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J. D’silva and A. Deshpande
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Fig. 17.13 (a, b) Suturing of the ADM to extend the muscle as well as to cover the implant
reconstructed breast during contraction of the major pectoralis muscle and is experienced by majority of patients
due to the absence of normal breast tisseu to mask the
muscle movement. This can be reduced by the use of
acellular dermal matrix (ADM) which can be derived
from human (allografts), animal (xenografts), or synthetic sources. These are sutured to the released pectoralis
muscle so as to extend the bres and re-attaching the
muscle to the chest wall as well as the inframammary
crease (Fig.17.13a, b).
ADMs allow for repopulation, revascularization, and
integration of the host’s cells into the implanted tissue.
They reduce the chances of capsular contracture as well
as help in lowering the breast implant and creating a
medial fullness; however, they may be associated with a
slightly higher risk of infection and seroma.
7. Two-stage breast reconstruction: In the 2 stage reconstruction (usually undertaken in people who need postsurgery radiation or do not have adequate skin laxity),
rst stage involves placement of an expander in the prepectoral or subpectoral plane with the inferior pole coverage using rectus abdominis and serratus anterior fascia or
ADM.The decision to use prepectoral plane depends on
the thickness of the skin ap and its vascularity. Serial
expansion of the expander is done in a few weeks so as to
expand the lower pole. In 3months’ time (longer in people undergoing radiation) the expander is removed and
replaced with an implant. Fat grafting to the overlying
skin to get a thicker skin ap can be undertaken at the
same time.
Delayed two-stage reconstruction is safer than DTI
in high-risk patients including those that use tobacco
products, have poorly controlled diabetes mellitus,
have had prior breast irradiation, have very thin mastectomy skin aps, or who are morbidly obese. We strongly
believe that the ideal patients for single stage immediate implant reconstruction are those with small or moderate breasts and who aim to have the same or less
volume.
Pearls
1. Fat grafting may be required to improve the soft tissue
coverage which can be undertaken prior to implant placement. It is specially required in patients who have undergone radiation.
2. Prepectoral placement of implant prevents ‘animation
deformity’ hence preferred if the skin ap is vascular and
thick. Edges of the implant if seen can be camouaged by
fat grafting.
3. Patient requiring post-mastectomy radiation should
undergo a 2 stage reconstruction with radiation being
given in the expansion stage. Prone radiation reduces the
risk of muscle and soft tissue contracture.
4. For a patient wanting a ptotic natural looking breast like
the other side, implant associated with a muscle ap
should be considered.
5. Smooth, round implants should be preferably used for
breast reconstruction as feel natural and have less chance
of infection as well as ALCL (Fig.17.14).
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c
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Fig. 17.14 (a, b) 4weeks after one stage breast reconstruction using an implant and a latissimus dorsi muscle ap. (c, d) Nipple reconstruction
was done 3months after the reconstruction. (e, f) Final result after areola tattooing
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17.4 Breast Reconstruction Using
aFreeFlap
The commonest tissue used for autologous breast reconstruction in the present times is DIEP or the SIEP ap (deep
inferior epigastric perforator or the supercial inferior epigastric perforator). This tissue is from the lower abdomen
and has signicantly more positives than negatives as compared to tissue taken from the upper inner thigh (TUG ap),
buttock (SGA ap), or the TRAM aps. Here we will discuss
only about the DIEP ap.
Preoperative assessment.
This includes an assessment of the recipient vessel, the
donor tissue as well as the overall clinical condition of the
patient. Since the internal mammary vessels (IMA) are the
commonest recipient vessels for breast reconstruction, it is
important to assess the future requirement of the patient for
an open heart surgery specially if the reconstruction is done
bilaterally. In such a scenario, the left IMA is left intact and
both side aps are anastomosed to the right IMA.
Clinical assessment (Fig.17.15): The chest is assessed for
scars and any skeletal deformities.
The abdomen is assessed for skin laxity, presence of surgical or trauma scars which would have damaged the perforators and or presence of hernias.
Imaging: Imaging of the chest, abdomen and pelvis is
undertaken using a CT angiography which helps visualize
the primary vessel and its relation to physical structures and
landmarks so that precise ap dissection can be undertaken.
Branching of the deep inferior epigastric vessels can be seen
on the coronal views. Also the perforators and supercial
vessels can be viewed in relationship to each other to help
select DIEP or SIEP aps. Axial views of the abdomen starting from 4cm above the abdomen, all the way down to the
pubic area help in visualizing the perforators along with its
branching superiorly and inferiorly. These vessels are then
traced through the rectus abdominis muscle and a comparison is made to the supercial system to see what appears to
be dominant.
Benets of CT angiography of the ap vasculature
(Fig.17.16)
1. Perforator location can be localized along with assess-
ment of dominant lateral or medial perforator.
2. Arborization of the vasculature.
3. Diameter of the perforator (ideal is 1.5 mm with good
supercial arborization).
4. Course of the feeding vessel through the muscle can be
Fig. 17.15 Preoperative assessment of the breast and abdomen with
markings made in the standing position
Fig. 17.16 (a) CT
angiography seen in the
transverse plane and the
sagittal plane showing the
medial and lateral perforators
along with their arborization
and cranio-caudal distance
from the umbilicus. (b) also
shows the complete course of
the DIEA till its origin
visualized.
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17.4.1 Planning theDIEP Flap
The position and design of the ap are based on two factors
(Fig.17.17):
1. Location of the perforator: This is important as this is
based the extent of at that is available for transfer. As
seen in gure the location of the perforator decides the
position and extent of zone IV which has to be
discarded.
2. The volume of tissue needed to reconstruct the defect.
This can be adequately assessed only after the excision of
the lesion (Fig.17.18).
General principles in designing the ap include:
1. Calculating the amount of tissue required from the contralateral breast. This is usually a guestimate. The length
and breadth of the ap can be measured by measuring the
projection as well as the base of the normal breast. It is
better to take more tissue than less as the excess can be
trimmed during ap tailoring on the table.
2. The length of the incision depends on the excess abdominal skin and the extent of skin removal possible with the
patient bending forward.
3. If doing bilateral reconstructions, and there is no premeasured size, then an approximation can be made with a
measuring tape, but curving it in the air to assess the size.
4. Conrming the radiologic position of the perforators
using handheld Doppler which are usually at or just
below the level of umbilicus (Fig.17.19).
5. If the Perforator Is below the Umbilicus, Then the Flap Is
Located Completely in the Infraumbilical Area and Can
Be Closed Easily with the Scar in the Groin Crease. When
the Perforator Is at the Level of Umbilicus, Then the Flap
Moves Cranially and the Final Suture Line May Not Be
Hidden (Fig.17.20)
6. The lateral extent of the ap depends on the patient’s
habitus and the extent of skin laxity. These extensions
may not be vascular enough to be used for volume
replacement but will surely prevent ‘dog ears’.
17.4.1.1 Dissection oftheRecipient Vessel
(Fig.17.21)
1. Selection of donor vessels can be internal mammary or
branch arising from axillary vessels. Thoracodorsal pedicle is avoided to preserve the vascularity of the LD muscle which may be required as a lifeboat.
2. Self-retainer retractors are used to gain access to recipient
vessels (secured with op tape or held by assistant). The
third costal cartilage is chosen and if required the 2nd.
3. Periosteum elevator is used to strip the perichondrium
and a surgical blade and bone nibbler are used to remove
the cartilage segments.
4. Remove costal cartilage segment to get space for dissection and anastomosis. third costal cartilage and if required
Fig. 17.18 Assessing the volume required for breast reconstruction to
match the contralateral breast
Fig. 17.17 Perforator
angiosome zones of the lower
abdomen supplied by medial
(L) and lateral (R) row
perforators of the deep
inferior epigastric artery
(Connon etal. 2018)
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J. D’silva and A. Deshpande
Fig. 17.19 Perforator has been conrmed using a handheld doppler
Fig. 17.20 Location of the
perforators decides the nal
position of the ap (Studinger
2013)
Fig. 17.21 The pectoralis major muscle has been retracted (blue
arrow), the costal cartilage has been excised, and a sterile gauze has
been placed in the defect to highlight the internal mammary artery and
vein (yellow arrow)
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the second of around 1 cm length is removed for good
exposure of the internal mammary vessels.
5. Taking care to avoid puncture to pleura. If it happens, a
chest tube has to be placed to prevent a pneumothorax.
6. Antegrade anastomoses is planned with an end-to-end
anastomoses of both Internal mammary artery and vein.
17.4.1.2 Raising oftheFlap
1. Inltration along the incision line (Fig. 17.22) 2%
Xylocaine with adrenaline is inltrated along the marked
incision line taking care to not get too close to the
perforator.
2. Skin incision at the umbilicus (Fig.17.23) and separate
it from the surrounding tissues using a 15 blade scalpel
and dissection is done to separate the umbilicus from the
surrounding tissues. Once the umbilicus has been freed,
then the markings are incised with a scalpel and the der-
Fig. 17.22 Local inltration along the incision line
mal and subcutaneous dissection is carried out with a
diathermy.
3. Identication of the supercial inferior epigastric vein
(SIEV) (Fig. 17.24a). Initial dissection with a scalpel
can be performed in this area to get through the dermal
layers. Dissection is then undertaken using cautery and a
ne tipped hemostat to lift the tissue and then cauterize.
A sizable vein will be found along the inferior incision
located towards midline usually visualized on the preoperative scans. The supercial arterial system is usually
located more laterally. The scarpa’s fascia is identied
(Fig.17.24b) and depending on whether more subcutaneous tissue is required, dissection is carried out in a
bevelled manner below the fascia.
These vessels are important to be dissected carefully
as they can help you in times of venous congestion to
provide a second or third draining vein; can convert your
ap from a DIEP to a SIEA if the artery appears to be
suitable. The vessels in this area have a tendency to
spasm often and hence using a vessel loop as soon as
they are found keeps them safe during dissection.
Usually the best view that you will have of them is the
rst view.
4. Raising of the ap (Fig.17.25): Once the subcutaneous
tissues have been dissected to the fascia on all edges of
the ap, then the ap can be raised to locate the
perforators.
Laterally, the Scarpa’s fascia is not located as far laterally as the incision hence a dissection of a presumed
equal depth to that of the main abdomen is performed,
leaving subcutaneous tissue underneath the dissection
until the actual fascia is located. This dissection is usually done while sitting down and having an assistant support the ap up and away from you from the opposite
side. The dissection can be safely carried out till the
lateral border of the rectus muscle which can be identi-
Fig. 17.23 Incision being made to release the umbilicus (a) and also to complete the inferior incision (b)
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Fig. 17.24 Identication of the supercial inferior epigastric vein (a) and the scarpa’s fascia (b)
J. D’silva and A. Deshpande
Fig. 17.25 Flap being raised from lateral aspect towards the
perforator
ed by electrocautery stimulation. If the direction of
contraction is vertical, then the rectus muscle is below, if
diagonal, then it is the external oblique. Once in the rectus muscle territory, a safe dissection mode is to switch
to bipolar cautery and hemostat dissection to nd the
perforators.
5. Dissection of perforator (Fig.17.26): Down to and identication of perforator (matched to computed tomography) using bipolar diathermy and/or dissecting scissors.
Circling cuff/isolation of perforator above rectus fascia
using tenotomy forceps. These can be identied as a
shadow (vein), oval defect in the rectus sheath from
where the perforator appears or as a group of vessels
condensing into a thicker branch. The assistant should
be careful not to be overly enthusiastic about retraction
else he may avulse the perforator.
Fig. 17.26 Perforators being dissected and isolated
6. Subfascial/intramuscular dissection (Fig. 17.27): Once
the perforator has been identied, further dissection
involves opening the fascia superior and inferior to the
fascial opening. The perforator is then dissected down to
the main branch of the deep inferior epigastric artery.
The vessels are not directly underneath the fascia
(although radiographs do help to see this), and the fascia
can be gently split and retracted so as to visualize the
perforator dipping into the main vessel. Careful attention is paid to crossing nerve branches in order to spare
them during the dissection. During the dissection keep
the bipolar tips clean, otherwise they can stick to the
cauterized tissue and can cause tearing and damage to
the small branches of the DIEA.There is often a continuation of the DIEA superior to the perforator which
has to be carefully isolated and ligated/clipped.
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Fig. 17.27 The intramuscular and subfascial dissection of DIEA along
with its multiple perforators to the ap. The cranial end of the DIEA has
been clipped (green arrow), while the lower end is being dissected into
the groin (yellow arrow)
Fig. 17.28 Isolated DIEP pedicle into the groin before division
7. Distal/inferior pedicle dissection to achieve adequate
pedicle length (Fig.17.28). After the attachments have
been released, an inspection of the vessels is done to
assess the calibre and length of the pedicle. If this is
adequate, then the artery and the vein can be dissected
separate and marked separately to save time.
Once the pedicle dissection is complete, the ap is
raised from the opposite side. Once the ap has been
separated of all attachments except the pedicle, we wait
and watch the perfusion of the ap for 15min. The zone
4 is demarcated and excised, discarding it on the table.
Division of the pedicle is now undertaken with the veins
clipped rst followed by artery so that the vein gets lled
with blood preventing collapse.
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8. On table ap contouring (Fig.17.29): Once the pedicle
has been divided, the ap is gently removed from the
surgical site taking care that the pedicle is not caught
up with any tissue. The ap ischemia time is recorded,
it is weighed and then placed onto the table to create a
conical breast mound. The excess skin surface is deepithelized and a purse string suture is placed in the
supercial fascia using PDS- 2-0 and tightened to create a mound which has its highest projection at the
NAC.
9. Microsurgery: Flap should be stabilized before anastomosis to chest wall (Fig.17.30a) to avoid any accidental
movement causing avulsion. This can be undertaken by
using sutures or staplers. The mobility of the recipient
vessel is checked and nal microscopic dissection of the
donor and recipient vessels is undertaken. A background
is inserted and the venous anastomosis is rst undertaken with or without a coupler. Use of coupler increases
reliability of anastomosis and reduces procedure time
signicantly. Microscopic arterial dissection with
clamping and the anastomosis is carried out. Release of
clamps is done and check for bleeding (Fig. 17.30b).
Ligaclips can be used to control bleeding as use of bipolar cautery is not suggested. Acland’s test is undertaken
to conrm ow of artery and vein across the anastomoses. Bleeding from the SIEV and the opposite DIEV is
checked. They can be clipped and kept safe with an
intention to anastomose if required. The ap dermal
edges and the periphery of the ap are checked for
bleeding. Number 26 needle is used to scratch the skin/
dermis and check for capillary bleed. Haemostasis is
now achieved. The skin paddle if kept for viewing is now
assessed.
10. Breast/ap closure: The ap is anchored using 2.0 Vicryl
sutures to the defect in the right orientation so that the
fullness of the breast is achieved. The ap is xed to the
inframammary ligament so that it does not slide inferiorly. Check the anastomosed pedicle for twisting/kinking. If the monitoring is done through a NAC skin paddle
(Fig.17.31), then it should be centred and sutured to the
skin edges. Subcuticular suture closure of the ap can be
done. Drains are placed away from the anastomotic site
and noncompressive dressing done. Check ap for capillary rell so that you are sure about the viability of the
ap.
11. Abdominal incision closure- Usually the second team
does this part of the procedure which includes haemostasis of the muscle, primary closure of the rectus
defect using a nonabsorbable loop Nylon suture
(Fig. 17.32a). Superior undermining of the ap is
undertaken so that it can be slid down to suture to the
lower ap. Sometimes exion at the waist is required to
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J. D’silva and A. Deshpande
c
d
Fig. 17.29 (a, b) Flap placed on the table for tailoring. (c, d) Purse string suture being placed to create a conical shape for the ap
complete the closure. Relocation of the umbilicus is
undertaken and nal closure is done after haemostasis
and a drain (Fig.17.32b, c).
12. Postoperative care: Post operative patient is kept in high
essary. In case of nipple-sparing mastectomy with no
skin defect small monitoring skin paddle is kept in
lateral incision which is removed under local anaesthesia after 1week.
dependency unit/recovery overnight. Flap monitoring is
done by observing colour and perfusion of skin paddle
of ap and if there is any doubt small scratch with hypodermic needle in unexposed area of breast is done. Fresh
red or bright red bleeding is suggestive of good perfusion. If there is no bleeding from scratch or dark or congested bleed, then further evaluation done and
re-exploration of the anastomoses has to be done if nec-
1. Soft bra is given from second post-op day taking care to
avoid compression to area of anastomosis.
2. Abdominal binder is applied from POD 2.
3. Pt is mobilized next of surgery out of bed.
4. Hospital stay usually 4–6days in uneventful cases.
5. Drains are removed once the drainage is less than 30cc
(Fig.17.33).
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Pearls for Microvascular Flap Based Breast
Reconstruction
1. Pre-op planning of perforators and marking in standing
position.
2. Dissection of supercial inferior epigastric vein to be
used for supercharging if venous drainage inadequate.
3. Harvest of subscarpal far superiorly to get additional
bulk.
4. Meticulous dissection of perforator through rectus sheath
and muscle with bipolar cautery.
5. Avoiding traction on perforators while raising ap.
6. Preservation of motor nerve to rectus muscle.
7. Taking as long a pedicle as possible to give exibility for
the anastomosis.
8. Good haemostasis in donor area especially in pre perito-
neal space.
9. Umbilical relocation and tension free closure of
abdomen.
Fig. 17.30 (a) The free ap being sutured to the chest wall to stabilize
it. (b) Microvascular anastomoses have been completed and the vessels
are patent
Fig. 17.31 (a, b) Showing inset of the microvascular ap as well as closure of the incision with the monitoring skin paddle forming the new
areola
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