Breast reconstruction

BREAST DISEASE: DIAGNOSIS ANDCONTEMPORARY MANAGEMENT 0889–8545/02 $15.00 � .00

BREAST RECONSTRUCTION

Pamela M. Antoniuk, MD

Women who are diagnosed with breast cancer must deal not only with itspsychologic implications but also with the devastating consequences of surgicaltreatment. If the woman refuses reconstruction, she is continuously reminded ofher diagnosis by the mastectomy scar or the deformed breast after lumpectomyand radiation. Women who desire breast reconstruction can regain a semblanceof the lost breast. Although they realize the reconstructed breast is not the sameas the lost breast, they incorporate it into their body and eventually accept it astheir own. Even women who have undergone difficult surgery agree, in mostcases, that it is better to be reconstructed than not. Many of these women alsoundergo surgery on the contralateral breast for symmetry. Breast reduction,augmentation mammaplasty, and mastopexy are now procedures that are cov-ered by health insurance in most states. A greater awareness by physicians thatbreast reconstruction is available has resulted in more women referred forconsultation. Better understanding of tumor biology also has contributed to anincrease in referrals.

At the initial consultation, the woman is counseled regarding all forms ofreconstruction unless she requests a specific type. Often, such a request is basedon information she has obtained speaking with other women who have gonethrough the procedures or through her own research. An unlimited amount ofinformation can be obtained on the Internet. The woman who presents with thisinformation at the initial consultation requires careful counseling. She may bringwith her a final result that can never be attained because of her body habitus,or she may not be aware of the amount of surgery that is required. For thesereasons, the initial consultation should consist of a discussion of autologousbreast reconstruction and the use of an expander or implant.

AUTOLOGOUS TISSUE RECONSTRUCTION

Because of the controversy surrounding silicone gel implants, many womenprefer to use their own tissue for breast reconstruction. At the initial evaluation,

From the Division of Plastic Surgery, Department of Surgery, Women and Infants Hospital,Providence, Rhode Island

OBSTETRICS AND GYNECOLOGY CLINICS OF NORTH AMERICA

VOLUME 29 • NUMBER 1 • MARCH 2002 209

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careful attention to the history and physical examination is essential. The historyshould assess for smoking, diabetes, hypertension, previous abdominal surger-ies, previous axillary dissection, and previous irradiation. The physical examina-tion should include observation of obesity, scars, lower abdomen pannus, andthe size and shape of the contralateral breast.

Social and personal aspects of the woman’s life need to be explored throughthe following questions: Does the woman stay at home or work? Does she havechildren, and what are their ages? Does she have support from a partner orfamily? How much time can she realistically give toward her recuperation?Because women lead active lives, unless these issues are explored before thereconstruction, the final result may be suboptimal.

TRAM FLAP

Since its introduction by Hartrampf and associates,15 the transverse rectusabdominis myocutaneous or TRAM flap has become the most popular form ofautologous reconstruction. Women choose this flap not only because of its abilityto reconstruct the breast but because of its secondary benefit for a flatter,better contoured abdomen.26 In unilateral reconstruction, it gives an estheticallysuperior result.19, 26 The TRAM flap has the ability to give a softer, ptotic breastthat better mimics the contralateral breast.

The TRAM flap is obtained from the lower abdomen. Its delivery into thebreast defect is based on the superior epigastric vessels or the deep inferiorepigastric vessels, allowing the flap to be raised on a pedicle or as a free flap.

The pedicle can be raised on the ipsilateral, contralateral, or, in selectedcases, bilateral rectus abdominus muscles (Fig. 1).34 The flap is then elevated,rotated, and passed through a tunnel under the chest wall. The breast mound isthen developed. Closure of the abdomen is performed by reapproximating thefascia, and mesh may or may not be used to reinforce the abdominal closure.Fascial closure alone can result in abdominal hernia formation.21 The use ofmesh or a double-layer fascial closure may decrease this occurrence.21, 36

The TRAM flap is divided into four zones.33 Zone I is over the muscleharvested. Zone II is directly across the midline. Zone III is adjacent to zone Ion its lateral end, and zone IV is next to zone II. This division is useful indetermining optimal survival of the flap. Zone IV is considered to have thepoorest blood supply in unipedicle reconstructions and is usually discarded atthe initial procedure. A woman who requires the maximum amount of tissuebut is not a free flap candidate can have either a ‘‘supercharged’’ procedure ora bipedicle flap. A supercharged procedure includes using a pedicle and thenaugmenting it with a microvascular anastomosis. The bipedicle flap uses bothrectus abdominus muscles to increase the vascularity of the flap.26, 35 Womenwho are candidates include patients with previous abdominal scars.

Obesity, smoking, previous breast irradiation, and other medical problemsare associated with a higher risk for complications.6, 35 Patients who are notcandidates for a microvascular anastomosis may require a delay in procedurebefore the TRAM reconstruction.7 The superficial and deep inferior epigastricvessels are divided. The lower abdominal tissue must then rely on the superiorepigastric and surrounding vessels. This procedure is particularly useful forenhancing venous return. In a second stage, the TRAM flap is elevated and insetin the usual fashion.

The TRAM also can be obtained as a free flap. This technique involvesraising the flap and a small rectangular piece of rectus muscle with anastomoses

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Figure 1. TRAM flap. A, The preoperative markings. The inframammary line is drawn. Themargins of the parenchyma, including the ptotic portion, are also drawn along with theposition of the inframammary fold. Whenever possible, the lower margin of the abdominalflap is sutured along the fold, although it is not advantageous to do so in every case if thefold has been spared and the remaining skin is of good quality. The transverse abdominalflap is harvested as shown and left attached to the rectus fascia overlying the rectusmuscle. A large portion of the contralateral skin island is discarded when doing a reconstruc-tion because of concern for the viability of the flap on the side opposite its pecicle. B, Theauthor prefers to use the ipsilateral pedicle and flap and pass it upward through a subcuta-neous tunnel directly to the area to be reconstructed. There are situations in which thecontralateral muscle pedicle is used, especially when options are limited owing to thepresence of abdominal scars from previous operations. (Data from Versaci AD: Breastreconstruction following mastectomy. In Marchant DJ (ed): Breast Disease. Philadephia,WB Saunders, 1997, pp 247–258; with permission.)

to the thoracodorsal or the internal mammary vessels. The deep inferior epigas-tric perforator (DIEP) flap is a new technique. This free flap uses the abdominalskin and subcutaneous tissue but spares the rectus muscle. Kroll18 noted de-creased abdominal pain and donor-site morbidity as the advantage of using thisflap over the conventional free TRAM. He cautioned that the vessels, especiallythe veins, must be of adequate caliber, and that these women should be non-smokers. Abdominal closure and flap insetting are carried out in the usualfashion. Although the free flap is extremely rewarding, it carries the risk of totalflap loss secondary to vascular thrombosis. In the presence of previous irradia-tion, a free TRAM flap has a higher success rate when compared with thepedicle TRAM.25

The TRAM flap has helped many women to cope with breast cancer;however, it is an involved operation and is associated with risks.26, 29, 35 As istrue for all surgical procedures, there is risk of bleeding, infection, and incisionaldehiscence. These complications are increased in women who are obese, smok-ers, or who have had previous irradiation. Seroma formation can occur after the

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drains are removed. The TRAM flap carries specific risks that include fat necrosis(partial or complete),20 flap loss secondary to vascular compromise (partial orcomplete), and abdominal bulges or hernia formation.

LATISSIMUS DORSI MYOCUTANEOUS FLAP

The latissimus dorsi myocutaneous flap is a pedicle flap based on thethoracodorsal arterial and venous systems. The thoracodorsal nerve supply ismaintained.9 Postoperative shoulder function usually is well tolerated.27 Usually,the muscle is harvested with a skin island whose orientation is dependent onthe mastectomy scar.5, 8 Although the transverse scar is popular and is hiddenunder the brassiere and clothing, it can be visible with bathing suits and eveningwear; therefore, the scar also can be oriented vertically or diagonally (Fig. 2).34

In most cases, the latissimus dorsi flap is used with an implant.30 Womenmust be willing to accept the use of an implant along with autologous tissue.Horn and co-workers16 have described a modification of the latissimus dorsibreast reconstruction that may result in an adequate amount of tissue harvestedwithout an implant. Germann and St. Elnau12 have described an extendedlatissimus dorsi flap used in women with medium-sized breasts. The scapularfat fascia is incorporated with the myocutaneous flap, adding extra volume and

Figure 2. Latissimus dorsi myocutaneous flap. Left, The preoperative markings. The posi-tion of the latissimus dorsi muscle is outlined. The skin paddle is custom-designed to fitthe individual needs of the case. Its position and dimensions are determined by measure-ments taken from the mastectomy specimen. The flap will include subcutaneous tissue thatwill be used to provide sufficient volume for the reconstruction. In the event the volume isinsufficient, an implant can be used in additon to the flap. Right, the muscle, skin, andsubcutaneous tissue are passed through a subcutaneous tunnel to the anterior thoracicarea where the unit is shaped into a ‘‘breast’’ and sutured in place. If further augmentationis necessary, the implant is placed in a pocket beneath the pectoralis major and the serratusanterior muscles. (Data from Versaci AD: Breast reconstruction following mastectomy. InMarchant DJ (ed): Breast Disease. Philadelphia, WB Saunders, 1997, pp 247–258; withpermission.)


avoiding an implant. If a large breast reconstruction is required, the latissimusdorsi myocutaneous flap can be harvested along with fat from the five fattyzones.9

The latissimus dorsi flap is also used for partial breast reconstruction.Candidates include women who have undergo partial mastectomy with orwithout radiation. Usually, an implant is not required. If no skin is required, themuscle flap can be raised endoscopically.3 Women who are candidates for thisprocedure must have an adequate amount of tissue that corresponds to thebreast removed. The reconstruction can be performed immediately after thepartial mastectomy, but caution is necessary if radiotherapy is required. Underthis circumstance, reconstruction should be performed as a delayed procedure.If a skin island is required, a more formal approach is used. As is true for anysurgical procedure, there are risks of bleeding, infection, and incisional de-hiscence. Any pedicle flap carries a risk of vascular compromise secondary tokinking or direct damage to the vessels. There is a risk of seroma formationafter the drains are removed.3, 5, 9, 12, 16, 30

IMPLANT RECONSTRUCTION

For the woman who does not wish to undergo reconstruction with autolo-gous tissue, reconstruction with an implant is an option. As described byBoswick,4 selected woman can undergo implant placement with available tissue.These women are slender, have ample and supple skin, and have not beenirradiated. Reconstruction is performed in a one-stage operation. When suchsurgery is not an option, a two-stage procedure is considered. The first stageinvolves placement of a tissue expander; stage two involves removal of theexpander and placement of the implant. As described by Argenta,1 there aremany advantages to this form of breast reconstruction, including a perfect skinmatch, no new scars, and no flap or donor-site complications. This form ofreconstruction is not recommended for women who have had previous radiationtreatment because the complication rates are high. Women who are identified ascandidates for radiation treatment after mastectomy and for reconstruction withan expander have an increased risk of capsular contracture and distortion of thebreast.1, 31 When this complication occurs, removal of the implant and reconstruc-tion with autologous tissue or salvaging the implant reconstruction with a flapis considered.28, 31

Immediately after mastectomy, a submuscular fascial pocket is created. Thisinitial amount of expansion is limited by flap tension and quality of the skinflaps. If the skin flaps are questionable or tight, fluorescein can be injected, orreconstruction can be delayed. Expansion is done in the office. The tissueexpander is overexpanded.1 The final implant is smaller to create a more ptoticbreast. The capsule, representing scar tissue that forms around every implant,may cause a tight constriction around the expander. During placement of thefinal implant, the capsule can be incised (capsulotomy) or excised (capsulectomy)to create a larger softer pocket.

During the process of reconstruction, the opposite breast may require sur-gery for symmetry, including augmentation mammaplasty, mastopexy, or breastreduction. Breast reconstruction with an implant gives the appearance of ayouthful breast. Projection is improved, but, with the sacrifice of the nipple-areola complex, the final appearance is flatter. This appearance can be improvedwith nipple reconstruction. There is superior fullness when compared with theappearance of the opposite breast. Surgery on the contralateral breast improves

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this difference. Initially, symmetry is good, but, because the normal breastcontinues to change, further procedures for symmetry may be required on thereconstructed breast.

With thin skin flaps and expansion, the implant may be easily palpated,and rippling may be noticeable. Deflation is another potential complication thatresults in removal and replacement of the implant. Other complications includebleeding and infection, each increasing the chance of a capsular contracture. Aninfection may require removal of the expander or implant.11 After the recon-structed breast is allowed to heal (usually, approximately 3 months), the ex-pander or implant can be replaced.

The implants used for reconstruction can be round or anatomic dependingon the shape of the contralateral breast. Smooth or textured surface implantscan be chosen if a round implant is used. Anatomic implants are available onlywith a textured surface.

NIPPLE RECONSTRUCTION

Nipple reconstruction is the final procedure performed.23, 26 This operationcan be done at any time. Some women delay the procedure. Symmetry shouldbe adequate before nipple reconstruction, and the woman should be satisfiedwith the results. A nipple-areola complex asymmetrically placed will actuallymake the final result worse.23

Nipple reconstruction is accomplished by raising local flaps from the sur-rounding skin.4, 16, 23 A nipple graft can be performed when the normal breastnipple is large enough. The areola can be reconstructed with skin grafts, theopposite areola, or by tattooing.12 An areola created by skin grafting can betattooed at a later date. Before the surgeon uses a nipple or areolar graft fromthe opposite breast, the patient must realize that sensation may be altered.Situations that allow the areola to be used as a graft include women undergoinga breast reduction or mastopexy on the contralateral breast; otherwise, the areolaused would be discarded during the procedure.

THE OPPOSITE BREAST

Breast Reduction

Some women have such large breasts that any form of reconstruction isunable to match the opposite breast. If autologous tissue is chosen for thereconstruction, the large breast mound will feel heavy. In this situation, thenormal breast and the reconstructed breast must be reduced. Postoperativechanges after a reduction may be evident on mammography. If these changesappear suspicious, a biopsy may be recommended.

The technique used for breast reduction depends on the size of the woman’sbreast, the degree of ptosis, and skin quality. Any technique used will result inreducing the size of the breast and improving the shape. In selected casesrequiring a minimal-to-moderate removal of breast tissue and minimal move-ment of the nipple-areola complex, liposuction alone may be used.24 For womenwith poor skin quality and greater ptosis, a more formal reduction is necessary.This operation requires an incision around the areola, vertically and possibly inthe inframammary fold, depending on the operative technique used. The nipple-areola complex is vascularized on a pedicle that can vary based on the breast


configuration and surgeon’s preference. For women who are smokers or womenwith extremely large breasts, the vascularity of the nipple-areola complex maybe compromised when maintained on a pedicle, and a free nipple graft is used.13

This maneuver requires more postoperative attention to ensure take of the freegraft. Loss of the graft with scarring or depigmentation may occur, requiringlater reconstruction. These women cannot breastfeed, and the nipples will haveno sensation.

All breast tissue removed must be evaluated by the pathologist. Breastcancer has been identified in the tissue on rare occasions.10, 17, 32

Mastopexy

When the breast volume is adequate and yet there is significant ptosissecondary to redundant skin, a mastopexy is indicated. Candidates for thisprocedure include women who have had significant weight loss or who havechanges in the breasts secondary to pregnancy and lactation. The operativeapproach and the incisions made depend on the degree of ptosis and the amountof excessive skin. Surgical approaches include a periareola incision and theinverted tear drop incision that results in a vertical and periareolar scar. If thereis still excessive skin redundancy, an inframammary fold incision is incorpo-rated.4

Augmentation Mammaplasty

Women who desire reconstruction but who have very small breasts need toconsider augmentation of the opposite breast for symmetry. Saline-filled im-plants are used unless the surgeon is involved in the silicone gel study. Theimplants are placed in the subpectoral or subglandular space depending on theconfiguration of the breast. Screening mammograms continue to be effective;however, special techniques are required. The requisition must note the presenceof the implants.

Placement of the implant can be through an axillary, periareolar, or infra-mammary fold incision. Textured implants are anatomic or round, whereassmooth implants are round only. All of the implants are filled with saline.Adjustable implants are now available and offer women the ability to have theimplant size changed to improve symmetry. Changes in volume can take placeup to 6 months after placement. The infusion port is then removed. This optioncan be advantageous for the patient who requires postoperative adjustments forsymmetry. When the port is removed, final adjustments to the breasts can bemade, or nipple reconstruction can be carried out.

Some women require not only augmentation but also a mastopexy of theopposite breast. The augmentation will replace superior pole fullness while themastopexy corrects ptosis.

COMPLICATIONS

Mastopexy, augmentation mammaplasty, and breast reduction are associatedwith risks.35 The operations and resultant scars can be continuous remindersthat the woman has had breast cancer. On the other hand, the woman gains

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breasts that have improved shape and size, and the associated risks are gladlyaccepted.

Any surgical procedure on the breast may result in an alteration of sensationto the nipple. Numbness or hypersensitivity may be permanent. The final scarsare permanent and may widen. Boswick4 leaves Steri-strips in place for 2 monthsto prevent the incisions from widening.

There are complications associated with saline implants.14 A saline implantmay deflate, requiring replacement. Scar tissue, also known as a capsule, formsaround every implant and is usually soft and undetectable. Capsular con-tractures can develop, resulting in a distorted, possibly painful breast requiringrevisional surgery. Patients who have received radiotherapy and who havehad complications of hematoma and infection are at high risk for capsularcontracture.2, 4

SUMMARY

Breast reconstruction after surgery for breast cancer has given women theability to survive a devastating time in their lives. Breasts are important to awoman’s femininity, and when one is lost it may be replaced by appropriateand timely reconstruction. Women continue to have control and make their owndecisions regarding reconstruction, including their acceptance of the final result.Even immediate reconstruction may require surgical revision to improve thecosmetic result. During this period, important relationships are established be-tween the patient, the oncology team, and the plastic surgeon.

The following case studies describe some of the author’s experience withthe various techniques in breast reconstruction.

Case Studies

Case 1. A 45-year-old woman was diagnosed with cancer in the left breast(Fig. 3A). She underwent a modified radical mastectomy of the left breastand prophylactic mastectomy of the right breast. Immediate reconstruction wasperformed using bilateral TRAM flaps. The patient underwent revision of bothreconstructed breasts, with removal of fat necrosis.

At the time of the immediate reconstruction, a fascial closure of the abdo-men was performed. A lower abdominal bulge developed 10 months aftersurgery. Repair of the abdominal wall bulge was performed with Prolene mesh.The patient recovered uneventfully from these procedures (Fig. 3B). Bilateralnipple-areolar reconstruction was performed (Fig. 3C).

Case 2. A 47-year-old woman was diagnosed with cancer in the left breast.She underwent a left mastectomy and reconstruction with a free TRAM flap(Fig. 4A). All wounds healed well (Fig. 4B). Approximately 5 months later, anodule developed in the superior aspect of the left reconstructed breast. Pathol-ogy of the nodule showed recurrent ductal carcinoma in situ. Revision of theleft breast reconstruction was performed after the nodule was removed by thebreast surgeon. A mastopexy was also performed on the right breast (Fig. 4C).The patient underwent nipple-areolar reconstruction of the left reconstructedbreast (Fig. 4D). The patient had no abdominal problems. Abdominal closurewas fascial only.


Figure 3. A, A 45-year-old woman diagnosed with left breast cancer underwent modifiedradical mastectomy of the left breast and prophylactic mastectomy of the right breast. B,Repair of the abdominal wall bulge with prolene mesh. C, Bilateral nipple and areolarreconstruction.

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Figure 4. A, A 47-year-old woman diagnosed with left breast cancer underwent leftmastectomy and reconstruction with a free TRAM flap. B, All wounds healed well. C,Revision of the left breast reconstruction after nodule was removed and mastopexy wasperformed on the right breast. D, Nipple and areolar reconstruction of the left breast.


Case 3. A 76-year-old woman was diagnosed with cancer in the right breast.She wore a 34B brassiere. Right mastectomy and left prophylactic mastectomywere performed. Immediate reconstruction was performed with McGhanBioDIMENSIONAL tissue expanders (McGhan Medical Corporation, SantaBarbara, California). Total expansion was 500 mL (Fig. 5A). The patientdesired larger breasts than her preoperative state. At a second stage, theexpanders were removed, and McGhan BioDIMENSIONAL saline BIOCELLtextured anatomic implants style 163 were placed. Each implant was filledto 440 mL. Bilateral nipple-areolar reconstructions were performed (Fig. 5B,C, and D). The patient and her husband were pleased with the final result.

Case 4. A 55-year-old woman was diagnosed with cancer in the right breast(Fig. 6A). Initial surgery included a mastectomy and reconstruction using aMcGhan BioDIMENSIONAL textured tissue expander. Total expansion was 400mL (Fig. 6B). At a second operation, the patient underwent removal of thetissue expander and placement of a McGhan style 163 BioDIMENSIONAL, full-anatomic, textured saline implant filled to 380 mL and augmentation of the leftbreast with a McGhan style 168 BioDIMENSIONAL textured implant. Thepatient was unhappy with the fullness in the superior pole of the right recon-structed breast and had the implant exchanged for a McGhan style 363 Bio-

Figure 5. A, A 76-year-old woman diagnosed with right breast cancer underwent rightmastectomy and left prophylactic mastectomy with 500 mL total expansion. At the secondstage, the expanders were removed, and an implant was placed and filled to 440 mL. B–D,Bilateral nipple and areolar reconstruction.

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Figure 6. A, A 55-year-old woman diagnosed with right breast cancer. B, Initial reconstruc-tion with mastectomy and textured tissue expander, expanded to 400 mL. C, This wasexchanged later with a low anatomic textured saline implant and nipple and areola recon-struction. D, Final result 1 year later.

DIMENSIONAL low-anatomic, textured saline implant. Nipple-areola recon-struction was performed (Fig. 6C). The final result 1 year after is shown inFigure 6D). No further surgery was performed.

Case 5. A 41-year-old woman had a left breast lumpectomy, radiotherapy,and was placed on tamoxifen (Fig. 7A). She requested reconstruction of the leftbreast but did not want autologous tissue reconstruction. A Mentor H/S SiltexSpectrum mammary adjustable textured prosthesis was placed in the left breast.Right breast augmentation was performed with a Mentor Siltex, saline-filledmammary prosthesis filled to 225 mL. Revisional surgery was performed tolower the inframammary fold (Fig. 7B). The implant was removed after aninfection developed. After 3 months, it was replaced with a Mentor H/S ContourProfile Natural prosthesis (The Mentor Corporation, Santa Barbara, California)filled to 300 mL. The final result 6 months later is shown in (Fig. 7C). No furthersurgery was performed.


Figure 7. A, A 41-year-old woman with left breast lumpectomy, radiation therapy, placedon tamoxifen. She underwent placement of an adjustable textured prosthesis and rightbreast augmentation with a saline-filled mammary prosthesis filled to 225 mL. B, She hadrevisional surgery to lower the inframammary fold. After 3 months it was replaced with aprosthesis filled to 300 mL. C, Final result 6 months later.

References

1. Argenta LC: Reconstruction of the breast by tissue expansion. Clin Plast Surg 11:257–264, 1984

2. Becker H, Springer R: Prevention of capsular contracture. Plast Reconstr Surg 103:1766–1768, 1999

3. Bostwick J: Endoscopic latissimus dorsi flap for partial breast reconstruction. In Opera-tive Techniques in Plastic and Reconstructive Surgery. Philadelphia, WB Saunders,1999, pp 61–67

4. Bostwick J III: Plastic and Reconstructive Breast Surgery, ed 2. St. Louis, Mosby, QualityMedical Publishing, Inc, 2000

5. Bostwick J III, Nahai F, Wallace JG, et al: Sixty latissimus dorsi flaps. Plast ReconstrSurg 63:31–41, 1979

6. Chang DW, Wang B, Robb GL, et al: Effect of obesity on flap and donor site complica-tions in free transverse rectus abdominis myocutaneous flap breast reconstruction.Plast Reconstr Surg 105:1640–1648, 2000

7. Codner MA, Bostwick J III, Nahai F, et al: TRAM flap vascular delay for high riskbreast reconstruction. Plast Reconstr Surg 96:1615–1622, 1995

8. Cohen BE, Cronin ED: Breast reconstruction with the latissimus dorsi musculocuta-neous flap. Clin Plast Surg 11:287–302, 1984

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9. Delay E, Gounot N, Bouillot A, et al: Autologous latissimus breast reconstruction: A3-year clinical experience with 100 patients. Plast Reconstr Surg 102:1461–1478,1998

10. Dinner MI, Artz JS: Carcinoma of the breast occurring in routine reduction mamma-plasty. Plast Reconstr Surg 83:1042–1044, 1989

11. Disa JD, Ad-El DD, Cohen SM, et al: The premature removal of tissue expanders inbreast reconstruction. Plast Reconstr Surg 104:1662–1665, 1999

12. Germann G, Steinau H-U: Breast reconstruction with the extended latissimus dorsiflap. Plast Reconstr Surg 97:519–526, 1996

13. Gradinger GP: Reduction mammaplasty with free nipple-areola graft. In OperativeTechniques in Plastic and Reconstructive Surgery. Philadelphia, WB Saunders, 1999,pp 141–150

14. Handel N, Jensen JA, Black Q, et al: The fate of breast implants: A critical analysis ofcomplications and outcomes. Plast Reconstr Surg 96:1521–1533, 1995

15. Hartrampf CR, Scheflan M, Black PW: Breast reconstruction with a transverse abdomi-nal island flap. Plast Reconstr Surg 69:216–224, 1982

16. Horn MA, Cimino V, Angelats J: Modified autogenous latissimus breast reconstructionand the box top nipple. Plast Reconstr Surg 106:763–768, 2000

17. Jansen DA, Murphy M, Kind GM, et al: Breast cancer in reduction mammaplasty: Casereports and a survey of plastic surgeons. Plast Reconstr Surg 101:361–364, 1998

18. Kroll SS: Fat necrosis in free transverse rectus abdominis myocutaneous and deepinferior epigastric perforator flaps. Plast Reconstr Surg 106:576–583, 2000

19. Kroll SS, Baldwin B: A comparison of outcomes using three different methods of breastreconstruction. Plast Reconstr Surg 90:455–462, 1992

20. Kroll SS, Gherardini G, Martin JE, et al: Fat necrosis in free and pedicled TRAM flaps.Plast Reconstr Surg 102:1502–1507, 1998

21. Kroll SS, Marchi M: Comparison of strategies for preventing abdominal wall weaknessafter TRAM flap breast reconstruction. Plast Reconstr Surg 89:1045–1051, 1992

22. Kroll SS, Schusterman MA, Reece GP, et al: Breast reconstruction with myocutaneousflaps in previously irradiated patients. Plast Reconstr Surg 93:460–469, 1994

23. Little JW III: Nipple-areola reconstruction. Clin Plast Surg 11:351–364, 198424. Matarasso A: Breast reduction by suction mammaplasty. In Operative Techniques in

Plastic and Reconstructive Surgery. Philadelphia, WB Saunders, 1999, pp 136–14025. Moran SL, Serletti JM, Fox I: Immediate TRAM reconstruction in lumpectomy and

radiation failure patients. Plast Reconstr Surg 106:1527–1531, 200026. Paige KT, Bostwick J III, Bried JT, et al: A comparison of morbidity from bilateral,

unipedicled and unilateral, unipedicled TRAM flap breast reconstructions. Plast Re-constr Surg 101:1819–1827, 1998

27. Russell RC, Pribaz J, Zook EG, et al: Functional evaluation of latissimus dorsi donorsite. Plast Reconstr Surg 78:336–344, 1986

28. Schuster RH, Kuske RR, Young VL, et al: Breast reconstruction in women treated withradiation therapy for breast cancer: Cosmesis, complications, and tumor control. PlastReconstr Surg 90:445–452, 1992

29. Slavin SA, Goldwyn RM: The midabdominal rectus abdominis myocutaneous flap:Review of 236 flaps. Plast Reconstr Surg 81:189–197, 1988

30. Slavin SA, Schnitt SJ, Duda RB, et al: Skin sparing mastectomy and immediate recon-struction: Oncologic risks and aesthetic results in patients with early-stage breastcancer. Plast Reconst Surg 102:49–62, 1998

31. Spear SL, Onyewu C: Staged breast reconstruction with saline-filled implants in theirradiated breast: Recent trends and therapeutic implications. Plast Reconstr Surg 105:930–942, 2000

32. Tang CL, Brown MH, Levine R, et al: Breast cancer found at the time of breastreduction. Plast Reconstr Surg 103:1682–1686, 1999

33. Taylor GI: The delayed TRAM flap for breast reconstruction: Why, When, and How.In Operative Techniques in Plastic and Reconstructive Surgery. Philadelphia, WBSaunders, 1999, pp 74–82

34. Versaci AD: Plastic surgery: Breast reconstruction following mastectomy. In MarchantDJ (ed): Breast Disease. Philadelphia, WB Saunders, 1997, pp 247–258


35. Watterson PA, Bostwick J III, Hester TR, et al: TRAM flap anatomy correlated witha 10 year clinical experience with 556 patients. Plast Reconstr Surg 95:1185–1194,1995

36. Zienowicz RJ, May JW: Hernia prevention and aesthetic contouring of the abdomenfollowing TRAM flap breast reconstruction by use of polypropylene mesh. PlastReconstr Surg 96:1346–1350, 1995

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