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CHAPTER 11 Free Flap Techniques
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TABLE
11.2
Surgical Principles for Free Flap Transfer for Post-BCT Deformity (*LaP: lumbar artery perforator)
Careful planning of the flap and the recipient vessels
Radiological assessment of the vessels
Excision of damaged tissue – release of scar – re-creation of defect
Careful preparation of the internal mammary vessels
Free flap options – DIEaP, SIEa, TMG, PaP, TDaP, MCFaP, SGaP, IGaP, LaP*
Consideration of muscle sacrifice (overcorrection, atrophy, functional impairment)
Improvement of shaping (based on aesthetic subunits)
Surveillance for cancer
complication rate due to the post-radiotherapy status.
Furthermore, every candidate for this technique should
undergo a complete history and physical examination
by the oncology team before considering an attempt at
surgical correction. is examination must be comprehensive and should encompass the entire body including
the breasts. Magnetic resonance imaging of the breast is
considered when there is ambiguity in the interpretation
of the preoperative mammogram or ultrasound examinations.
• e patient is usually marked the day before surgery. e
breast size, defect size, and location are estimated.
• Preoperative computed tomographic angiography (CTA)
images of the donor site and thoracic region are routinely
obtained for perforator mapping and recipient vessel evaluation. After the ap markings and the grid localization
of the perforating vessels are completed according to the
anticipated defect, the location of the dominant perforator is conrmed with a unidirectional handheld Doppler.
• Good communication between teams, oncologic and
reconstructive, is mandatory.
• It is important to understand the importance of blood
supply to the nipple, placement of skin incisions, and
to have an appreciation of breast aesthetics.
• It is equally important that the reconstructive surgeon
appreciate the size and location of the tumor, margin status following excision, and the need to ensure
locoregional control.
• Both surgeons should review the radiographic imag-
ing, discuss the anticipated defect location and size, as
well as whether or not the resection will include skin.
is will assist with determination of the most appropriate glandular pedicle required to maintain nipple
viability and reshape the mound.
• Anticipate a back-up plan, as occasionally the defect
is dierent from that anticipated, and an alternative
approach may be required. e incisions for the tumor
resection are based on optimizing oncologic excision as
well as reconstructing an aesthetically pleasing breast.
• Immediate partial breast reconstruction should be
delayed if the surgeon is uncertain about the margins or
tumor extension (e.g., tumors with large in-situ component) despite the preoperative radiological assessment. A
delayed immediate reconstruction can still be safely performed within a few days following determination of the
denitive margin.
Free Flap Selection
• Flap planning should account for what is missing from
the breast skin and parenchyma but also should consider
the reduced elasticity in the residual breast tissue. In a
free ap reconstruction, an ample and adequate skin
paddle should be available with proper planning. Usage
of free aps also facilitates orientation of the skin paddle.
In our ap plethora, we consider perforator aps to be
the gold standard for reconstruction because of their low
donor site morbidity.
• Our rst choice is the deep inferior epigastric artery
perforator (DIEaP) ap (Video 11.1). It provides an
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ample amount of soft tissue with good color and consistency match.
26,27
e supercial inferior epigastric
artery (SIEa) ap is a good alternative to the DIEaP ap
whenever the direct cutaneous SIE vessels are available
and suitable in diameter to perform safe ap transfer.28
erefore, the lower abdominal incision is made rst
to assess to availability of the SIE vessels. Because the
abdominal donor site can only be used once, its use for
partial breast reconstruction makes it unavailable in the
future for whole breast reconstruction; therefore, its use
should be evaluated very carefully. In some patients,
the quantity of abdominal tissue is insucient for total
breast reconstruction; thus it may be more suitable for
partial breast reconstruction. Another argument supportive of the DIEaP ap is that, in body contouring
surgery, this tissue is often discarded in a population
that is at higher risk for breast cancer compared with the
risk of a recurrence in adequately treated breast cancer
after BCT.
16,28
e cosmetic result obtained by removing excess tissue from the abdominal area coupled with
minimal donor site morbidity and a well-concealed scar
make abdominal aps an attractive option for partial
breast reconstruction. Some patients view the opportunity to improve their overall appearance as an overwhelming benet of free abdominal perforator ap
surgery.
• e transverse myocutaneous gracilis (TMG) ap has
become a valuable alternative in absence of availability
of abdominal perforator aps.17 For bilateral reconstruction cases, TMG is in particular a good option due to
the easy accessibility of both donor sites without need
for repositioning. Another option is the Profunda artery
perforator (PaP) as well as medial circumex femoral
artery perforator (MCFaP) aps that have also been used
to reconstruct medial quadrant lumpectomy defects.
29
• Other alternative aps include the superior gluteal
artery perforator (SGaP) and inferior gluteal artery
perforator (IGaP) aps that may also be considered for
post-BCT reconstruction. However, in cases of bilateral free ap breast reconstruction, simultaneous SGaP
or IGaP reconstruction is time-consuming due to the
multiple repositioning of the patient that is required.
In our institute, bilateral gluteal ap surgery is usually
performed in two stages with a 3–6-month interval
between stages.
• A free LD myocutaneous ap has been reported as a salvage option for partial medial breast reconstruction after
partial loss of a free TRAM ap.30 To limit donor site
morbidity, we advocate the use a thoracodorsal artery
perforator (TDaP) ap.
22
• Omental aps have been used as a pedicled ap for
medial quadrant defects and as a free ap for lateral
defects.31 However, due to the diculty of predicting the
ap volume, problems in harvesting the ap in patients
with previous abdominal surgery, and the lack of a skin
island, in our hands the use of this ap for partial breast
reconstruction is rare.
Surgical Technique
• During surgery, all damaged skin, scar, and brotic
tissue is excised. Frozen section examination can be
requested if recurrence is suspected within the excised
tissue. A completion subcutaneous mastectomy can be
performed. icker skin aps are developed, with preservation of internal mammary perforators to the medial
breast tissues. is maximizes vascularity and thereby
minimizes ischemic slough of the previously irradiated
skin. We believe that, by performing a completion subcutaneous mastectomy, a signicant reduction in the
cancer recurrence rate and a more complete release of
the postirradiation parenchymal brosis can be achieved.
Patients can be reluctant to sacrice the remaining breast
tissue or lack the adequate donor tissue for whole breast
reconstruction. Another reason to preserve the internal
mammary artery perforator (IMaP) vessels is to have the
option to perform microanastomosis on these vessels that
may be more adequate as recipient vessels based on size
and position in certain aps compared with the internal
mammary artery and vein.
• e mastectomy skin should be treated with great care,
especially after previous radiation. Lengthening an incision is preferable to traumatizing the skin with retractors
that may result in skin ap necrosis. If there is any doubt
on skin ap viability, peroperative evaluation of perfusion can be performed using indocyanine green technol-
32
ogy.
• e recipient vessels should be carefully prepared if irradiation was delivered specically to the selected region.
e internal mammary vessels and their branches are
preferred because these vessels usually have less damage following radiation when compared with the thoracodorsal vessels. In addition, sparing the thoracodorsal
vessels allows for the future use of a pedicled TDaP or
LD ap for breast salvage in the case of free ap failure
or cancer recurrence.22 e internal mammary vessels are
usually prepared without removing rib cartilage.
• After harvesting the free ap and performing the microanastomosis, the ap inset is completed with a larger
skin paddle than the original breast skin deciency. e
ap skin paddle ideally replaces an entire breast aesthetic
subunit rather than leaving a small and poorly concealed
patch that is very conspicuous when viewed alongside
the native breast skin.33 e ap inset and shaping is performed with the patient in a seated position to match
the cavity. Flap inset in partial reconstructions has some
particular challenges that include:
• Variability of the defect location, shape, and size
• Dierent positioning of pedicle and recipient vessels
• Limited skin incision results in a more challenging
ap inset and also inhibits a clear view of the anastomoses following inset. e use of an implantable
Doppler probe on the vein should be considered when
visualization of the pedicle is not possible and the ap
has to be inserted through a small incision. A limited
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incision with tight skin can result in ap compression
and limit venous drainage, which may be dicult to
identify when there is only a small skin island.
In aps that include a small segment of muscle, future
muscle atrophy and reduction in ap volume should be
anticipated; therefore, initial ap volume should be oversized. In immediate or delayed-immediate reconstruction
volume loss due to radiotherapy should also be considered.
Other options in achieving symmetry in the future include
liposuction and/or lipolling, excision, and/or contralateral
reduction. Although irradiated aps are less tolerant for
liposuction.
• Donor site closure should be performed with great care.
Closing the abdomen, thigh, or gluteal region should
be performed with the same attention as in an aesthetic
body contouring. Attention to these details will make the
dierence between a nicely healed and well-accepted scar
or result in another stigma and reminder of cancer sur-
gery.
16
Postoperative Care
• Patients are administered low molecular weight heparin
(LMWH) during the time of relative immobilization for
prophylaxis against deep venous thrombosis.
• Patients typically are discharged from the hospital when the
drains are removed, on average about 5 days after surgery.
• A compression garment is applied over the donor site for
approximately 6 weeks postoperatively.
• When immediate reconstruction is performed, adjuvant
irradiation of the breast, if indicated, can be started at 6
weeks post-reconstruction. Adjuvant chemotherapy can
start 3 weeks postoperatively. is type of reconstruction
rarely results in a delay starting adjuvant therapy.
used for partial breast reconstruction compared with a ap
used for total breast reconstruction.11 A radiated ap however has less tolerance for liposuction.
Surprisingly, more patients express gratitude toward the
functional outcome following delayed free ap reconstruction after BCT. Patients report less tightening sensations in
their chest wall and reduced arm edema or heaviness following microvascular ap transfer to the chest. It is postulated
that, by releasing the postirradiation scar and importing
healthy nonirradiated tissue, subjective improvement is
commonly described by patients.
Following partial or total breast reconstruction, patient
surveillance proceeds on a regular basis and in the same
manner as before the surgical correction. Proper communication between the plastic surgeon, oncologist, and radiologist is essential during the follow-up period of these
patients. e characteristics of the transferred tissue (fat
alone, or muscle and fat combined) and the characteristics of the residual breast tissue (position and amount
of retained parenchyma) should be communicated along
with any areas of fat necrosis that are identied on postoperative follow-up.
Complications and Side Effects
• Free ap failure
• Donor site complications
• Tumor recurrence (ipsi- or contralateral)
• Dicult oncologic follow-up due to fat necrosis which
may lead to more frequent imaging, biopsy of unclear
lesions, and anxiety for the patients
• Mastectomy ap necrosis
Conclusion
Outcome
When these measures are incorporated into clinical practice,
minimal complication rates can be expected. An increase in
free ap failure following partial breast reconstruction has
not been observed.
Some patients may develop reactive breast edema that
subsides after 6–12 months. erefore, if further correction is needed, it should be postponed for at least 6 months
after the microvascular reconstruction to allow these reactive changes to resolve. A stable aesthetic outcome is usually
achieved by 1 year after reconstruction. Improved long-term
outcomes are usually observed in patients following completion subcutaneous mastectomy and free ap replacement
when compared with patients treated with limited partial
reconstruction by pedicled aps, because most of the irradiated tissue has been eliminated.
Patient satisfaction scores of 87% have been reported
following immediate ap reconstruction of partial mastectomy defects.34 e eect of post-lumpectomy radiotherapy
causes signicantly fewer deleterious eects on a free ap
e judicious use of free aps for oncoplastic reconstruction
expands the possibility for breast conservation.
Post-BCT deformity is addressed in a graded manner depending on the degree of deformity, the oncologic
requirements, and the patient’s wishes (Table 11.3 Preop-
erative evaluation by a plastic surgeon should be included
in BCT protocols. It is necessary to increase awareness of
possible replacement techniques among breast surgeons and
patients.
Free tissue transfer is an important option for treatment
of severe post-BCT deformities. Although the indications
are limited, when utilized appropriately it oers superior
cosmetic and functional results over other techniques. e
potential for microvascular failure remains an important
caveat of this technique. e surgeon must remember that
the abdominal tissue is the optimal choice for whole breast
reconstruction of future recurrence or new tumors and,
therefore, free tissue transfer should not be performed indiscriminately. Careful patient selection, surgical planning,
and technical execution are essential to the success of this
procedure.
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TABLE
11.3
Graded Approach for Post-BCT Deformity
Severe radiotherapy
damage / Difficult
oncologic control /
BRCA 1&2
YES
Mastectomy & Free
flap reconstruction
NO
Breast correction
PTOSIS?
Non-ptotic breast
Replacement
techniques
Ptotic breast
Displacement
techniques
Clinical Cases
e patients discussed in this section gave their consent to
the use of their data and photographic material for scientic
use and publication.
Case #1
A 51-year-old patient who had a conservative breast treatment and multiple previous biopsy procedures in the right
breast presented with severe breast deformity and pain. A
ONCOLOGIC
ISSUES?
No oncologic
issues
Fat grafting
Unclear tumor
margin / Extensive
scar tissue
Wide excision &
Pedicled flaps
completion mastectomy was performed with an immediate breast reconstruction using a free DIEaP ap. e postBCT deformity was restored.
A. Preoperative views (photo I & II).
B. e plan of surgery: the most damaged breast skin was
planned for excision. A DIEaP ap was designed at the
lower abdominal wall and the mapped perforator was
also marked preoperatively. e microanastomoses were
done to the internal mammary vessels (photo I).
C. 2 weeks postoperative view (photo III).
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• Photo I—preoperative view
• Photo III—2 weeks postoperative view
Case #2
A 47-year-old patient presented for a correction of postBCT deformity on the medial quadrant of the left breast
and a right prophylactic mastectomy with immediate reconstruction. e microanastomoses were done to the internal
mammary vessels in both sides.
A. Preoperative views (photo IV, V, VI)
B. Peroperative views:
Bilateral SIEa ap is planned. SIE vessels are shown with
surgical retractors (photo VII)
One SIEa ap harvesting (photo VIII)
e donor site after harvesting bilateral SIEa free aps
(photo IX)
C. e results at 2 years postoperative show good breast
symmetry (photo X, XI, XII).
• Photo II—preoperative view
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• Photo IV—preoperative view
• Photo VI—preoperative view
• Photo VII—peroperative view
• Photo V—preoperative view
• Photo VIII—unilateral SIEa flap
• Photo IX—peroperative view of abdomen after harvest of both SIEa
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flaps
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• Photo X—2-year postoperative result
• Photo XI—2-year postoperative result
• Photo XII—2-year postoperative result
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References
1. Veronesi U, Cascinelli N, Mariani L, etal. Twenty-year followup of a randomized study comparing breast-conserving surgery
with radical mastectomy for early breast cancer. N Engl J Med.
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2. Fisher B, Anderson S, Bryant J, etal. Twenty-year follow-up of a
randomized trial comparing total mastectomy, lumpectomy, and
lumpectomy plus irradiation for the treatment of invasive breast
cancer. N Engl J Med. 2002;347:1233–1241.
3. Arriagada R, Le MG, Rochard F, etal. Conservative treatment
versus mastectomy in early breast cancer: patterns of failure with
15 years of follow-up data. Insitut Gustave-Roussy breast cancer
group. J Clin Oncol. 1996;14:1558–1564.
4. Fisher B, Redmond C, Poisson R, et al. Eight-year results of
a randomized clinical trial comparing total mastectomy and
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5. Poggi MM, Danforth DN, Sciuto LC, etal. Eighteen-year results
in the treatment of early breast carcinoma with mastectomy versus breast conservation therapy: the national cancer institute randomized trial. Cancer. 2003;98:697–702.
6. Lagendijk M, van Maaren MC, Saadatmand S, et al. Breast conserving therapy and mastectomy revisited: breast cancer-specic
survival and the inuence of prognostic factors in 129,692
patients. Int J Cancer. 2018;142(1):165–175.
7. Zhou X, Li Y. Local recurrence after breast-conserving surgery and mastectomy following neoadjuvant chemotherapy for
locally advanced breast cancer – a meta-analysis. Breast Care.
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8. Killander F, Karlsson P, Anderson H, et al. No breast cancer subgroup can be spared postoperative radiation after breast-conserving
surgery. Fifteen-year results from the Swedish breast cancer group
randomized trial, swebcg 91 Rt. Eur J Cancer. 2016;67:57–65.
9. Munhoz AM, Aldrighi CM. Determining the optimal approach
to breast reconstruction after partial mastectomy. Plast Reconstr
Surg. 2006;118:813–814.
10. Negenbron VL, Volders JH, Krekel NMA, etal. Breast-conserving
therapy for breast cancer: cosmetic results and options for delayed
reconstruction. J Plast Reconstr Aesthet Surg. 2017;70(10):1336–
1344.
11. Losken A, Hamdi M. Partial breast reconstruction: techniques in
oncoplastic surgery. Quality Medical Publishing; 2009:61–72,
401–418.
12. Vrouwe SQ, Somogyi RB, Snell L, McMillan C, Vesprini D,
Lipa JE. Patient-reported outcomes following breast conservation
therapy and barriers to referral for partial breast reconstruction.
Plast Reconstr Surg. 2018;141(1):1–9.
13. Clough KB, Cuminet J, Fitoussi A, etal. Cosmetic sequelae after
conservative treatment for breast cancer: classication and results
of surgical correction. Ann Plast Surg. 1998;41:471–481.
14. Hamdi M, Woli J, Van Landuyt K. Partial mastectomy reconstruction. Clin Plast Surg. 2007;34:51–62.
15. Kronowitz SJ, Feledy JA, Hunt KK, etal. Determining the optimal approach to breast reconstruction after partial mastectomy.
Plast Reconstr Surg. 2006;117:1–11.
16. Spiegel AJ, Eldor L. Partial breast reconstruction with mini
supercial inferior epigastric artery and mini deep inferior epigastric perforator aps. Ann Plast Surg. 2010;65(02):147–154.
17. McCulley SJ, Macmillan RD, Rasheed T. Transverse upper gracilis (TUG) ap for volume replacement in breast conserving surgery for medial breast tumours in small to medium sized breasts.
J Plast Reconstr Aesthet Surg. 2011;64(08):1056–1060.
18. Berrino P, Campora E, Santi P. Postquadrantectomy breast
deformities: classication and techniques of surgical correction.
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19. Clough K, Kroll S, Audretsch W. An approach to the repair of
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20. Kroll SS, Schusterman MA, Reece GP, etal. Breast reconstruction with myocutaneous aps in previously irradiated patients.
Plast Reconstr Surg. 1994;93:460–469.
21. Chang DW, Kroll SS, Dackiw A, etal. Reconstructive management of contralateral breast cancer in patients who previously
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22. Hamdi M, Van Landuyt K, Monstrey S, etal. Pedicled perforator aps in breast reconstruction: a new concept. Br J Plast Surg.
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23. Smith ML, Molina BJ, Dayan E, et al. Dening the role of
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24. Hamdi M, Van Landuyt K, Ulens S, Van Hedent E, Roche N,
Monstrey S. Clinical applications of the superior epigastric artery
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Surg. 2009;62(9):1127–1134.
25. Nahabedian MY, Patel KM, Kaminsky AJ, Cocilovo C, Miraliakbari R. Biplanar oncoplastic surgery: a novel approach to breast
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26. Blondeel PN. One hundred free DIEP ap breast reconstructions: a personal experience. Br J Plast Surg. 1999;52:104–111.
27. Hamdi M, Weiler-Mitho E, Webster M. Deep inferior epigastric perforator ap in breast reconstruction: experience with the
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28. Rizzuto RP, Allen RJ. Reconstruction of a partial mastectomy
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J Reconstr Microsurg. 2004;20:441–445.
29. Izumi K, Fujikawa M, Tashima H, et al. Immediate reconstruction using free medial circumex femoral artery perforator aps
after breast-conserving surgery. J Plast Reconstr Aesthet Surg.
2013;66:1528–1533.
30. Serletti JM, Higgins J, Carras AJ. Free latissimus dorsi myocutaneous ap for secondary breast reconstruction after partial loss of
a TRAM ap. Plast Reconstr Surg. 1997;100(03):690–694.
31. Zaha H. Oncoplastic volume replacement technique for the
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2015;4(03):263–269.
32. Moyer HR, Losken A. Predicting mastectomy skin ap necrosis
with indocyanine green angiography: the gray area dened. Plast
Reconstr Surg. 2012;129(5):1043–1048.
33. Spear SL, Davison SP. Aesthetic subunits of the breast. Plast
Reconstr Surg. 2003;112:440–447.
34. Yang JD, Kim MC, Lee JW, et al. Usefulness of oncoplastic volume
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Breast Augmentation Technique
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(Biplanar) for Oncoplasty
YOAV BARNEA
Conflict of Interest Statement
No funding was provided for this chapter. Dr. Barnea is a
speaker for Johnson Medical.
Introduction
Breast conservation therapy (BCT) has become the mainstay in surgical breast oncology practice and is now a routine technique for the treatment of early-stage cancers.1
Improvements in diagnostic technology and mammographic
screening as well as increased use of preoperative local and
systemic therapies have extended the indications for BCT,
with reported rates of 58% in the UK and 60–75% in the
United States.
sive tissue resection consisting of lumpectomy with tumorfree margins followed by radiation therapy, major contour
irregularities have been observed following these proce-
4-6
dures.
in 5–40% of patients.
from the lumpectomy defect with added postoperative
radiation eects may sometimes lead to substantial distortions in breast shape and size as well as nipple position.
e management of breast deformities secondary to BCT
in such cases can pose considerable diculties, particularly
when operating in a radiated eld with poor tissue compliance. Several oncoplastic breast surgery techniques were
introduced in an attempt to optimize the balance between
the risk of local recurrence and the cosmetic outcome in
7-11
BCT.
replacement or tissue rearrangement involve a wider local
excision while achieving enhanced breast shape and symmetry, and reduced surgical dead space.
Patients with small volume breast and relative large
lumpectomy volume are at risk of developing severe breast
deformity and breast asymmetry following BCT, thus presenting a unique surgical challenge.
can be used to replace the volume loss in small-breasted
patients,10 but many of them are reluctant to undergo this
2,3
Although BCT has enabled a less exten-
Poor cosmetic results of BCT have been reported
7-11
e surgical dead space created
7-11
e combined plastic surgery techniques of tissue
7-11
10-12
Regional aps
procedure due to additional scarring and morbidity, leading them to forgo oncoplastic reconstruction altogether or
to undergo mastectomy and immediate reconstruction.
e use of a prosthetic device for volume replacement in
small breasts may seem appealing, but it has been largely
rejected on the basis of studies that cited high complication rates following radiation therapy.
16,17
One such study
showed that subcutaneous implant placement in the immediate setting led to high incidences of capsular contracture
and other complications.17 Nevertheless, there is reason to
believe that with increasing surgical expertise and improved
radiation delivery methods, implant-based procedures in
patients planned for radiation therapy might have a better
outcome compared with earlier experience.
18-21
selection of the radiotherapy technique can reportedly help
to improve the dose distribution and cause fewer radiationinduced side eects.
22-24
Recent studies have advocated
immediate implant-based reconstruction for patients receiving post-mastectomy radiotherapy, especially those who
may not be candidates for autologous reconstruction.
Moreover, patients with previous breast augmentation who
later undergo BCT were reported to have good to excellent
outcomes following their radiation treatment.
25,26
With growing experience and renement in breast tissue rearrangement techniques, together with implant-based
reconstruction and modern radiation therapy methods,
more consistent results may be oered to breast cancer
patients with small volume breasts who are considering
BCT by means of the oncoplastic biplanar breast augmentation technique.
12,27
is technique consists of immediate
local glandular tissue rearrangement after a lumpectomy
procedure and the use of bilateral subpectoral breast augmentation of dierent size and projection implants to
compensate for the lumpectomy-caused volume loss. e
technique aims to achieve immediate correction of shape
and volume before radiotherapy without the added morbidity associated with the use of autologous aps or delayed
BCT reconstructions.
12,27
13-15
Judicious
22-24
91
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A
• Fig. 12.1 (A) Illustrations of the OBA technique. Breast tumor in the upper pole of the breast. (B) A radial
incision was performed over the tumor area, and the tumor was removed with adequate margins. (C) Tissue
approximation was done using parenchymal advancement with limited undermining of the parenchyma or
the skin flaps.
B
Patient Selection
Patient selection is processed through the multidisciplinary
breast team, after reviewing all relevant breast imaging
studies and after planning the surgical scars and resection area based on tumor size and location. It is essential
to ensure that all patients are motivated to enhance their
breasts, and that they understand that the possible eects
of radiation therapy on the implant range from negligible
to severe capsular contracture and breast deformity. Currently, we have no way to predict which patient will do well
after radiation.
Indications and Contraindications
Indications for the oncoplastic biplanar breast augmentation technique include patients scheduled for BCT who
have small and non-ptotic breasts (bra cup A–B), with relatively large tumors that could not be addressed by local
tissue rearrangement alone. Tumor size should be smaller
than 25% of the total breast volume. Preferences for tumor
location include the upper pole of the breast, above a horizontal line at the lower areolar position. Lower-positioned
tumors, especially near the inframammary fold area, are
close to the pocket of the implant, thus making it dicult
to dissect separate tumor implant pockets. For these selected
cases of lower-pole breast tumors, an acellular dermal matrix
(ADM) graft can be used to reinforce the lower pole of the
breast and improve the separation between the implant and
the lumpectomy pockets.
C
Patients with previous breast augmentation are also candidates for this technique. e implant on the aected side
is exchanged for a larger one in order to compensate for the
lumpectomy volume loss. Implants in a previous subglandular position are exchanged for a subpectoral dual plane
pocket.
Patients with tumor involvement of the nipple–areolar
complex (NAC), distant metastasis, or tumors growing into
the chest wall or skin (oncologic stage T4) are not candidates for this technique.
Operative Approach (Video 12.1)
e patient is marked in a manner similar to a breast augmentation procedure, with the addition of the area of the
planned lumpectomy. After prepping and draping the
supine patient, the breast surgeon performs a wire-guided
lumpectomy (Fig. 12.1A). e incision of choice is periareolar, with an incision extension if needed. For cases in which
the tumor is not centrally located, the surgeon performs a
radial or an arched incision over the tumor area. e tumor
is removed, marked, weighed, and sent to mammography
and pathology. Additional tissue extensions are taken from
the tumor bed, and the space is marked with metal hemostatic clips (Fig. 12.1B). e lymph node procedure is performed from a separate axillary incision.
After irrigation and careful hemostasis, the tumor bed is
inspected and tissue approximation is performed by local tissue advancement. Further limited undermining of the breast
parenchyma or the skin aps is occasionally necessary before
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