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16 Breast Reduction withFree Nipple Graft Transfer
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Fig. 16.13 (a, c) Presurgery photographs of a 46-year-old unmarried
lady who underwent free nipple graft procedure along with a reduction
mammoplasty of 1100gm on the left side and 1200gm on the right
References
Ahmed OA, Kolhe PS.Comparison of nipple and areolar sensation after
breast reduction by free nipple graft and inferior pedicle techniques.
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bjps.1999.3235.
Benelli L. A new periareolar mammaplasty: the “round block” tech-
nique. Aesthet Plast Surg. 1990;14:93–100.
Casas LA, Byun MY, Depoli PA, Gradinger GP.Maximizing breast
projection after free-nipple-graft reduction mammaplasty. Plast
Reconstr Surg. 2001;107(4):961–4.
side. (b, d) Photographs taken 4weeks after the surgery showing good
survival of the NAC on both sides
Koger KE, Sunde D, Press BHJ, Hovey LM.Gigantomastia using infe-
riorly based pedicle and free nipple transplantation. Ann Plast Surg.
1994;33:561–4.
Kotti B. A simple classication and a simplied treatment’s algo-
rithm for ptotic breasts. Plast Aesthet Res. 2018;5:16. https://doi.
org/10.20517/2347- 9264.2018.11.
Oneal RM, Goldstein JA, Rohrich R, Izenberg PH, Pollock
RA.Reduction mammoplasty with free-nipple transplantation: indications and technical renements. Ann Plast Surg. 1991;26(2):117–
21.
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M. Mammadli et al.
Stephen R, Colen MD. Breast reduction with use of the free nipple
graft technique. Aesthet Surg J. 2001;21(3):261–71. https://doi.
org/10.1067/maj.2001.116439.
Sterodimas A, Pineda EF, Meirelles V, Pitanguy I.Maximizing nipple
graft survival after performing free nipple-areolar complex reduction
mammaplasty. J Plast Reconstruct Aesthet Surg. 2008;61(8):971–2.
https://doi.org/10.1016/j.bjps.2008.04.004.
Thorek M.Possibilities in the reconstruction of the human form. Aesthet
Plast Surg. 1989;13(1):55–8. https://doi.org/10.1007/bf01570326.
Part IV
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Reconstructive Breast Surgery
Breast Reconstruction
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JamesD’silva andAkshayDeshpande
17
With the increase in early diagnosis of breast cancer there
has been a spurt in breast conserving surgery as well as
breast reconstruction after mastectomy. Breast reconstruction (BR) is considered an integral part of interdisciplinary
treatment of breast cancer. Restoration of body image
through breast reconstruction is very important to address
the critical issue of loss of self-image which negatively
impacts quality-of-life in breast cancer survivors. Various
options of BR are available which include implant-based
reconstruction or the ones using autologous tissue such as
transverse myocutaneous rectus abdominis myocutaneous
(TRAM) ap, latissimus dorsi (LD) ap or more complex
techniques such as deep inferior epigastric perforator
(DIEP) ap. Currently, implants or expanders are the most
frequently used techniques for reconstruction. Based on the
latest statistics from the American Society of Plastic
Surgeons (ASPS), more than 100,000 breast reconstructions are performed annually in the USA.Of these, almost
70% underwent 2-stage reconstruction using a tissue
expander (TE), while 13% had direct-to-implant (DTI), and
18% were autologous, predominantly with a DIEP ap
(Flaherty etal. 2020).
The ideal modality of breast reconstruction after mastectomy is still a point of debate and will differ from patient to
patient and the surgeon’s expertise. Nowadays, implantbased breast reconstruction is the leading reconstructive
method in the USA as in many countries including Argentina
(ISAPS 2018).
Once the patient is interested in reconstructing her operated breast, then consideration must be given to two main
factors:
Timing of the procedure: Can be immediate or delayed
with immediate reconstruction being the commonest as it
prevents psychological problems of a at chest, better results,
and lower costs.
Type of reconstruction: It can be implant-based reconstruction or autologous reconstruction. The commonest procedure all over the world is Implant-based reconstruction
which may be single stage or a two-stage implant placement.
The only time when immediate implant-based reconstruction
may not be a good choice is when postsurgery radiation is
required. This can be further divided based on the material
used in the implant (saline vs silicone), the tissue plane in
which the implant is placed, i.e. total submuscular, partial
submuscular, or prepectoral and if any adjunctive tissue scaffold has been used to reinforce the tissue covering the
implant.
Frequently the reconstructive surgeon walks into one of
the scenarios (Fig.17.1) wherein the amount of breast tissue
removed is limited (a) or the vascularity of the skin cover is
doubtful (b) due to extensive excision. In such a scenario use
of the local ap for reconstruction or just primary closure
and delayed reconstruction may be a good option.
Complications in a patient who has to undergo radiation may
delay the primary treatment of the cancer hence we always
offer the option of delayed reconstruction for such people.
Supplementary Information The online version contains supplementary material available at
J. D’silva (*)
Plastic Surgery, The Cosmetic Surgery Institute and The D Y Patil
University, Mumbai, India
A. Deshpande
Plastic and Reconstructive Surgery, Saifee Hospital, Mumbai,
India
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
M. Thomas, J. D‘silva (eds.), Manual of Cosmetic Medicine and Surgery, https://doi.org/10.1007/978-981-99-3726-4_17
https://doi.org/10.1007/978- 981- 99- 3726- 4_17.
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J. D’silva and A. Deshpande
a
Fig. 17.1 (a) Patient who has undergone lumpectomy may require a local ap for reconstruction. (b) Patient who has undergone a skin and nipple-
sparing mastectomy but needs radiation therapy should consider a delayed reconstruction
17.1 Implant-Based Breast Reconstruction
An evidence based approach is the goal of all reconstructive
surgeons performing implant-based breast reconstruction.
Here we review the steps that are commonly pursued during
the process of implant-based reconstruction.
17.2 Advances inCancer Surgery That
Favours Implant-Based
Reconstruction (Flaherty etal. 2020)
Skin Sparing Vs Nipple-Sparing Mastectomy: With the
increased incidence of early diagnosis, localized malignancy,
genetic mapping studies, and planned bilateral mastectomies
more oncosurgeons are considering a skin sparing and even
more advanced the nipple-sparing mastectomy. These procedures are usually carried through a midlateral incision at the
level of the nipple-areola complex, which helps to protect the
vascularity of the lower aps as well as allows complete
exposure to the upper pole. This procedure cannot be undertaken in ladies with droopy breasts as a skin reducing Wise
pattern will have to be used with a risk about the vascularity
of the nipple-areola complex. A nipple-sparing approach can
often be considered:
• if these criteria are met:
– the tumour does not involve the area around the
nipple;
– the patient has small- or medium-sized breasts (gener-
ally, A to a small C cup size); and
b
– the patient has good native nipple position (minimal
ptosis).
1. Immediate Placement of Implant or Two Staged:
Immediate placement of breast implant is undertaken in
patients whose residual skin vascularity is good, is a nonsmoker, is not obese, and has relatively average size
breasts. The superiority of 2 stage reconstruction has
been conrmed in patients with diabetes, breast irradiation, thin skin aps, and obesity. Intraoperative angiography if possible is a good way to assess the vascularity of
the skin ap which will aid in the decision process.
2. Various Planes for Implant Placement: Prepectoral vs
subpectoral implants. Subpectoral implants have the
added advantage of having a tissue cover in the upper
pole preventing edge visibility and having tissue covering
the implant in case there is skin necrosis. The disadvantage is that patient may have pain and there is signicant
animation in the breast implant. Prepectoral implants give
a natural look to the breast with a better positioned IMF
but they need a covering of acellular dermis and the skin
aps have to be vascular as seen using the indocyanine
green angiography.
3. Use of Scaffolds: Scaffolds such as acellular dermal
matrix give extra protection and cover to the implant/
expander without putting pressure on the overlying skin
ap. Moreover these are useful to create an inframammary crease, prevents implant migration and an improved
nal result. The concerns associated include seroma and
increased risk of infection.
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4. Newer Varieties of Expanders/Implants: The options for
breast reconstruction have been varied with the introduction of double lumen expander cum implants (Becker’s),
in built injection ports with safety features, various shapes
and surfaces of the implants, different lls giving the
rmness and safety.
5. Autologous Fat Grafting: Use of autologous fat grafting
to the breast as part of a touch up procedure in an implantbased or autologous tissue based breast reconstruction.
This can take care of the minor implant related concerns
such as show of the edges and rippling. It also improves
the quality of skin even in a post-radiation scenario.
Indications of implant-based breast reconstruction include
1. Oncologic post-mastectomy with adequate skin cover
2. Congenital absence of a breast (Amastia)
3. As part of sex re-assignment surgery (male to female)
Relative contraindications of implant-based breast reconstruction (these are the indications when Free or pedicled
autologous tissue based breast augmentation is preferred
over an implant-based reconstruction):
1. Patient having inadequate skin cover due to excess skin
excision during the primary mastectomy.
2. Need of postsurgery radiation to the chest.
3. To achieve a ptotic large breast similar to the unoperated
side.
There are primarily two ways by which an implant-based
reconstruction can be undertaken (Brown and Namnoum
2018):
17.3 Implant-Based Breast Reconstruction
1. Assessment: Before undertaking the implant-based reconstruction assessment of the area post-mastectomy is
important. Ultimately, the decision on whether a DTI
reconstruction is possible is based on the quality of soft
tissue cover. If there is a very vascular skin ap with adequate soft tissue and with easily available acellular dermal matrix, then a consideration can be made for a
prepectoral or a submuscular implant or a 2 stage breast
reconstruction using an expander.
In the absence of adequately thick skin ap with
doubtful vascularity or when acellular dermis is not available, a muscle or fascia cover should be considered in
association with a subpectoral implant placement. The
commonest muscle ap done to cover the implant completely is a pedicled latissimus dorsi ap and if fascia
cover is to be done, then a serratus anterior muscle and
fascia along with rectus abdominis fascia is mobilized to
cover the implant completely.
2. Total submuscular coverage using local tissues: Local
muscles such as the pectoralis major, serratus anterior,
and the rectus abdominis fascia and/or muscle are mobilized to cover the implant/expander completely. These are
sutured to each other so that the implant/expander has
adequate vascular cover which even if irradiated does not
expose the implant. These steps are well illustrated in
Figs.17.2, 17.3, 17.4, and 17.5.
3. Latissimus dorsi muscle ap to cover the inferolateral
implant: In instances where a ptotic breast has to be created or the chances of achieving adequate soft tissue
cover is limited, we consider cover of the lower third of
1. Direct-to-implant (DTI) procedure
2. Two-stage reconstruction using an expander and later an
implant
The direct-to-implant reconstruction is a single stage
breast reconstruction procedure where the implant is placed
either prepectoral (implant wrapped by acellular dermis) or
under the pectoral muscle with the lower pole covered by a
transposed muscle (latissimus dorsi), fascia (serratus anterior), autologous dermis (de-epithelized dermis in a ptotic
breast where skin excision is required), or by an acellular
dermal matrix to support the device which effectively lengthens the pectoralis major muscle which has to be released
from its costal and lower sternal origins, simplifying device
placement and helping to ensure that the implant is sited
properly at the inframammary fold (IMF).
Fig. 17.2 The lateral edge of the pectoralis major muscle (yellow
arrow). Implant will be placed in the subpectoral pocket (green arrow)
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Fig. 17.3 The subpectoral implant in situ and serratus anterior muscle
and fascia will be raised to cover the implant (yellow arrow)
J. D’silva and A. Deshpande
Fig. 17.5 Closure completed in layers over a drain
c
Fig. 17.4 (a) The ap sutured to the lateral edge of the pectoralis major muscle to cover the implant completely. Yellow arrow (b) shows the suture
line. (c) Shows the serratus anterior muscle being raised to cover the implant laterally
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the implant using a pedicled Latissimus dorsi ap. Various
techniques have been discussed which include taking a
partial muscle ap, endoscopic assisted dissection, use of
skin island, etc. (Fig.17.6a). It is important to note that
the success of this muscle ap depends on the intactness
of the thoracodorsal pedicle of the muscle which has to be
conrmed. This is conrmed preoperatively by actively
contracting the muscle as well as undertaking the CT
angiography of the subclavian vessels which will show
the intactness of the thoracodorsal vessels. This fan
shaped ap extending the lower lateral area of the back
below the scapula can be used to cover almost the whole
of the breast. The muscle is sutured as an extension of the
pectoralis major muscle to the sternum and also xed to
the inframammary crease (Fig.17.6b).
1. Extension of the primary incision for exposure of the
Latissimus dorsi muscle.
The position of the patient is changed to a lateral decu-
bitus with support of the hand at right angle (Fig.17.7).
A new incision can be made along the lateral border of
the latissimus dorsi muscle or the primary incision can be
extended as seen in Fig.17.8a, b.
2. Dissection of the latissimus dorsi muscle: Once the incision has been made based on the requirement, the lateral
border of the latissimus dorsi muscle is rst dissected
(Fig.17.9a). Once the lateral border has been identied,
subcutaneous dissection is carried out toward the inferior
angle of the scapula to identify the superior border
(Fig.17.9b). This is a little difcult as the superior border
is not clearly demarcated and it intersperses with the
bres of teres major muscle.
3. Identication of the vascular pedicle (Fig.17.10): The
muscle is now stripped off the thoracic wall using nger
dissection (Fig. 17.10a). Superiorly there is a clearly
demarcated dissection plane consisting of loose areolar
tissue which makes it easy to strip the latissimus dorsi.
By careful dissection the pedicle should become visible
as it enters the muscle on its deep aspect, superiorly
(Fig.17.10b).
4. Complete release of muscle from its origin and transposing it to cover the exposed implant in the lower medial
quadrant (Fig.17.11). Once the vascular pedicle has been
identied, the muscle is dissected on the supercial and
deeper aspect and released from its inferior and medial
attachments (Fig.17.11a). It is then transposed anteriorly
with the inferior border of the muscle sutured to the new
inframammary crease. The pectoralis major muscle is
Fig. 17.7 Lateral decubitus position with arm supported
Fig. 17.6 (a) Illustration
showing the skin island along
the long axis of the
Latissimus dorsi muscle to be
used to increase the skin
cover of the breast. (b) The
latissimus dorsi muscle
sutured in place
a
b
Skin Paddle
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Fig. 17.8 The incision can
be made along the lateral
border of the latissimus dorsi
(a) or the mastectomy
incision (b) can be extended
vertically to harvest only the
muscle as no skin paddle was
required to be used for
coverage
J. D’silva and A. Deshpande
Fig. 17.9 The lateral border of the latissimus dorsi is clearly visible with vertical bres and seperates the serratus anterior with a pad of fat (a).
The superior border is identied at the inferior angle of scapula (b)
a
Fig. 17.10 The latissimus dorsi muscle is dissected off the thoracic wall using blunt dissection (a) and superiorly the vascular pedicle can be seen
entering the deeper aspect of the muscle (b)
b
ab
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now release from its costal and lower sternal attachments
and the latissimus dorsi muscle is advanced to cover the
defect (Fig.17.11b).
5. Placement of Implant and nal closure with drains
(Fig.17.12): We use a smooth or a ne textured silk surface implant which is placed in the submuscular pocket
formed by the pectoralis major superiorly and latissimus
dorsi inferiorly. Haemostasis is achieved and closure is
done in layers over a suction drain. Quilting sutures are
placed in the donor area between the subcutaneous tissue
and the chest wall. This prevents the dreaded seroma formation on the back. Suction drain is placed and closur
edone in layers (Fig.17.12b.
6. Alternatives to latissimus dorsi ap for implant cover
(Fig.17.13): Total submuscular placement of implant has
its own set of challenges, such as limits to the size of the
breast reconstruction and incidence of “animation deformity.” Animation deformity refers to distortion of the
Fig. 17.11 Dissection of the muscle is completed and muscle is seperated all around except the insertion where the pedicle enters on the deeper
aspect (a). The muscle being sutured to create the new Inframammary crease (b) and provides extention to the pectoralis major muscle
ab
Fig. 17.12 (a) A smooth round implant has been placed in the pocket and the muscles are sutured with each other and to the chest wall to create
a totally submuscular implant. (b) The donor site incision has been closed in layers over a suction drain
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