specialtopic - connecting repositories · specialtopic shaping the breast in aesthetic and...

SPECIAL TOPIC

Shaping the Breast in Aesthetic andReconstructive Breast Surgery: An EasyThree-Step Principle. Part II—BreastReconstruction after Total MastectomyPhillip N. Blondeel, M.D.,

Ph.D.John Hijjawi, M.D.

Herman Depypere, M.D.,Ph.D.

Nathalie Roche, M.D.Koenraad Van Landuyt,

M.D., Ph.D.

Ghent, Belgium

This is Part II of four parts describing the three-step principle being applied inreconstructive and aesthetic breast surgery. Part I explains how to analyze aproblematic breast by understanding the main anatomical features of a breastand how they interact: the footprint, the conus of the breast, and the skinenvelope. This part describes how one can optimize results with breast recon-structions after complete mastectomy. For both primary and secondary recon-structions, the authors explain how to analyze the mastectomized breast and thedeformed chest wall, before giving step-by-step guidelines for rebuilding theentire breast with either autologous tissue or implants. The differences inshaping unilateral or bilateral breast reconstructions with autologous tissue areclarified. Regardless of timing or method of reconstruction, it is shown that bybreaking down the surgical strategy into three easy (anatomical) steps, thereconstructive surgeon will be able to provide more aesthetically pleasing andreproducible results. Throughout these four parts, the three-step principle willbe the red line on which to fall back to define the problem and to propose asolution. (Plast. Reconstr. Surg. 123: 794, 2009.)

Sculpting a flap of autologous tissue into anaesthetically pleasing breast has becomethe most demanding aspect of breast re-

construction, as the technical aspects of flap har-vesting and microsurgery have become routine inmost centers.1–9 There is no question that breastreconstruction is an important component in thefinal recovery of many breast cancer patients andis a main contributor to the quality of life of thepost–breast cancer patient. An unreconstructedmastectomy defect but also a poorly executed re-construction serves as a constant reminder of acancer diagnosis. Therefore, it stands to reasonthat the more aesthetic and natural a recon-structed breast appears and feels, the more com-pletely a breast cancer patient will recover. In-deed, in an era where the success rates of electivemicrovascular breast reconstruction approach 100percent, a flap that “survives” but fails to recreate

an aesthetic breast is appropriately judged a re-constructive failure.

Why then does so little literature exist on thiscritical and challenging aspect of breast recon-struction? Three-dimensional thinking and theability to manipulate tissue in three dimensionsare skills that typically need to be well developedby plastic surgeons. Despite these talents, themere fact of adequately describing the manip-ulation of an essentially flat structure such as askin and fat flap into a three-dimensional struc-ture such as a breast is challenging and difficult,particularly in writing.

Recreating an aesthetically pleasing breast af-ter partial or total mastectomy is a combination ofgood measurements and artistic insight. The ex-perience of the surgeon is the final determiningfactor. Unfortunately, artistic insight and experi-ence are very abstract and ill-defined elements. Inthis article, we will put forward a very systematic

From the Department of Plastic and Reconstructive Surgeryand the Division of Gynaecological Oncology, UniversityHospital Ghent.Received for publication April 27, 2008; accepted August20, 2008.Copyright ©2009 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e318199ef16

Disclosure: None of the authors has a financialinterest to declare in relation to the content of thisarticle.

www.PRSJournal.com794

approach for recreating the female breast afterradical, modified radical, and skin-sparing mas-tectomies and giving the new breast attractive di-mensions and proportions.

This consists of three important steps: creatingthe breast footprint on the chest wall, placing aproper conus on the footprint, and redraping theappropriate skin envelope over the conus. If eachstep is executed properly, the combination of thesethree steps will create an aesthetically pleasing breasteven in the most difficult reconstructions. Thebreakdown of the reconstructive process into threebasic steps makes it easier for the surgeon to under-stand and analyze the problem and will facilitate astep-by-step buildup of the breast.

PREOPERATIVE STRATEGY FOR GOODRESULTS

Patient selection is always very important. Thisarticle specifically describes not only how to re-build an entire breast after ablative surgery butalso the reconstruction of a subtotal absence offormation of the breast after congenital agenesisor extreme hypotrophy. Extreme cases of Polandsyndrome can be reconstructed following the sameprinciples. The patient’s desire to undergo such areconstruction is probably the most important fac-tor in patient selection. Different techniques ofimplant and autologous tissue reconstruction needto be explained to the patient, together with all ofthe possible complications and disadvantages. Weavoid implant reconstruction in patients who haveundergone irradiation. We also feel that we canprovide a more pleasing aesthetic result with au-tologous tissue compared with implants.

Potential donor sites are evaluated to deter-mine which site will be used, taking into consid-eration the condition of the receptor site and thepatient and surgeon preference. If sufficient tissueis present at the lower abdominal wall, the transverserectus abdominis musculocutaneous (TRAM)1,2 ordeep inferior epigastric artery perforator flap4–7 willprovide sufficient adipose tissue bulk and morethan sufficient skin. The superior or inferior glu-teal artery perforator flap8,9 is always bulky, but theskin paddle is relatively small. For that reason,gluteal artery perforator flaps offer the best resultsin primary reconstructions where most of the skinenvelope is preserved. Gluteal artery perforatorflaps generally have a more rigid consistency, mak-ing shaping slightly harder to perform. Therefore,gluteal artery perforator flaps are chosen only ifthe lower abdominal wall cannot be harvested.Latissimus dorsi flaps3 or thoracodorsal artery per-forator flaps allow the harvest of large skin islands

but generally the total volume of the flap is notlarge enough to reconstruct the breast completely,necessitating the addition of an implant. Thora-codorsal artery perforator flaps are the first choicein partial breast reconstruction of the lateral quad-rants of the breast (see Part III).

If an implant reconstruction is preferred, theappropriate shape, size, and volume need to beselected. If an important part of the skin envelopeis missing, a temporary expansion of the remain-ing skin needs to be performed to acquire suffi-cient ptosis in the new breast. All this demonstratesthat the choice of reconstructive tool or type of flapwill directly influence the final aesthetic outcome.A wrong choice of flap may lead to a situationwhere a good result may never be obtained re-gardless of all the secondary corrections thatwould be performed afterward.

The degree of surgical postablative and radio-therapy damage to the three different anatomicalstructures at the recipient site also has an influ-ence on the final result. More aggressive ablativesurgery, higher doses of radiotherapy (or highersensitivity to radiotherapy), the number and typeof previous reconstructive attempts, and the ab-sence of the nipple-areola complex will all makethe reconstructive procedure more complex andnegatively influence the final result. It will be eas-ier to recreate the normal shape of a breast afteran immediate skin-sparing mastectomy where theborders of the footprint have been respected com-pared with the secondary reconstruction after rad-ical mastectomy intensively damaged by radiother-apy where the footprint, conus, and envelope havebeen damaged dramatically. The preoperativeanalysis of the different problems at the threeanatomical levels can be clearly marked on thechest wall with detailed preoperative drawings.These markings are explained below for the dif-ferent situations encountered after mastectomy.In the following sections, we describe a step-by-step approach to autologous and implant breastreconstruction after mastectomy by breaking upthe analysis of the problem and the surgical solu-tion for the footprint, the conus, and the skinenvelope.

AUTOLOGOUS BREASTRECONSTRUCTION

Delayed Unilateral Autologous ReconstructionFootprintIn a secondary breast reconstruction, the pa-

tient presents with a breast gland that has partiallyor totally been removed and with overlying skin of

Volume 123, Number 3 • Postmastectomy Breast Reconstruction

795

the breast that is partially or totally preserved. Theskin may be irradiated or scarred or damaged byprevious infections, hematomas, or other means.In modified radical mastectomy cases and all caseswhere the inframammary fold can no longer beidentified, it is important to determine the level ofthe new inframammary fold. Mostly, this is posi-tioned approximately 2 to 3 cm higher than thecontralateral inframammary fold (Fig. 1). If sig-nificant skin fibrosis and contraction are presentat the mastectomy site, the fold should be posi-tioned slightly higher. Simple incision and resec-tion of that scar will release all surrounding tissueand the skin will shift caudally. Soft pliable tissuewill not move as much and therefore the infra-mammary fold can be placed slightly lower. Bypulling on the abdomen later, this fold will movedown even farther and the normal inframammaryfold will stay in place. When in doubt, it is alwaysbetter to put the new inframammary fold a littlehigher than too low. Correcting an inframam-mary fold that is positioned too high is mucheasier to perform than raising the fold in a sec-ondary procedure.

Surgery starts by excising all scars and severelyscarred tissue that lie over the footprint. In mod-ified radical mastectomy cases, the new inframam-

mary fold is incised following the lines markingthe limits of the new breast footprint (Fig. 1). Theincision is performed to a depth of approximately1 cm to allow easy suturing of the flap to the skinedges of the inframammary fold. The skin in be-tween the mastectomy scar and the inframammaryfold is only deepithelialized. In this way, we pre-serve a layer of 1 to 2 cm of fat in the lower partsof the breast that will assist in improving projec-tion of the lower pole. The skin edges of the uppermastectomy flap are thinned down to the dermisfor the first 5 mm and then progressively trimmedto obtain a fluid and stepless transition of themastectomy flap into the upper skin edge of theflap. The upper mastectomy flap is then furtherundermined up to the preoperative markings on thelateral, cranial, and medial borders of the breastfootprint. The internal mammary artery and vein aresubsequently prepared for anastomosis.

ConusThe conus is made up by the bulk of a lower

abdominal or gluteal flap. The principle of shap-ing the lower abdominal flap applies to all myo-cutaneous flaps (pedicled, free, or muscle-sparingTRAM) or perforator flaps (deep inferior epigas-tric artery perforator). The same goes for myocu-taneous or perforator flaps from the upper orlower gluteal area (superior or inferior glutealartery perforator). The art consists of transferringa certain volume to the recipient site and turninga flat fat structure into a three-dimensional asym-metrical conus.

In a unilateral reconstruction, we harvest bothhalves of the lower abdomen centered over theentire (pedicled TRAM) or part of (free muscle-sparing TRAM) the rectus abdominis muscle orthe most dominant perforator (deep inferior epi-gastric artery perforator flap) as a single unit, al-lowing maximum flexibility in breast shaping oncethe flap is revascularized. It is rare that a breast isso large and the abdomen so thin that the entirelower abdomen needs to be used to obtain ade-quate volume. If necessary in free flap surgery, thepedicles can be harvested on both sides and anas-tomosed to each other or to two different sets ofrecipient vessels. We discourage the use of bi-pedicled TRAM flaps because of their importantdonor-site morbidity and limited freedom forshaping the flap. We routinely explore both sidesof the abdomen in an effort to find the best avail-able perforators. There is a preference neverthe-less to use the vessels of the contralateral hemia-bdomen. Using these vessels and turning the flap180 degrees allows for easy microsurgery, eventualsensory nerve suturing to the lateral intercostal

Fig. 1. The footprint of the new breast can be estimated from thecontralateral breast. Upper, medial, and lateral borders aremarked, as is the mastectomy scar. The new inframammary fold(short arrow) is positioned 2 to 3 cm higher than the existing con-tralateral inframammary fold (lower longer arrow). The stripedarea between the new inframammary fold and the mastectomyis deepithelialized.

Plastic and Reconstructive Surgery • March 2009

796

nerve(s), and easy access to the superficial inferiorepigastric vein when it is necessary to improve ve-nous outflow. Turning the flap 180 degrees alsoplaces the bulk of the thicker midabdominal regionin the inferior pole of the breast, contributing to theasymmetric projection of the breast conus.

After the anastomoses, the shaping of the conusstarts (Fig. 2, above, left). A wedge of skin is removedover the periumbilical region and closed in two lay-ers. By so doing, more volume is gathered togetherin the lower half of the flap. The more skin that isremoved, the more projection that is achieved butthe more compression of the subdermal plexus inthis area that should be expected (Fig. 2, above, right).Shaping starts at the pectoralis tendon.

In lower abdominal flaps with a contralateralpedicle, the contralateral tip of the flap is fixed justbelow the pectoralis tendon by suturing Scarpa’sfascia to the pectoralis fascia 2 to 3 cm medial tothe lateral pectoral muscle border in the supero-lateral edge of the footprint. In lower abdominalflaps with an ipsilateral pedicle, the most remoteand poorest vascularized contralateral part of theflap (previously called zone IV) needs to be re-sected first after a correct estimation of volume hastaken place (Fig. 2, above). Next, the contralateralcorner of the remaining flap is sutured just belowthe pectoralis tendon in the same fashion (Fig. 2,second row, left). This first key suture and filling ofthe upper lateral part will recreate the anterioraxillary fold. In the next steps, skin staples are usedto create a temporary shape of the conus. Once afinal shape is achieved, the staples are replaced bypermanent sutures.

The lateral edge of the flap is then stapled tothe most lateral part of the inframammary foldunder slight tension. Sufficient tension needs tobe applied nevertheless to avoid excessive lateralfullness. The transition from the lateral pectoralborder into the lateral portion of the flap alsorecreates a natural lazy-S shape along the lateralborder of the breast (Fig. 1). This lazy-S contourshould also be a smooth transition into the tissuesof the lateral thorax. The exact position of thelateral key suture is determined by shifting the flapalong the inframammary fold while assessing thelazy-S contour. By shifting the flap laterally, morelateral fullness will be obtained (Fig. 2, second row,right). Pulling the lateral edge of the flap moremedial will flatten the lateral part of the new breast(Fig. 2, third row, left). It is always better to haveminimal fullness at the time of reconstruction, asthe flap will shift laterally and distally in the post-operative period.

Medial to the second key suture and around themidclavicular line, the skin of the flap is bunched up.This effect together with the triangular skin re-section around the umbilicus will dramatically in-crease the projection of the flap (Fig. 2, third row,right). This will also help in creating a straightangle between the skin of the flap and the ab-dominal skin below the inframammary fold.

The third key suture is placed at the medialend of the inframammary fold where it extendsmost medially. In the medial part of the infra-mammary fold, the flap is no longer bunchedtogether to avoid overfilling of the inferomedialquadrant of the new breast. In contrast, if the flapis not placed medially enough, it can be difficultto achieve sufficient medial cleavage.

At this point, in lower abdominal flaps with acontralateral pedicle, two important points needto be considered. First, a volume estimation mustbe performed in cases where the surgeon attemptsto obtain a volume comparable to the contralat-eral side. Second, the most remote and mostpoorly vascularized contralateral part of the flap(previously called zone IV) needs to be evaluatedfor its vascular supply. This can be accomplishedby visual inspection of the skin or by carving intothe dermal plexus with a Bistouri in the most distalcorner. All poorly vascularized tissue needs to beresected immediately. Tissues that show mixed ar-terial and venous bleeding can be kept. More tis-sue from this region can obviously be resected ifthe contralateral breast is smaller.

We generally make the reconstructed breast 5 to10 percent larger than the contralateral one, antic-ipating some decreased swelling postoperatively. Ifthe contralateral breast is hypertrophic and the pa-tient has expressed the desire to have a reduction onthat side, a breast is constructed with well-vascular-ized tissue that fits with the proportions of her torso.In thinner patients, the final volume will depend onwhatever fat volume is present on the lower abdom-inal wall. If the patient wishes to enlarge the con-tralateral breast, a larger flap is taken, if available,and a larger breast is constructed.

In lower abdominal flaps with an ipsilateralpedicle, the same decision making with regard tovolume has occurred earlier. The inner, ipsilateraltip of the flap is best rounded off by resecting a fewcentimeters of skin. This will provide a nice medialcontour with a smooth transition into the prest-ernal region (Fig. 2, third row, right). The subcu-taneous fat at the border of the upper mastectomyflap sometimes needs to be trimmed to allow fora gradual transition of the flap skin into the uppermastectomy skin flap.


797

Fig. 2. Photographs showing step-by-step shaping of a deep inferior epigastric artery perforator flap in a secondaryautologous breast reconstruction. (Above, left) The flap is positioned with an ipsilateral perforator (blue X) over the


798

Finally, it is important to slightly overfill thesuperomedial quadrant of the breast with the flap.Sometimes, the superior part of the flap may needto be sutured to the chest wall to pull up the conusin the region of the infraclavicular fill. Overfillingthis region will correct itself, as gravity will be pullingthe flap caudally over the ensuing 6 months. It isalso better to have too much fat in this region thantoo little. Excessive fat can easily be removed laterby liposuction, whereas a depression in this area isvery disturbing for the patient, as it is often ex-posed in the decollete area. Also, complex pro-cedures are often necessary in a later phase to addfat to that area. Finally, the upper part of the flapis deepithelialized according to the dimensions ofthe upper mastectomy flap (Fig. 2, below).

Creating a nice conus out of a gluteal flap canbe much more challenging. Overall, the glutealflap is shorter (24 to 34 cm) and of limited width(maximum, 12 cm). The flap is overall thicker but,more importantly, much more consistent and firmthan the abdominal flap. Before starting the insetof the flap, both tips of the flap are thinned byobliquely resecting fat below the skin (Fig. 3). Byso doing, the oblique angles of the ideal conus aremimicked and a natural transition into the chest wallcan be provided at the superolateral and medialparts of the breast. One tip is sutured to the pecto-ralis tendon as described above.

Further shaping progresses in the same fash-ion as with an abdominal flap. After placing thesecond key suture at the lateral part of the infra-mammary fold, the gluteal flap does not need anybunching. The rigidity of the flap creates suffi-cient projection around the midclavicular line.The medial tip of the flap can be further trimmedto achieve a progressive transition into the prest-ernal area. Because of the limited width of the flap,it is very typical to find at the end of the shapingprocedure a shortage of tissue at the superior bor-der of the flap. This will cause a depression orcavity that needs to be corrected by redraping the

flap or lipofilling during the second procedure 6months later.

EnvelopeIncreased skin requirements are the obvious

difference between immediate and delayed breastreconstruction. Attractive breast projection andshape result from a combination of the innateprojection of the conus and an appropriately tai-lored skin envelope. Even a perfectly shaped flapwill fail to achieve an aesthetic breast if the over-lying mastectomy skin is inelastic, redundant, andill fitting. In secondary reconstructions, the skinenvelope is composed of both the upper mastec-tomy flap and the skin of the flap itself. The levelof the horizontal or oblique mastectomy scar willdetermine the shares of mastectomy skin and flapskin. If in any way the upper mastectomy flap isscarred, retracted, or damaged, one must considereither resecting a part or releasing the skin on theinside by transecting and scoring constricting bands.Often, in the lateral part of the skin envelopetoward the axilla, excessive scarring can be found,limiting the expansion of the upper flap. Dissec-tion and scar release down into the axilla is some-times necessary. After mastectomy, skin has shiftedtoward the axilla. Also, this skin needs to be re-cruited and brought forward. By putting one handunderneath, the upper skin flap should be easilylifted up from the chest wall and no restrictingbands should be felt. In no way should the uppermastectomy skin flap compress the lower abdom-inal flap.

Once the final volume of the flap is deter-mined, one can make a rough estimation of howmuch skin paddle will be required. The flap canbe pushed up into the upper pouch or pulled down,leaving, respectively, less or more vertical skin heighton the skin paddle of the flap. The more skin thatis left at the midclavicular line, the more ptosis thatwill be achieved. The more the skin of the flap isresected in the lateral part of the flap, the morethe flap will be pushed medially. Once again, the

Fig. 2. (Continued) right breast. (Above, right) The least vascular-ized zone of the flap has been marked for removal and a trian-gular excision of skin over the umbilicus has been performed.(Second row, left) The contralateral corner of the remaining flap issutured just below the pectoralis tendon. (Second row, right andthird row, left) The lateral fullness of the breast is determined: themore the flap is moved medially, the less bulging in the lowerouter quadrant. (Third row, right) The medial flap excess is deter-mined and resected. (Below, left) Deepithelialization of the upperpart of the flap and the final result (below, right) are shown.

Fig. 3. Superior and inferior gluteal artery perforator flaps aremore rigid and more difficult to shape. A long, narrow, thick glu-teal flap needs to be thinned at its tips to ensure a smooth tran-sition into the chest wall. Basic shaping at the first operation con-sists only of beveling both corners of the flap.


799

clinical and aesthetic assessment of the contralateralbreast becomes key in fine tuning the shape. Eitherthe surgeon attempts to mirror the contralateralbreast if the other side is not to be touched or thesurgeon creates a totally new attractive shape if amastopexy or other shape adjustment is foreseen atthe contralateral breast. In the former case, exactvertical and horizontal measurements will help inobtaining a symmetrical result. The part of the skinpaddle that will be covered by the upper mastectomyflap is consequently deepithelialized.

Immediate Unilateral Reconstruction

FootprintIt is crucial to identify whether the mastectomy

procedure has violated the normal boundaries ofthe breast footprint. If so, it is very important tometiculously repair the footprint and verify itsheight and width on the chest wall. The preoper-ative markings of the borders of the breast need tochecked and if necessary resutured to the chestwall. The most commonly violated borders are theinframammary fold and the lateral border of thebreast, particularly after an axillary dissection. Par-ticular attention should be given to the inframam-mary fold, as this will be the main support of thenew breast. Whether or not the pectoral muscle isresected is not an issue with an autologous recon-struction. Meticulous preparation of the footprintwill facilitate insetting of the flap and will reducethe number of sutures that need to be placeddirectly into the flap.

ConusIn unilateral reconstruction with any flap, the

weight of the flap and of the mastectomy specimenprovide guidance for gross trimming of the flap.As with delayed reconstructions, a breast will bereconstructed that will be 10 percent larger thanthe original breast, particularly if radiotherapy isexpected. If not enough flap volume is available,a contralateral breast reduction needs to be con-sidered or an augmentation procedure (implan-tation or lipofilling) performed in a second op-eration 6 months later.

The shaping of lower abdominal, gluteal, orother flaps used for primary (immediate) recon-struction is performed exactly the same way as withdelayed reconstructions. Any type of suture in-stead of staples is used to suture the edge of theflap to the superficial fascia at the inframammaryfold. Otherwise, a basic shape is given to the flapusing the three key sutures as described above.The skin is draped gently over the flap and theshape is evaluated. The key sutures are adjusted

until an acceptable shape is obtained. A few ad-ditional resorbable sutures can help redistributethe fat better and spread the fat over the entirefootprint. However, we have noticed that the moresutures that are placed, the less natural the result.The volume of the flap needs to spread itself outover the footprint and provide sufficient anteriorand circumferential pressure to keep the skin en-velope under tension.

EnvelopeThe availability of an abundant skin envelope

is a major difference between immediate and de-layed breast reconstruction. Excessive skin can beresected if the reconstructed breast is smaller thanthe original breast. In excessively ptotic breasts, amastopexy needs to be performed at the initial re-construction using a keyhole or Wise pattern. Cau-tion needs to be used in smokers or in patients whohave had their skin flaps thinned excessively dur-ing mastectomy. In these situations, extensive skinexcisions are best delayed to a secondary shapingprocedure. Clearly devascularized mastectomy flapsshould be debrided back to viable skin. The portionof the skin paddle that will be covered by the mas-tectomy flap is consequently deepithelialized.

In immediate reconstruction, once the newbreast pocket, footprint, volume, and projectionare established, the final tailoring of the skin en-velope is determined. With the flap in position,staples are used with a tailor-tacking method todetermine the optimal amount and orientation ofskin excision. Skin islands of the flap can be left aspatches in between the mastectomy skin to fill upareas of limited skin resection. Additional flap skinneeds to be left to be able to perform the nipplereconstruction in a second operation. Drains areused to suck the skin envelope to the flap surface,thereby limiting subcutaneous collections, scar-ring, and shape deformities.

Bilateral ReconstructionFootprintThe footprint for both breasts is prepared in

the same way as for unilateral, immediate or de-layed, reconstructions.

ConusThe main difference between unilateral and

bilateral immediate breast reconstruction relatesonly to the availability of an adequate amount ofdonor tissue. If the lower abdomen is preferred,the flap is divided into two (symmetrical) halvesearly during flap harvest. This allows one team toproceed with microsurgical anastomosis of thefirst flap while the second flap is harvested. To


800

increase the volume of the flap, the lateral cornerof the flap design can be extended farther laterallyand can be expected to completely survive becausethe pedicle needs to perfuse only half of the ab-domen. By splitting the abdomen in two, less vol-ume will be available. Therefore, there will be lessliberty to shape the breast through the process ofsculpting an excessively large flap until the desiredshape is obtained. Shaping needs to be performedby repositioning and redistributing the fat on thechest wall.

After harvesting, the contralateral triangularhemiabdomen is rotated 180 degrees and placedon the footprint with the lateral tip of the flaporiented toward the pectoralis tendon (Fig. 4,above, left). The lower skin incision of the flap isnow at the cranial border of the new breast and theskin around the umbilicus is pointing caudally. Inthis position, the thickest part of the flap is placedin the lower pole and the thinnest part is spreadout in the upper lateral part of the breast. Also, thesuperficial inferior epigastric vein protrudes inthe cranial part, allowing for easy anastomosiswith the internal mammary, external jugular, orcephalic vein. As performed in unilateral recon-structions with a contralateral pedicle, the first twokey sutures are placed just below the pectoralistendon (Fig. 4, above, right and second row, left) andat the most lateral point of the inframammaryfold. Instead of bunching skin together, the nec-essary projection is obtained by turning the peri-umbilical part of the flap underneath the mostcaudal part of the flap (Fig. 4, second row, right),thereby folding the flap under itself (Fig. 4, thirdrow, left). The more tissue that is rotated under theflap, the more projection that can be achieved butthe more cranial height of the flap that is lost. Themidline inferior incision angle of the flap is placedat the medial border of the footprint. The verticalheight of this angle is determined by the balancebetween sufficient cleavage and sufficient fullnessof the upper medial quadrant of the new breast.Shifting this part of the flap up and down themedial border of the footprint will quickly showthe ideal proportions in terms of shape and vol-ume distribution. A third key suture is placed atthe medial border. Skin is tightened in a verticaldirection at the inframammary fold by adding afew skin staples until a nicely rounded inferiorcurvature of the flap is found (Fig. 4, third row,right). If the flap is too large, fat can be resectedfrom the medial border of the flap (Fig. 4, below,left). Thinning of the subcutaneous fat at the bor-der of the upper mastectomy skin is crucial for

obtaining a progressive transition between flapand mastectomy skin (Fig. 4, below, right).

In case we need the superior gluteal arteryperforator flap for bilateral reconstruction afterbilateral mastectomy, we propose a two-step pro-cedure to our patients. A single surgeon, with orwithout surgical assistance, often prefers to trans-fer only one flap at the time, with a 3- to 6-monthinterval, because of the prolonged operating time.Obviously, shaping the superior gluteal artery per-forator flap in two different steps for a bilateralbreast reconstruction is identical to a unilateralprimary or secondary reconstruction.

EnvelopeOnce the conus is formed, the remaining mas-

tectomy skin will cover the flap. Draping of this skinis performed in the same way as in immediate ordelayed unilateral reconstructions described above.

GENERAL ISSUES IN AUTOLOGOUSRECONSTRUCTION

Although it is not the purpose of this article toexpand on secondary corrections, it is obvious thatthe final result cannot be achieved after one op-eration. The goal of the first operation, regardlessof which reconstructive technique or flap was ap-plied, is to obtain a basic shape that resembles anormal breast quite closely. Frequently, a secondoperation is needed 6 months later to adjust thereconstructed breast, the contralateral breast, orboth. Ipsilateral corrections include nipple recon-struction, scar revisions, volume adjustments eitherby reduction (i.e., direct resection or liposuction) orby augmentation (i.e., implants, additional flaps, orlipofilling), and shape corrections. This can beaccomplished by repositioning and/or rotatingthe flap or implant, skin resections, and adjust-ments of the inframammary fold or other bordersof the flap. The contralateral side may be adjustedby the common techniques of augmentation, re-duction, and mastopexy. Symmetry is our finalgoal after the second procedure.

In reality, it is not always easy to obtain thatsymmetry, and in specific cases it might be nec-essary to repeat flap corrections and adjustmentsof the contralateral breast. These small “nip-and-tuck” procedures are very individual, can almostalways be performed under local anesthesia, andneed to be repeated until the patient with realisticexpectations is happy with the result. The opinionand wishes of the surgeon are important but alwayssecondary to those of the patient.

In a third phase, 3 months after the last correc-tive procedure, a tattoo of the areola is performed.As our eyes are very sensitive to color differences,


801

Fig. 4. Step-by-step shaping of a deep inferior epigastric artery perforator flap in a bilateral secondary autologousbreast reconstruction. (Above, left) The flap is positioned over the left breast: the inferior border of the flap with the


802

bilateral tattoos, even over the normal contralateralareola, provide the most natural results. Unfortu-nately, tattoos keep on fading at a slower pace andmay need to be repeated several years later.

For autologous reconstructions, we like to fol-low the principles of classic sculpturing. A largeblock of material (in this instance, fat tissue) isplaced on a platform, here obviously the chestwall. The first operation is intended to create arough “basic” shape by removing larger pieces offat from the newly transplanted flap. The flap ap-pears like a breast but the volume and shape arenot yet perfect after the first procedure. The totalvolume of the flap is left with a surplus of 10 to 15percent to allow removal of smaller amounts of fatduring the second procedure. Six months aftertransplantation, the flap has undergone the ef-fects of gravity; has acquired a new, more naturalshape; and will be at its final position on the foot-print. To obtain perfect symmetry, it is wiser toremove small fat deposits and excess skin duringthe second procedure by relatively simple tech-niques such as direct excision and/or liposuctionthan it is to add more tissue with more involvedtechniques such as local flaps or lipofilling. Theflap can easily be sculptured on the table with thepatient in the sitting position until symmetry isperfect (Fig. 5).

It is our preference not to perform immediateautologous reconstructions when it is certain thatpostmastectomy irradiation will be performed.Temporary expanders are placed in these circum-stances to preserve the mastectomy skin flaps, anddelayed primary reconstruction is performed 6months after finishing the last adjuvant therapy(i.e., chemotherapy or radiotherapy). If it is un-certain whether postoperative radiotherapy will beperformed, we make the reconstructed breast 15to 20 percent larger than the desired final volume.

Postradiotherapy sclerosis is often responsible fora volume loss of approximately 10 percent, and weneed an additional 10 percent surplus to preservethe liberty of removing fat to shape the breast.

We never perform a nipple reconstruction atthe time of transplantation and delay nipple re-construction until a later stage because of an un-acceptably high rate of venous congestion. Mostlikely, there is a significant challenge to the bloodflow in the dermal plexus just after microvasculartransfer that makes the failure rate of such a “flap-on-a-flap” significantly higher than performing anipple reconstruction on a well-healed flap. Also,it is virtually impossible to determine the exactlocation of the new nipple on the breast mound,as the flap will shift an unpredictable distance onthe chest wall in the postoperative phase. How-ever, it remains important to plan ahead, and sowe retain an excess of skin of approximately 6 �4 cm at the center of the breast mound to beelevated in later nipple reconstruction.

The shaping of the flap to form the conus ismostly performed by correct positioning by meansof the three-key-suture technique as describedabove. In rare cases, the flap can be very thin,making it impossible to create sufficient projec-tion in the lower part of the breast. The skin sur-face in such cases is too large, and too many wrin-kles will develop in the skin paddle if one attemptsto push the flap together. In that case, the flap canbe folded onto itself over the midline with the skinon the outside. The tips of the flap are roundedby resecting the corners. The tips are placed notexactly over each other but next to each other.One tip is sutured below the pectoralis tendon; theother one, slightly more medial. By so doing, theupper pole is nicely filled. The rest of the shapingtakes place as with half a flap in bilateral recon-structions. The perforator vessels lie in betweenboth halves of the flap and exit medially towardthe internal mammary artery and vein.

IMPLANT RECONSTRUCTION

FootprintRegardless of timing or side of reconstruction,

the footprint needs to be prepared in a way similarto that used with autologous reconstructions.There are nevertheless some specific differences.In primary skin-sparing mastectomies, the foot-print and overlying skin are preserved and thefootprint needs to be created or restored by un-dermining or resuturing as described earlier.

In secondary reconstructions, a new pocketwith a new footprint needs to be created. After

Fig. 4. (Continued) superficial epigastric vein (microforceps) isplaced cranially with the periumbilical tissues facing caudally.(Above, right and second row, left) Scarpa’s fascia of the lateralcorner of the flap is anchored to the pectoral fascia at the anterioraxillary fold. (Second row, right and third row, left) The lateral full-ness of the breast is determined: the more the flap is moved me-dially, the less bulging there is in the lower outer quadrant. Tem-porary skin staples are used to easily reposition the flap andfacilitate shaping. (Third row, right and below, left) Turning thethickest periumbilical part of the flap onto itself will increase pro-jection in the lower and central part of the flap. (Below, right) Re-moval of medial fat excess and deepithelialization of the upperpart of the flap finalizes the shaping.


803

resecting the mastectomy scar, both mastectomyflaps are undermined up to the preoperativemarkings of the borders of the footprint. The con-tralateral breast can be very helpful for determin-ing the exact location of these borders.

An important difference is that a second dis-section below the pectoralis major muscle andeventually below the serratus anterior fascia needsto be performed to obtain muscle-fascia coverage.The extent of this undermining will depend onthe dimensions of the implant but is never toexceed the borders of the footprint. It is oftennecessary to cut the lower origin of the pectoralismajor muscle to lower the footprint down to itscorrect position. Depending on the dimensions ofimplant used, the footprint needs to be 1 to 2 cmwider than the implant to allow sufficient expan-sion of the pocket, but dissection must never sur-pass the outer borders of the normal breast.

ConusThe conus is made entirely of the implant

itself. The shape of the implant determines thefinal shape of the breast. It is unclear to whatextent the compression of the upper pole of around implant by the overlying pectoralis muscledeforms the implant and thereby creates a naturalslope with sufficient projection in the lower pole.Today, mostly anatomically shaped implants areused for complete breast reconstruction to ensurea natural shape.

Expanders, permanent expandable im-plants, and (cohesive) silicone gel– or saline-filled implants differ by only their volume andfilling. The surgeon chooses the volume anddimensions (i.e., height, width, and projection)of the conus but cannot alter the shape of theimplant. Fine tuning of the shape is impossible.The height and width of the implant are deter-mined by the dimensions of the footprint andvice versa. In general, higher implants are usedto fill up the infraclavicular part of the breast, incomparison with implants used for breast aug-mentation. Some companies produce specificimplants with increased projection to be used inimplant reconstruction. Until now, the utility ofthese expensive implants have not been proven.Sometimes, larger volume breast reconstructioncan be performed only by placing implants thatgo over the limits of the footprint. This mayresult in an awkward appearing breast.

The main disadvantage of using an implant,next to the commonly known drawbacks of for-eign bodies, is the possible displacement on thechest wall caused by pectoralis movements, exte-rior forces, and/or capsular contracture. This dis-placement will immediately deform the entirebreast, resulting in an unnatural breast. Visiblerippling of the implant and deformation of theimplant by capsular contracture are other im-portant problems that will cause distortion ofthe conus.

Fig. 5. Preoperative (left) and postoperative views (center and right) of the shape of the breast after unilateral secondary autologousbreast reconstruction by means of a deep inferior epigastric artery perforator flap and later nipple reconstruction and tattoo of thenipple-areola complex. This patient refused any contralateral breast surgery.


804

EnvelopeThe skin envelope will cover the implant to-

gether with the pectoralis muscle. Draping of theskin proceeds in the same way as with autologousreconstructions. The lower skin flap is preservedand all scar tissue is removed from its inner sur-face. If there is a shortage of skin in secondaryreconstructions or in cases where the mastectomyflaps cannot be adequately stretched, an expanderneeds to be placed first. Expansion continues untilenough skin surface is obtained to fit the perma-nent implant. The fibrosis and sclerosis caused byradiotherapy will impede expansion of the skin oreven lead to contraction of the skin and the sub-cutaneous layers. Lack of elasticity and contrac-tion and deformation of the envelope will signif-icantly deteriorate the final aesthetic result. Forthose reasons, many believe that implant recon-struction is incompatible with radiotherapy ad-ministered either before or after the placement ofthe implant. Implant reconstruction together witha pedicled latissimus dorsi or thoracodorsal arteryperforator flap can be a valuable alternative to addmore coverage of the implant and to insert moreskin between the edges of the mastectomy flaps. Ifthe skin envelope is too large, a simultaneous skinresection following the Wise pattern or other mas-topexy design can be performed.

Phillip N. Blondeel, M.D., Ph.D.Department of Plastic and Reconstructive Surgery

University Hospital GhentDe Pintelaan 185, 2K12C

B-9000 Ghent, [email protected]

REFERENCES1. Holmstrom H. The free abdominoplasty flap and its use in

breast reconstruction: An experimental study and clinical casereport. Scand J Plast Reconstr Surg. 1979;13:423–427.

2. Hartrampf CR, Scheflan M, Black PW. Breast reconstructionwith a transverse abdominal island flap. Plast Reconstr Surg.1982;69:216–225.

3. Bostwick J III, Vasconez LO, Jurkiewicz MJ. Breast recon-struction after a radical mastectomy. Plast Reconstr Surg.1978;61:682–693.

4. Koshima I, Soeda S. Inferior epigastric artery skin flaps with-out rectus abdominis muscle. Br J Plast Surg. 1989;42:645–648.

5. Allen RJ, Treece P. Deep inferior epigastric perforator flap forbreast reconstruction. Ann Plast Surg. 1994;32:32–38.

6. Blondeel P. One hundred free DIEP flap breast reconstruc-tions: A personal experience. Br J Plast Surg. 1999;52:104–111.

7. Blondeel PN, Boeckx WD. Refinements in free flap breastreconstruction: The free bilateral deep inferior epigastric per-forator flap anastomosed to the internal mammary artery. BrJ Plast Surg. 1994;47:495–501.

8. Fujino T, Harasina T, Aoyagi F. Reconstruction for aplasia of thebreast and pectoral region by microvascular transfer of a free flapfrom the buttock. Plast Reconstr Surg. 1975;56:178–181.

9. Allen RJ, Tucker C Jr. Superior gluteal artery perforator freeflap for breast reconstruction. Plast Reconstr Surg. 1995;95:1207–1212.

American Society of Plastic Surgeons Mission StatementThe mission of the American Society of Plastic Surgeons� is to support its members in their efforts to providethe highest quality patient care and maintain professional and ethical standards through education, research,and advocacy of socioeconomic and other professional activities.


805

specialtopic - connecting repositories · specialtopic shaping the breast in aesthetic and...

Documents