion 10

2 Reoperative Plastic Surgery of the Breast

Chapter 1 Introduction to Reoperative Plastic Surgery of the Breast 3

4 Reoperative Plastic Surgery of the Breast

Chapter 1 Introduction to Reoperative Plastic Surgery of the Breast 5

6 Reoperative Plastic Surgery of the Breast

Chapter 1 Introduction to Reoperative Plastic Surgery of the Breast 7

8 Reoperative Plastic Surgery of the Breast

Chapter 1 Introduction to Reoperative Plastic Surgery of the Breast 9

10 Reoperative Plastic Surgery of the Breast

The surgeon and the patient should understand that REFERENCES

Revision Breast Augmentation Consent

I understand the consequences of the procedure(s) to be as follows: _____________________________________

Revision Breast Reconstruction with

I, ________________________, authorize Dr. Kenneth C. Shestak and/or such assistants

I, ________________________, authorize Dr. Kenneth C. Shestak and/or such assistants

I understand the consequences of the procedure(s) to be as follows:_____________________________________

Revision of Augmentation Mastopexy

I understand the consequences of the procedure(s) to be as follows:_____________________________________

Revision of TRAM Flap Breast

Revision of Breast Reduction Consent

I understand the consequences of the procedure(s) to be as follows:_____________________________________

Breast Aesthetics in the Nonoperated

Breast Development and Anatomic Skin Envelope Asymmetry 39

Applied Aesthetics 22 The Effect of Implant Placement on Breast

18 Reoperative Plastic Surgery of the Breast

BREAST DEVELOPMENT AND

Anatomically, the breast vertically overlies the sec-

Chapter 2 Breast Aesthetics in the Nonoperated and Reoperative Breast 19

FIGURE 2-3. AP view with commonly used dimensions for

represents the base width, which is an important

20 Reoperative Plastic Surgery of the Breast

tion and appearance of the nipple areolar complex

Breast Volume and Skin Envelope

Nipple Areolar Complex

Chapter 2 Breast Aesthetics in the Nonoperated and Reoperative Breast 21

22 Reoperative Plastic Surgery of the Breast

FIGURE 2-8. (CONTINUED)

A simplification of breast aesthetic analysis may be

Topographical Breast Aesthetics