139
CLINICS IN
Revision in Autologous Breast
Reconstruction: Principles
and Approach
a,
Elisabeth K. Beahm, MD *, Robert L. Walton,
- Autologus breast reconstruction
Sequence and approach for revisions of
the breast mound
- Management of the contralateral breast
- Approach to the donor site: maintain form
and function
Approaches to maximize the aesthetics
of the abdominal donor site
- Nipple–areolar reconstruction
- Special considerations
Obesity
Prior abdominal surgery
Surgical revisions are integral parts of most com-
plex reconstructions. Because lactation function is
not currently a feasible goal in breast reconstruc-
tion, the primary purpose of a secondary surgical
intervention following breast reconstruction is to
enhance the appearance of the breasts. This may
involve altering the shape, contour, or volume of
the reconstructed and/or normal breast, perform-
ing nipple–areolar reconstruction (NAR), manag-
ing a surgical complication, or a combination of
these events. The need to pursue revisions in breast
reconstruction has been largely influenced by the
introduction of ‘‘aesthetic’’ as a major endpoint
in the reconstructive effort. This concept has
evolved from advances made by master surgical
a
Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
b
Department of Plastic and Reconstructive Surgery, University of Chicago, Chicago, IL. USA
* Corresponding author.
E-mail address: ebeahm@mdanderson.org (E.K. Beahm).
0094-1298/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
PLASTIC
SURGERY
Clin Plastic Surg 34 (2007) 139–162
b
MD, FACS
Potential vascular compromise: collagen
vascular disease and smoking
Radiation therapy
- Coincident procedures with autologus
breast reconstruction
Mastectomy skin flap loss
Revision after partial and total flap loss
Augmentation of free flaps with breast
implants
Fat grafting
- Summary
- References
pioneers such as Millard, McKissock, Hartrampf,
Shaw, Grotting, Allen, Spear, and others [1–8]
who have introduced and exercised the application
of flap and implant technology to a level hereto-
fore unachieved in clinical surgery. Their collective
results have raised the level of expectation of out-
come in breast reconstruction that has influenced
both the surgical community as well as the public
at large.
This overview examines revision in autologous
breast reconstruction from the perspective of clini-
cal priority. The author examines the major prob-
lems that befall autologous breast reconstructions
and defines the current therapeutic interventions
for their resolution.
doi:10.1016/j.cps.2006.11.016
140 Beahm & Walton
Autologus breast reconstruction
Sequence and approach for revisions of the
breast mound
Our standard algorithm for breast reconstruction is
a sequence comprising two to three procedures set
several weeks to months apart (Fig. 1). As the ma-
jority (approximately 70%) of our reconstructions
are immediate, we must first consider the onco-
logic imperative, including the need for adjuvant
therapies. After flap transfer, we wait for the tissues
to settle for several months (usually approximately
3 months) and then proceed with the revision and
balancing procedures. In cases associated with ei-
ther pre- or postoperative radiation, it generally
takes longer for the flaps to settle and we often
wait 4 to 6 months before proceeding with the sur-
gical revision. After the desired shape and volume
of the reconstructed and normal breast has been
surgically rendered, we will then proceed with
NAR (Fig. 2). NAR performed in conjunction
with breast reconstruction has been promoted as
a means of avoiding a separate operative interven-
tion. In general, however, this approach is plagued
by a number of variables that can adversely affect
outcome. Issues of partial flap loss, unanticipated
radiotherapy, weight fluctuations, or alternation
of the contralateral breast may result in changes
in the reconstructed breast mound that may result
in malposition of a prematurely placed nipple.
Once created, removing or repositioning a NAR
can be highly problematic.
Fig. 1. Standard reconstructive algorithm for immediate and delayed autologous breast reconstruction. Initial
flap transfer with an interval of 3 months between stages to allow for stabilization of the construct. Tx, treat-
ment; XRT, radiation.
Creation of the breast mound
Flap selection Autologous tissues provide the
most optimal means of breast reconstruction, per-
mitting a far greater ability to match a native breast
than afforded by implant-based techniques. Autolo-
gous tissues maximize the ability to predictably cre-
ate a soft natural-appearing breast that is durable
over time [1–9]. Careful selection and transfer of
the most appropriate flap for reconstruction is the
most critical step toward minimizing the number
of subsequent surgical revisions. Free flaps from
the lower abdominal wall have proven superiority
over most other territories because the vascular anat-
omy is generally reliable, and the lower abdomen, in
most females, provides an unparalleled volume of
skin and subcutaneous tissue that is well-suited for
replicating the missing breast [1,3–5,8–16].
It is imperative to correctly estimate the volume
of skin and soft tissue that will be necessary for cre-
ation of the breast mound during the initial proce-
dure. Failure to do so will compromise ultimate
breast shape and volume, and result in lack of sym-
metry with the opposite breast. Patients in whom
the reconstructive requirements of the breast exceed
the capabilities of a lower abdominal territory that
can be safely carried on a single vascular pedicle (eg,
thin patients with large breasts, delayed or radiated
reconstructions, patients who have midline abdom-
inal scars, and so forth) pose a particular challenge.
Approaches for volumetric correction of the breasts
(eg, in reduction of the contralateral breast or in the
use of implants to augment the reconstruction)
 Revision in Autologous Breast Reconstruction 141

Fig. 2. Immediate bilateral breast reconstruction after prophylactic mastectomy. (A) Forty-seven-year-old woman
BRCA1/2 underwent bilateral prophylactic mastectomy and immediate breast reconstruction with bilateral deep
inferior epigastric flaps. (B) To minimize the potential for compromise of the free flaps and limit operative time,
the endoscopic total abdominal hysterectomy/bilateral salpingo-oophorectomy was performed during a second-
ary shaping procedure including revision and NAR with double opposing tab flap and skin grafts from the me-
dial thigh. (C ) Three-year postoperative result is demonstrated.

may be employed, but frequently result in a com-
promise of the aesthetics of the reconstruction in
some settings. Bilateral pedicled rectus abdominis
flaps from the lower abdomen have been used in
these circumstances, but are rarely employed today
because of their propensity for causing increased
donor site morbidity including pain, hernia, and
abdominal bulge [17–21]. In these instances, the
use of bilateral lower abdominal free flaps is highly
efficacious for reconstructing a unilateral breast
[21,22]. By using perforator flaps and by exerting
meticulous attention to the abdominal closure, do-
nor site morbidity can be comparable to that re-
ported for unilateral flaps [23–28]. This technique
provides the ability to use perforator and muscle
sparing flaps for the transfer of a large volume of
tissue using the vascular support of two pedicles
(Figs. 3–8).
The abdominal pannus—our first choice in autol-
ogous breast reconstruction—is unusable in approx-
imately 20% of all cases. Flaps from the gluteal
territory have emerged as the best of the ‘‘second
line’’ flaps in breast reconstruction. The evolution
and refinement of these flaps has mirrored the clin-
ical experience with abdominal flaps, progressing
from full muscle to perforator flaps. The superior
gluteal artery perforator and inferior gluteal artery
perforator flaps have longer vascular pedicles and
improved donor sites over their myocutaneous pre-
decessors, and this has led to an increased interest
and application of these flaps in breast reconstruc-
tion [2,29–31]. In gluteal flaps, the subcutaneous

Fig. 3. Delayed breast reconstruction. (A, B) Fifty-two-year-old woman desired delayed breast reconstruction
4 years after modified radical mastectomy and adjuvant radiotherapy for T2 N1 cancer. The patient wished to
preserve her large breast size. (C ) To meet the volumetric and shape requirements of her delayed reconstruction,
the majority of her abdominal pannus was deemed necessary to complete the best possible unilateral breast
reconstruction. Secondary mastopexy/reduction was anticipated.
142 Beahm & Walton

Fig. 4. Preliminary result

after initial flap transfer.
(A, B, C, D) Patient depicted
in Fig. 3 seen 4.5 months
after bilateral free flaps
(superficial inferior epigas-
tic artery and deep inferior
epigastric perforator flaps)
revascularized to the inter-
nal mammary and thoraco-
dorsal systems. The flaps
were coned to provide ade-
quate projection despite
the large flap volume and
overcorrection of the supe-
rior pole; her axilllary defi-
ciency is still not fully
corrected. At this juncture,
flaps were deemed stabi-
lized and soft, and the pa-
tient underwent planned
flap revision and contralat-
eral balancing procedure.

tissue tends to be more septate, firmer, and provides
a smaller volume compared with flaps from the ab-
domen. Importantly, the amount of skin that may
be harvested without undue distortion of the but-
tock is quite limited, and this may be highly prob-
lematic in delayed reconstructions whereby the
native breast skin envelope is limited. Use of gluteal
flaps will generally necessitate an increased number
of revisions in the breast mound as well as the but-
tock donor site compared with flaps from the lower
abdomen. The unprotected vascular pedicle of the
gluteal artery perforator flap may significantly limit
the ability to shape the flap during its initial transfer,
and this may necessitate a secondary procedure for
definitive shaping. In general, gluteal flaps are
more suitable for reconstructing small breasts with
minimal ptosis in the setting of immediate breast
reconstruction.
Free flap shaping: primary and
secondary Contouring of the autologous tissues
used to create the breast mound requires diligent
preoperative planning to avoid inadvertent injury
to the vascular pedicle with subsequent risk of com-
promising flap viability. Autologous flaps used in
breast reconstruction are oriented and inset accord-
ing to the demands of each particular reconstruc-
tion in accommodating the given volume and
other variables that characterize the donor site.
The internal mammary vessels are generally
 Revision in Autologous Breast Reconstruction 143

Fig. 5. Contralateral reduction and flap revision. (A, B, C, D) Patient depicted in Figs. 3 and 4 seen 4 months after
suction contouring of flanks, vertical mastopexy, and contouring of reconstructed breast mound. In the setting
of radiation, a longer time interval (approximately 4 months) is recommended between operative stages during
the revisions after breast reconstruction to permit adequate settling and stabilization of the breast mound.

preferred for revascularization of free flaps in breast
reconstruction because these vessels are easily ac-
cessed and enable the best positioning of the flap
on the chest wall. Compared to the thoracodorsal
vessels, the internal mammary vessels provide supe-
rior vascular inflow. A contralateral abdominal flap
is preferred for reconstruction when using the inter-
nal mammary vessels as recipients, and an ispilater-
al flap is used when the thoracodorsal vessels are
employed. This orientation ensures that the maxi-
mum adipose volume of the flap will be positioned
centrally with the thinner lateral portion of the flap
oriented toward the axilla. The use of perforator
flaps has given such flexibility in flap placement
that harvest of the flap from the side of the abdo-
men with the most favorable vascular configuration
has become the prevailing rule, disregarding previ-
ous notions of laterality. Whenever possible, flap
volume is kept slightly greater than the opposite
breast to account for the effects of edema, fat necro-
sis, and patient weight changes that will have
bearing on the outcome. In cases whereby bilateral
lower abdominal flaps are used for unilateral recon-
struction, the combined flaps can be kept attached
at the midline and then folded into a cone to create
the breast mound (see Figs. 3–7). Alternatively, the
flaps may be separated at the midline and oriented
in a ‘‘ying–yang’’ fashion to create the breast
mound. In each case, the orientation of the flaps
is tailored to approximate the unique three-dimen-
sional volume structure of the opposite breast. In
unilateral reconstruction with an abdominal flap,
the best shape is often accomplished by simply po-
sitioning the flap medially to create a well-shaped
cleavage, folding or coning the flap centrally (usu-
ally near the umbilicus) to create the most projec-
ting point of the breast mound, and using the
remainder of the flap to fill out the lateral ‘‘Tail of
Spence’’ area. The point of maximal projection of
the breast can be located preoperatively by marking
the patient in the standing military position and
noting the point of intersection of the nipple along
144 Beahm & Walton
Fig. 6. Final result. (A, B, C, D, E ) Patient depicted in Figs. 3–5 seen 5 years after NAR with double opposing tab
flap and tattoo. No interval revisions. Bilateral free flap transfer ensured adequate restoration of the volume
and projection of her large native breast.
the inframammary fold. In a delayed reconstruc-
tion, this point can be transposed from the contra-
lateral native side (Figs. 9 and 10).
Mismatch between breast envelope and flap
volume Discordance between the mastectomy
skin flap envelope and the size of the flap to fill it
will necessitate a revision. This issue is particularly
problematic and may be addressed in several
ways. Immediate reduction and tailoring of the
skin flaps akin to ‘‘reduction mammaplasty’’ is ap-
pealing and, when successful, eliminates a surgical
step. Unfortunately, aggressive tailoring of the mas-
tectomy flaps can result in significant compromise
of blood flow with resultant skin loss. This compli-
cation will have profound implications in the
efforts to achieve an ultimate aesthetic result. Sim-
ply placing the free flap in a voluminous skin enve-
lope may lead to seroma, unfavorable scarring, as
well as a bizarre appearance that may be unsettling
to the patient and surgeon alike. Management of
these challenging situations must be individual-
ized. The degree of initial surgical intervention is
usually based on the degree of macromastia and
the vascular status of the mastectomy skin flaps as
made by visual inspection. We usually avoid com-
mitting to a ‘‘Wise’’ pattern in preference to a gener-
ous periareolar doughnut mastopexy-type incision
with standardized markings to determine the de-
sired nipple point and inframammary dimensions.
Smaller volume discrepancies can be managed with
a circlage (‘‘purse string’’) closure of the mastectomy
skin defect, but this will flatten the breast a bit and
decrease projection of the breast mound, and so
must be used judiciously (Fig. 11). Although
some degree of shape deformity will settle out, es-
pecially in the lower pole of the breast because of
the effects of gravity, it is best to emphasize to the
patient the importance of maintenance of viability
of the mastectomy skin flaps toward achieving an
optimal result, and the need to stage the final
shaping. A highly conservative staged approach is
most prudent in patients who smoke, have had
prior radiation, are macromastic, or who have unfa-
vorably oriented biopsy scars on the breast skin that
may compromise the intervening skin bridges.
The discrepancy of skin envelope to breast mound
is often seen in the bilateral breast reconstruction. In
 Revision in Autologous Breast Reconstruction 145

Fig. 7. Efficacy of bilateral lower abdominal free flaps for unilateral breast reconstruction. (A) Forty-nine-year-
old woman underwent a delayed breast reconstruction 3 years after modified radical mastectomy and adjuvant
radiotherapy. Reconstruction was completed using a muscle sparing free TRAM flap and a deep inferior epigas-
tric perforator flap revascularized exclusively to the internal mammary vessels (anterograde and retrograde)
because of her prior abdominal surgery and suction-assisted lipectomy. (B–G) She underwent revision of the
mound with suction contouring and subsequent NAR using the Anderson purse string technique.

these cases the volume and shaping options are quite
limited because of the ‘‘triangle’’-shaped hemiabdo-
minal flap, which is often inadequate in fully restor-
ing the volume, shape, and projection of a native
breast. Even in a patient with a relatively generous
abdominal pannus, the limited flap length afforded
by a single pedicled lower abdominal flap often pre-
cludes the ability to fully restore each aspect of the
breast mound and achieve the desired medial full-
ness, central projection, and lateral contour.

Fig. 8. Importance of patient positioning for accurate revision of the breast mound. This same patient in Fig. 7 is
seen the same day in the (A) upright and (B) dependent position before her revision. Note the differential effect
of gravity on the native and reconstructed breast, which is especially significant in the setting of a delayed ra-
diated breast that will not have the same drape or ptosis of a native breast. Patients must be counseled as to this
asymmetry.
146 Beahm & Walton

Fig. 9. Flap shaping and

abdominal flap design. (A)
Forty-eight-year-old woman
underwent three prior at-
tempts at implant recon-
struction that failed due to
infection. The position for
flap inset was carefully
marked with the patient up-
right including the position
of the native inframammary
fold. (B, C, D) Patient is seen
20 months after delayed
muscle sparing free TRAM.
She deferred NAR or any re-
visions. Use of an abdominal
flap design with minimal
central tension limits ten-
sion at the watershed area
and elevation at the mons
pubis; the abdominal donor
site is closed with a ‘‘high
lateral tension’’ approach to
maintain a nice abdominal
contour. This design also
facilitates coning of the free
flap, which affords nice pro-
jection of breast, important
for reconstruction of cases
with significant skin loss
and/or larger breast size
and match of the patient’s
contralateral augmentation
mammaplasty.

Restoration of the medial breast contour is a primary
goal in these cases (see Fig. 11). A second priority is
modest coning of the flap for projection, which of-
ten necessitates some sacrifice of lateral/axillary vol-
ume and shape. Bilateral breast reconstruction
affords reasonable symmetry, but volume and shape
limitations imposed by the hemiflap configuration
may be problematic in patients used to large projec-
ting breasts, and in those patients having undergone
prior breast augmentation. This problem is most no-
table in delayed cases because of the significant
amount of skin needed to restore adequate shape
and projection. In bilateral cases in which one side
is delayed and the other immediate, the best ap-
proach is to create an asymmetric abdominal flap de-
sign with the larger flap targeted for the delayed side
(see Fig. 10).
The above issues become paramount in the radi-
ated breast as the radiated chest wall skin will ‘‘shrink
wrap’’ around the flap and magnify the volume-defi-
cient areas. This may lead to a rather abrupt transi-
tion from flap to chest wall, particularly at the
medial and superior aspects of the reconstruction,
that will not be fully appreciated until the flaps
have scarred down and settled (see Fig. 10). In this
setting, subsequent operative ventures for shaping
and contouring will be necessitated.
The degree of shaping that may be necessary dur-
ing revision will be influenced by several factors, not
only the accuracy of the initial surgical plan but by
complicating factors such as flap compromise, fat
necrosis, or unanticipated adjuvant radiotherapy.
Significant revision of the breast mound can be un-
dertaken with confidence, even if aggressive tailoring
and reinset is required. Utilizing a ‘‘vertical reduc-
tion’’ approach with central coning can afford signif-
icant improvement in shape and projection (see
Fig. 10). However, a word of caution on the extent
of secondary flap mobilization is in order. although
free flaps for breast reconstruction should theoreti-
cally establish adequate revascularization from their
recipient bed to permit flap survival in the event of
division of the vascular pedicle, this is not universal.
The vulnerability and dependence of the flap on the
vascular pedicle must be a consideration even in
well-established flaps. Violation of the flap’s vascular
pedicle may in some instances profoundly compro-
mise the flap, particularly in cases of large flaps and/
 Revision in Autologous Breast Reconstruction 147

Fig. 10. Bilateral reconstruc-

tion: combined delayed and
immediate reconstruction.
Fifty-seven-year-old woman
3 years after modified radi-
cal mastectomy and adju-
vant radiotherapy. Patient
insisted on contralateral
prophylactic mastectomy.
(A) Reconstruction with bi-
lateral free flaps (right mus-
cle sparing free TRAM for
the delayed left breast and
right DIEP flap for the left
breast reconstruction). (B)
Despite the larger volume
of tissue on the left, note
the superior deficiency of
tissue imposed by a hemi-
TRAM and the contour de-
formity exacerbated by the
radiated tissues. (C) Patient
necessitated a planned
‘‘mastopexy’’ of the preven-
tative side due to concerns
for initial mastectomy skin
flap compromise. Note the
significantly greater degree
of ptosis in the nonradiated
immediate reconstruction.
(D) Patient deferred NAR
and is seen 28 months
postoperatively.

or recipient sites compromised by extensive prior
surgery or radiation. Accordingly, we pay careful at-
tention to the medial inset of the flap in the initial
procedure by the internal mammary recipients and
avoid the need to dissect near these vessels during
surgical revision.
Technical points in revision of the breast
mound
Careful marking and planning for the surgical revi-
sions with the patient in the upright position is crit-
ical for maximizing symmetry between the breast
mounds, especially in the case of matching a native
breast to a delayed and/or radiated reconstruction.
Critically comparisons are made in the breast with
the patient in both the upright and supine posi-
tions. In a natural breast, a significant gain in the
projection and volume of the breast is noted
when the patient is standing due to the mobility
of adjacent tissues that become dependant. Gravity
does not affect an autologous reconstruction in the
same way, especially if radiation has been involved.
In the delayed radiated reconstruction, there will be
little change in the shape and position of the breast
in any position, analogous to a significantly aug-
mented breast (see Fig. 8). Accordingly, patients
must be counseled in this regard, clearly discussing
the issues of symmetry with positional changes, and
soliciting patient input for their desires and
concerns.
The issue of symmetry of the inframammary fold
and its correction must be considered not only in
terms of the fold position, but also in terms of the
shape and position of the reconstructed breast
mound on the chest wall. The inframammary fold
will invariably have been lowered during the mas-
tectomy, even by a meticulous surgical oncologist
in an effort to remove the maximal amount of
breast tissue. In immediate reconstruction, recrea-
tion of the correct level for the fold should be ad-
dressed during the initial flap inset, and this can
be accomplished with suture fixation. Establishing
148 Beahm & Walton

Fig. 11. Bilateral breast

reconstruction: problem ra-
tio of breast skin envelope
to flap volume. (A) Forty-
eight-year-old woman
underwent unilateral ther-
apeutic and contralateral
prophylactic mastectomy
with immediate recon-
struction using bilateral
muscle sparing free TRAM
flaps. (B) The patient’s large
breast volume relative to
abdominal pannus and the
limited volume of flap ne-
cessitated a purse string
closure with subsequent re-
vision. (C) Patient’s 2-year
(D) and 6-year postopera-
tive result after NAR with
star flap and tattoo noted.
Patient required secondary
tattoo after 36 months
because of fading.

a symmetric anatomic level for the inframammry
fold in a delayed case can be extrapolated by com-
parison with the contralateral native breast, marked
with the patient in the standing position (see Figs.
7–10). This is used for reference only as the final po-
sition of the inframammary fold should be a visual
one based on the appearance of symmetry as op-
posed to exact measurements. In order that the
breast mound appears to lie on the chest wall sym-
metrically, the correct level for the inframammary
fold may actually be lower than the native infra-
mammary fold.
The degree of ptosis of the reconstructed breast,
even an autologus one, will not equal that of a native
breast. An exception to this can be seen in bilateral
lower abdominal flaps for unilateral breast recon-
struction whereby ptosis of the reconstructed breast
can be more effectively created by the increased soft
tissue and skin envelope dimensions afforded by the
use of two flaps. As with lowering of the inframam-
mary fold, placement of the reconstructed breast
mound lower than the native breast to achieve sym-
metry in the naked upright position may result in
difficulties with the fit of a brassiere and clothing.
This situation is most common in autologus recon-
structions performed before or after radiation and
in implant-based techniques in which the breast
mound will exhibit minimal ptosis. In the final anal-
ysis, however, careful consideration of the visual and
measured endpoints of symmetry must be balanced
against patient desires and the realistic goals of
reconstruction (see Figs. 6, 9, and 10).
Contouring of the breast mound may involve mi-
nor adjustments of flap volume to ‘‘fine tune’’ the
reconstruction or major resections to accommodate
for excessive flap volume. Suction contouring of the
breast mound is quite effective for achieving subtle
modifications in breast contour. Large volume re-
sections are best performed by direct excision, be-
cause shrinkage accommodation of the skin
envelope in the reconstructed breast is unpredict-
able. Additionally, excessive suctioning of the fat

volume of the reconstructed breast is at risk for in-
curring fat necrosis. In large volume adjustments,
skin resection is frequently performed in conjunc-
tion with fat resection. For isolated small-volume
deficiencies in the reconstructed breast, structural
fat grafting has been employed with great success.
This has proved invaluable for restoring volume
in the frequently encountered superior medial
pole deficit of the breast mound and medially
over the internal mammary access site.
There is no algorithm that can be practically ap-
plied for revision contouring of every breast recon-
struction. Suffice it to say that the reconstructive
surgeon should employ the available surgical tools
of tissue rearrangement, volume reduction, and vol-
ume supplementation combined with his/her per-
sonal aesthetic to produce a result that
approximates the desired goals.
Management of the contralateral breast
Effective management of the contralateral breast is
a major element in achieving symmetry in breast re-
construction [9,32,33]. This intervention, however,
carries certain surgical risks. Patients need to under-
stand that these procedures are not foolproof and
may require additional revisionary surgery. In uni-
lateral reconstructions, the application of reduction
mammaplasty/mastopexy is often necessary to ac-
commodate for large and/or ptotic breasts. Al-
though a reduction mammaplasty adds time and
blood loss to the initial operative procedure, in
cases whereby there is a large volumetric and shape
discrepancy between the native breast and the re-
construction, it is not unreasonable to proceed
with a reduction procedure in concert with flap
transfer. This will minimize the period of asymme-
try for the patient, but falls short in the degree of ac-
curacy that can be achieved when breast reduction/
mastopexy is done as a secondary procedure. Our
preference is to delay procedures on the contralat-
eral breast because of the uncertainties of unfavor-
able final pathology (which may necessitate
postoperative radiotherapy), fat necrosis, and so
forth, all of which may impact upon the final result.
To maximize the success of reduction/mastopexy
procedures on the opposite native breast, patients
must stop smoking. A baseline mammogram
(with or without ultrasound pending the preference
of the oncologist) should be obtained before any
intervention on the breast, and one approximately
6 months postoperatively. Patients must be warned
of the possibility of nipple and tissue loss as well as
fat necrosis and the need for subsequent biopsy and
revision.
There are several available surgical approaches
for reduction mammaplasty and mastopexy
Revision in Autologous Breast Reconstruction 149
[34,35]. We vary our technique depending on the
best means for achieving symmetry. It must be re-
membered that the approach and requirements of
a unilateral reduction are somewhat different than
a bilateral one, in which the descent and settling
of the two breasts may be expected to be compara-
ble. In a reconstructive setting, the goal is to match
a reconstructed breast that will not drape or settle in
the same manner as a native breast. The short scar
approach in reduction mammaplasty can effectively
mobilize and correct axillary fullness and maximize
projection, but this technique does limit control in
terms of the skin envelope (see Fig. 6). Addition of
a small horizontal limb as an inverted ‘‘Y’’ can help
in this regard. It is important to consider how much
the native breast will settle, because this will be af-
fected by skin tone, parenchymal volume and qual-
ity, and the degree of lift required. The final breast
form is often difficult to fully anticipate.
The parenchymal pedicle technique of reduction
mammaplasty can be helpful in matching a recon-
struction because this approach allows for precise
measurements and control of both the vertical
and horizontal aspects of the breast to most accu-
rately match the contralateral side. This technique,
however, requires an inverted ‘‘T’’ scar, which may
be objectionable to some surgeons [34]. To maxi-
mize breast symmetry using either technique, it is
best to mark the patient carefully in the upright po-
sition and transpose the measurements to the con-
tralateral side (Fig. 12). A perioareolar ‘‘round
block’’ mastopexy is not effective for any significant
degree of breast lift. Although periareolar doughnut
mastopexy will flatten an overly projecting native
breast, this maneuver may, nevertheless, aid the ef-
fort to achieve symmetry in the breast reconstruc-
tion. We rarely use this approach in deference to
a vertical limb incision that is needed for projection
of the breast mound. It is important not to deform
the native breast for the purpose of matching a bad
reconstruction autologous or otherwise. Patients
should be prepared for the potential need for sec-
ondary interventions. We will not hesitate to stage
or revise the mastopexy/reduction. Only when we
are completely satisfied with the shape and symme-
try of the reconstructive effort, will we proceed with
NAR.
Approach to the donor site: maintain form
and function
Approaches to maximize the aesthetics of the
abdominal donor site
Aesthetics of the abdominal wall
The aesthetic standards of the abdomen have not
been well established or defined. A pleasing ab-
dominal aesthetic may be considered to be one
150 Beahm & Walton

Fig. 12. Techniques for contralateral balancing procedures. (A) Thirty-two-year-old woman had a prior abdom-
inoplasty and deferred flap reconstruction. She underwent implant reconstruction, which necessitated an aug-
mentation mastopexy of the contralateral native breast. The proposed nipple point is marked out on both the
reconstructed mound and the native breast and the dimensions of the reconstructed breast transposed to the
native breast, oriented with the point of maximal projection of the breast along the inframammary fold. (B) Re-
sult after parenchymal pedicle technique for mastopexy with an inverted ‘‘T’’ incision to afford for the degree of
lift and skin excision required to match an implant. (C, D) NAR was completed with a double opposing tab flap
and skin graft. Note the relatively pale nipple compared with the surrounding areolar pigment. Two-year post-
operative result.

that replicates a youthful contour and includes def-
inition of the costal margin, a waistline, adequate
skin tone, a natural position and contour of the
mons pubis, and a midline umbilicus. Attention
to these features provides a different but pleasing
abdomen in the spectrum of body habitus. This is
best established in the initial operative venture
rather than with attempts at later revision. Careful
design of the abdominal flap should minimize cen-
tral tension.
Recreation of the overall abdominal contour will
often necessitate plication of the abdominal wall
fascia. To ensure there will not be a bulge above
or below the site of flap harvest, it is imperative to
sit the patient up in the operating room after fascial
repair. Abdominal wall bulges may be corrected
with fascial plication using a permanent suture.
This technique should be used prudently, especially
if the fascia is of poor quality and/or it has been
elevated off the underlying rectus muscle and is par-
tially devascularized. Patient discomfort notwith-
standing overzealous attempts at deep fascial
plication, akin to that used in an abdominoplasty,
can create a pleasing contour but may also contrib-
ute to ischemia and subsequent compromise of the
abdominal wall fascia. The use of muscle and fascial
sparing perforator flaps combined with inlay repair
of the rectus fascial defect has made aggressive pli-
cation of the abdominal wall a less common thera-
peutic adjunct.
A poorly executed umbilical closure on the abdo-
men stands out like a beacon and will detract from
the overall result. The aesthetics of the umbilicus
have been hotly contested as evidenced by the innu-
merable designs available for use. The shape and
size of the umbilical defect are varied so as to suit
the habitus of the patient: a tiny umbilicus in a large
abdomen looks both silly and surgical. The precise
design employed for the creation of an umbilicus is
less important, in our opinion, than two key ele-
ments: contour of the periumbilical soft tissues,
and accurate placement of the umbilicus on the an-
terior abdominal wall. It is best to minimize the vi-
sual junction of the native umbilicus with the skin
flap by bringing the abdominal flaps down to the
umbilical stalk and securing them to the fascia. It

is critical to defat the soft tissues adjacent to the um-
bilicus to create depth and replicate the normal
contour ‘‘pout’’ of the umbilical aperture.
Abdominal flap design Careful design of the ab-
dominal wall flap will help to ensure an aesthetic-
appearing donor site while maximizing the tissue
available for creation of the breast mound. We pre-
fer to place the abdominal scar higher and recruit
the lateral hip area for closure as described in the
‘‘high lateral tension abdminoplasty,’’ by Lockwood
[36]. This visually draws the eye up with a resultant
narrower look to the hips, and also ensures capture
of unsullied perforators in patients who had prior
lower abdominal surgical procedures. A conserva-
tive amount of tissue is harvested in the midline,
with the flap design resembling a ‘‘butterfly.’’ This
design helps to maximize restoration of an aesthetic
abdomen after flap harvest by minimizing tension
in the most vulnerable portion of the central water-
shed area of the abdominal closure, limiting the po-
tential for vascular compromise and elevating the
mons pubis. This configuration also provides the
ability to configure the lower abdominal flap for
projection as a soft tissue cone. In a delayed setting,
this technique may serve to limit the number and/
or extent of contralateral reduction and balancing
procedures that are required for symmetry. The
lower abdominal flap should be designed with
equal limb lengths. Careful attention to flap length
and the patient’s adipose distribution will mini-
mize resulting dog ears and the need for revisions
(see Fig. 9).
Maximizing the functional outcome of the
abdominal donor site
Significant deformities of the abdominal wall such
as bulge and hernia that may result from autolo-
gous flap harvest are often difficult to repair second-
arily. Every effort should be made to minimize the
possibility of the development of these defects at
the time of initial flap elevation and transfer. The
best means to minimize functional deformity of
the abdomen include careful patient and flap selec-
tion, and meticulous closure of the flap donor site.
Algorithm for abdominal flap selection
A primary means to maximize the aesthetic and
functional outcome of the lower abdominal donor
site is the use of a perforator or muscle sparing
transverse rectus myocutaneous (TRAM) flap vari-
ant. We use a standardized approach for flap selec-
tion. We first examine the superficial inferior
epigastric vascular system. If the superficial inferior
epigastic artery (SIEA) vessels are absent or inade-
quate caliber (preferably 1.3–1.5 mm in external
Revision in Autologous Breast Reconstruction 151
diameter and have a strong palpable pulse), the
SIEA flap is excluded, preserving 5 to 9 cm of a su-
perficial inferior epigastric vein (if available) as a po-
tential ‘‘lifeboat’’ for possible venous augmentation.
After examination of the SIEA pedicle, the deep in-
ferior epigastric perforators (DIEP) are dissected. A
palpable pulse and identifiable vein are preferable
for a use of single DIEP perforator reliably to sup-
port a flap. If a single perforator is deemed inade-
quate based on the above criteria, one to three
smaller perforators will be chosen for inclusion.
The vascular system exhibiting optimal perfusion
will be chosen for use in reconstruction. If multiple
small DIEP perforators are noted, a muscle sparing
TRAM may be preferable. Every effort is made to
leave both medial and lateral innervated vascular-
ized rectus muscle in situ (‘‘MS-2’’ configuration af-
ter Nahebedian) in the muscle sparing flaps [14]. A
free TRAM flap incorporating the full breadth of rec-
tus muscle represented the final and last option in
our decision tree of reconstructive options, and
we rarely find this option necessary.
Abdominal donor site closure
Significant attention should be paid to the integrity
of the abdominal wall after flap harvest. It is imper-
ative to ensure integrity of the donor site repair, and
this task must not be relegated to the most junior
member of the operative team. Abdominal contour
deformities including hernia and bulge have been
associated with both DIEP and TRAM flaps, with
a wide range of reported incidence [1,4,5,11–
15,23,25–28]. Careful donor site closure in the
TRAM donor site has been shown to reduce the in-
cidence of abdominal hernia and bulge to between
1% and 1.5%, as has the use of prophylactic mesh
a percentage comparable to that cited with DIEP
flaps [25–28,37–39]. We generally use an inlay re-
pair of the fascia with a polypropylene mesh if the
rectus muscle has been violated in flap harvest.
We have found this approach to be more effective
than onlay mesh at the prevention of postoperative
abdominal contour deformities and less likely to re-
sult in postoperative pain or neuroma, which can
result from inadvertent trauma to the intercostal
nerves and significant postoperative discomfort
and distress to the patient. We have on occasion
used an onlay mesh in addition to an inlay insetting
in which fascial quality is extraordinarily poor (eg,
patients with extensive prior abdominal proce-
dures). There are several options for prosthetic
and biomaterials to repair or reinforce the abdom-
inal wall [38–45]. An increasing number of bioma-
terials have become available and demonstrate
significant promise. Traditional prosthetic mate-
rials, even those that facilitate tissue ingrowth, re-
main a foreign body and therefore pose
152 Beahm & Walton
a potential risk for infectious sequella, even long af-
ter implantation. Biomaterials become vascularized
and fully integrated into the adjacent tissues. The
use of bioprosthetics that are biocompatable and
permit tissue ingrowth with incorporation have
been increasing in application. These materials ap-
pear to be efficacious for abdominal hernia repair
and TRAM donor site repair [43,44]. AlloDerm
(Life Cell Corp, The Woodlands, Texas) has received
the greatest amount of longitudinal study in this
application. It is soft and pliable and thus can be
placed directly over bowel without the concerns
for adhesions and fistula that accompany mesh
placed in this location. It appears to demonstrate
significant tensile strength experimentally.
In addition to these distinct advantages, some of
the limitations of the product deserve consider-
ation. AlloDerm may lead to seroma and additional
drains should be placed above and below the fascial
repair to limit this. AlloDerm is expensive and more
than one piece may be needed to complete an ade-
quate repair. Splicing these pieces together may sig-
nificantly increase the time for abdominal repair.
AlloDerm requires a suitable amount of time to re-
hydrate (40 minutes or more) and should not be
placed in situ until it is fully rehydrated. If the prod-
uct is not inset under suitable tension or is inset be-
fore maximal hydration, it will stretch and may lead
to an abdominal bulge. Although vascular ingrowth
may first appear by day 3, the time to full incorpo-
ration (nearly 6 weeks in some settings) is signifi-
cantly longer. Biomaterials act as foreign bodies
and can suffer the same infectious complications
as a traditional prosthetic until fully integrated. Im-
portantly, AlloDerm is a human cadaveric product.
Although every effort is made to ensure adequate
screening of donors and there has been no reported
viral infection as a result of using the product, a re-
cent recall of the product was necessitated when
practices of one of the donor facilities was brought
into question. This necessitated notification and
HIV testing of patients. Although there have been
no instances of conversion, this did cause some un-
derstandable concern in patients and prudence
would dictate that patients be informed of these is-
sues preoperatively.
The application of prosthetic mesh in a lower ab-
dominal flap has not, in our hands, resulted in any
significant infectious sequella in over 10 years of
use. We are careful to avoid an overly tight abdom-
inal closure and take great pains to ensure viability
of the umbilicus if we will be using mesh. Gortex
(W. L. Gore & Associates, Inc., Elkton, MD) pro-
vides a smooth surface, which limits potential in-
jury and fistula formation, which are
considerations if a thicker rigid mesh is placed di-
rectly on bowel [45]. These are not usually pertinent
considerations in the repair of a lower abdominal
flap because of the presence of a posterior sheath.
We do not recommend the use of Gortex for closure
in TRAM donor sites. Gortex is impervious to tissue
ingrowth, and because it does not become incorpo-
rated, it remains problematic in terms of possible
infectious sequella with exposure. A polypropylene
mesh has been the first line of therapy in our hands
(Prolene, Marlex) as it is readily available, inexpen-
sive and although it does remain a foreign body, the
pore size permits tissue in growth. Patients should
be cautioned as to the firmness of the abdomen
and the potential for discomfort with any signifi-
cant weight gain that is associated with an increase
in intrabdominal fat because of the somewhat un-
yielding nature of the inlay application of mesh.
Secondary repair of the abdomen
Our approach to therapeutic secondary repair of
a donor site hernia or bulge reflects these same prin-
ciples. The strength and integrity of the abdominal
fascia is often culpable in the defect and a significant
limitation to satisfactory repair. The tensile strength
of the biomaterial or prosthetic will often eclipse
the native tissue resulting in compromise of the re-
pair at the junction of these tissues due to inade-
quate anchorage. Continued attenuation and
stretch of the fascia due to intrinsic weakness may
also occur. The patient will usually need to undergo
an open abdominal procedure, and an inlay bioma-
terial alone or one used to reinforce any needed
component separation is our first line approach.
Several patients demonstrate abdominal contour
deformities after TRAM flap harvest that are asymp-
tomatic and they do not seek treatment. In our early
experience with full muscle TRAM flap harvest and
onlay mesh techniques, we saw these cases more of-
ten. We have been gratified that secondary repair of
these deformities has not been an issue since the
use of prophylactic inlay mesh and muscle/fascial
preserving approaches.
Nipple–areolar reconstruction
Nipple reconstruction has been linked to overall
patient satisfaction with reconstruction, yet it is re-
quested by only about half of the TRAM patients at
M.D. Anderson. It is best to ensure a stable breast
mound before undertaking reconstruction of the
nipple. There are several available techniques for
NAR, each of which has its advocates as well as its
limitations [46–48]. First and foremost, all nipple
reconstructions result in the loss of projection
over time. Patients who have very large and/or pro-
jecting nipples must be warned of the likelihood of
the inability to match these proportions, even with
overcorrection of the reconstruction. These patients

may benefit from nipple reduction and/or nipple
sharing procedures.
One of the most critical aspects of nipple recon-
struction is the appropriate placement of the nipple
on the breast mound. Minimally, there are subtle
asymmetries of the breasts and proper placement
of the nipple that may require some judgment.
We encourage the patient to decide where she wants
the nipple. We will make a Duoderm (ConvaTec
Professional Services, Princeton, NJ) cutout of the
proposed areolar and nipple, which enables the pa-
tient to position the NAR on the breast mound at in
an unhurried fashion at home in front of the mir-
ror. (Spot bandaids can also be used for this
purpose.)
Several factors will affect the quality of the NAR
and the technique used. Areas of skin that have
healed by secondary intent should be avoided in
nipple reconstruction, because the size and stability
of the NAR relies primarily on the quality of the un-
derlying dermis used for the reconstruction. Latissi-
mus dorsi flaps provide a robust and projecting
nipple reconstruction that is superior to abdominal
and/or breast skin flaps because of the intrinsic
thickness of the dermis of the skin on the back.
Scars on the breast mound may affect the NAR tech-
nique used. A double opposing tab flap may be ef-
fective in cases in which a scar runs through the
middle of the proposed nipple point. We have crit-
ically compared our experiences with a modified
star flap, double opposing tab flaps, and a purse
string approach, developed by Dr. Anderson over
the last 4 years. The latter technique, which distrib-
utes the tension created by elevation of the nipple
Revision in Autologous Breast Reconstruction 153
flaps away from the nipple to the surrounding con-
struct by a Gortex circlage suture, is highly effica-
cious [47]. Although this approach results in loss
of nipple projection over time, it does limit scarring
to the areolar border and can be quite effective in
implant-based reconstructions, which in general
have the greatest degree of tension at the proposed
nipple point (see Fig. 7; Fig. 13).
The issue of the best means to establish color in
the NAR is open for discussion. We have found
that the medial thigh skin graft, (in the manner de-
scribed by plastic surgeon, T.R. Broadbent) will pro-
vide a very natural and stable areolar color. The
downside of this approach has been a pale nipple,
which may benefit from tattooing (see Fig. 12).
The majority of our patients prefer a tattoo, because
it limits the number of operative interventions. The
tattoo avoids the skin graft donor site, but does
fade. Patients need to be warned of the need for re-
vision and ‘‘touch ups’’ over time, especially those
that necessitate a pink hue because the browner pig-
ments tend to hold up better over time (see Fig. 11).
Another limitation of the tattoo is the potential for
loss of projection of the nipple. The tattoo pigment
is placed intradermally, the vascular base of the nip-
ple reconstruction. In our experience, even in well-
established nipple reconstructions, the tattoo has
been implicated in compromise of nipple projec-
tion. Although all nipple reconstructions lose
some projection (on average in our experience by
approximately 50%), secondary attempts to correct
the loss with dermal fat or AlloDerm have not been
entirely successful. We therefore endeavor to mini-
mize the volume loss of the nipple by careful design
Fig. 13. Modified purse string
technique for NAR (after Dr.
James Anderson). (A) Desired
nipple height is set using a
modified star flap. (B) The ra-
dius of the proposed areolar is
measured on each side of the
nipple flap and incised circum-
ferentially. (C) The nipple is
assembled and the areolar ele-
ments approximated. (D) A
periareolar purse string of Gor-
tex prevents spreading of the
areolar dimensions and distrib-
utes tension away from the
nipple flap.
154 Beahm & Walton
and execution of the flaps initially. We also wait 3 to
6 months for full shrinkage of the nipple before tat-
tooing, as suggested by other authors [48]. In our
experience we have found that the Anderson tech-
nique held up best to the tattoo compared with
the other flaps, yet retention of nipple projection
was best with a double opposing tab and skin graft
alone for color.
A nipple areolar complex (NAC) sparing mastec-
tomy, when applicable, can provide a highly aes-
thetic result. Although the nipple is unlikely to
have any significant sensation after a NAC sparing
procedure, this technique preserves tissue at the
point of maximal projection (and tension) in the
reconstructed breast. This can significantly improve
the aesthetic outcome of the reconstruction, espe-
cially in implant-based approaches. The NAC spar-
ing mastectomy is a technically demanding
procedure for the surgical oncologist, and should
not be undertaken by the novice because partial/to-
tal loss of the nipple is clearly possible and can be
problematic. The NAC sparing technique is appeal-
ing to patients and has been increasingly applied in
selected cases such as prophylactic mastectomy or
with very small tumors remote from the breast.
The safety of this procedure with invasive carci-
noma and extensive DCIS remains to be proved
and is currently under investigation.
Special considerations
Obesity
Obesity represents a rapidly growing phenomenon,
particularly in the United States. An increasing
number of significantly obese patients are present-
ing for breast reconstruction (Fig. 14). At M.D. An-
derson, we have seen a steady rise in the body mass
index (BMI 5 kg/m2) and of our population over
the last 10 years with a three fold increase in the
number of obese (BMI >30) and morbidly obese
(BMI > 40). The greatly increased complication
rate in these patients is well documented, as is the
need for postoperative revision [49–51]. The ab-
dominal donor site after flap harvest is an area of
significant concern in this population. Reviews of
the experience at our institution suggest a four to
six fold higher rate of hernia and bulge in the obese
population, particularly in those patients who have
a BMI greater than 35. The use of implant-based
techniques in the obese patient population is high-
er proportionately than purely autilogous ap-
proaches at our institution, likely reflecting these
concerns. Unfortunately implant-based techniques
are often inadequate in terms of volumetric correc-
tion of the breast in patients who have larger
breasts, and the complication rate (including
implant loss) is higher than compared with normal
and overweight patients [50].
These data argue for the need for careful scrutiny
of these patients, especially those patients who are
being considered for bilateral lower abdominal
flap harvest, where donor site morbidities are
more common [18,21,25–28,49–51]. In this set-
ting, delayed reconstruction after weight loss to
a BMI less than 35 may be warranted. Specific atten-
tion to the body habitus and abdominal tone of
each patient should be examined carefully. Patients
who have a ‘‘pot belly’’ habitus, reflecting a higher
intrabdominal fat collections and poor quality fas-
cia, represent a population at higher risk for postop-
erative donor site complications.
Revisions of the breast reconstruction in the
obese patient primarily focus on reduction and
mastopexy of a large contralateral breast as well as
shaping of the transferred flap. The thickness of
the abdominal tissue of the flap in an obese patient
often greatly limits shaping of the breast mound at
the initial operative venture. The thickness may me-
chanically limit coning and inset or risk flap com-
promise. Significant thinning of the flap
immediately after transfer risks increased fat necro-
sis, already an added concern in this population.
These limitations often necessitate an initial over-
correction of volume in certain areas, such as the in-
fraclavicular area initially, with subsequent
thinning of the flap to create an improved shape
(see Figs. 3–6).
Prior abdominal surgery
Patients who had prior abdominal surgery may ne-
cessitate additional surgical intervention and revi-
sion to maximize the functional aesthetic
appearance of the breast and donor sites. Signifi-
cant damage to the perforating vessels, deep inferior
epigastric and superficial inferior epigastric vessels
may have been sustained during previous gyneco-
logic procedures, especially those for cancer. Prior
damage to the rectus abdominus muscle and fascia
may necessitate reinforcement with a prosthetic
mesh or bioprosthetic such as AlloDerm. Existing
scars on the abdominal wall may compromise the
ultimate aesthetic appearance of the abdominal
wall and the closure of the donor site. Midline, par-
amedian, and subcostal scars will increase the po-
tential for donor site vascular compromise with
excessive undermining and restrict the elasticity of
the adjacent tissues and ability to close the donor
site after flap harvest. More conservative flap harvest
is imperative in these cases. Some may be nicely
managed with a staged approach to the abdominal
donor site: initially harvesting the flap with mini-
mal tension and undermining excising with an
 Revision in Autologous Breast Reconstruction 155

Fig. 14. Radiation of a TRAM flap in an obese patient. (A, B) Thirty-six-year-old obese woman who had T1 cancer
and clinically negative axilla underwent immediate breast reconstruction with unilateral muscle sparing TRAM
and inlay polypropylene mesh reinforcement because of her obesity and degree of intra-abdominal fat. Final
pathology revealed five positive lymph nodes. (C) Patient is seen 3 months after radiation therapy to chest
and axilla (note the erythema). (D, E, F, G) Patient underwent a contralateral reduction mammaplasty with a
parenchymal pedicle approach, flap revision, and NAR with a double opposing tab flap and skin graft 14 months
after the end of her radiation therapy after her tissues had settled. The free flap tolerated the radiotherapy well,
with some loss of volume and minimal fibrosis. The patient’s 30-month postoperative result is demonstrated.

asymmetric incision, then secondarily revising the
donor site to improve the scar (Fig. 15). The breast
mound may have significant deformity from these
scars that may require secondary revision to avoid
contour deformities.
Potential vascular compromise: collagen
vascular disease and smoking
Patients who have the potential for poor local
wound healing and vascular compromise of the do-
nor site, such as those who are smokers or have
156 Beahm & Walton
collagen vascular disease, require special comment.
Microsurgical transfer limits the potential for com-
promise of the breast flap in these patients, but the
donor site remains vulnerable (Fig. 16). In these
patients, we emphasize the need to harvest a small
flap, minimize undermining and tension, and we
will not attempt the degree of periumbilical defat-
ting used to achieve an aesthetic abdominal con-
tour that we usually undertake. Additionally,
conservative management of the mastectomy skin
flaps is imperative to avoid undue compromise.
We have found cutaneous vasodilators, specifically
low-dose Nifedipine (10 mg po BID) to be helpful
in these patients administered orally for several
weeks preoperatively and continued for several
weeks postoperatively. Patients must be warned
about symptoms of light-headedness and flushing,
which they may find objectionable. Significant low-
ering of systemic blood pressure measures is rarely
a problem with the low dosage. Those patients
who are undergoing delayed reconstruction should
be asked to stop smoking for a minimum of 6
weeks before surgery. Assays of recidivism using
Fig. 15. Abdominal donor
site revision for prior ab-
dominal scars. Forty-two-
year-old woman who had
a T2 N0 breast cancer and
donated a kidney to her
brother; Phannensteil inci-
sion from a C-section. Two
options for flap harvest were
considered: (A) a midabdo-
minal TRAM or (B) harvest
asymmetric lower flap. (C)
The resulting initial donor
scar was revised secondarily
during NAR. (D) Patient is
seen at 12 months and
49 months postoperative.
measures of nicotine/continine can be helpful in re-
calcitrant patients.
Radiation therapy
There has been a recent increase in the application
of radiotherapy in our institution and nationwide
due to suggestions of an increased efficacy of local
control and survival in patients with one to three
positive lymph nodes [52,53]. Radiation signifi-
cantly negatively impacts upon the quality of the re-
construction whether the reconstruction is done
before or after the radiation. We currently recom-
mend delayed reconstruction in patients who will
need adjuvant radiation. The rationale for this is
two fold. Recent data suggest that a reconstructive
breast mound, even an autologous one, may inter-
fere with the accurate delivery of radiotherapy. Ad-
ditionally it is clear that radiation may
significantly compromise the transferred flap [53].
The advantages of immediate reconstruction in
terms of preservation of the mastectomy skin enve-
lope, technical ease, and patient preference prompt
us to proceed with this approach whenever it seems

prudent. Despite extensive preoperative analysis,
there are times that postoperative radiotherapy
will unexpectedly be necessary. If intraoperative
findings suggest postoperative radiotherapy, we
will endeavor to overcorrect the flap volume by ap-
proximately 20% and shy away from a single vessel
perforator flap, preferring a muscle sparing flap.
Muscle sparing flaps tolerate radiation relatively
well, in contradistinction to single vessel perforator
flaps, but this reflects our own experience and has
not been subjected to prospective study (see
Fig. 14). Radiation of a free TRAM flap will likely re-
sult in 10% to 20% shrinkage and a very ‘‘perky’’-ap-
pearing reconstruction, similar to that of an
implant. Revisions after radiation must be cautious
because the potential for postoperative fat necrosis
and seroma are common. Radiation will greatly in-
crease the overall revision rate and decrease options
for salvage, because local tissue rearrangement or an
implant are not a reliable options. In an earlier
study from our institution, nearly a third of these
patients were felt to benefit from a second flap
[53]. Although we have not found the complication
rate to be this high, there is no question that radia-
tion of a unilateral reconstruction is highly
Revision in Autologous Breast Reconstruction 157
Fig. 16. Abdominal donor
site compromise: (A) Forty-
three-year-old recent ex-
smoker who had mixed
connective tissue disease
underwent delayed free
TRAM breast reconstruc-
tion. (B) Abdominal donor
site and mastectomy skin
flaps manifested delayed
wound healing and skin
loss. There were no free
flap complications. (C ) Pa-
tient underwent surgical
debridement, negative pres-
sure therapy (VAC, Kinetic
Concepts, Inc., San Antonio,
TX) for 14 days with serial
closure. (D) Two-year post-
operative result is noted.
problematic. The timing for intervention in this set-
ting is unclear, but we usually wait 6 to 12 months
after the end of radiation before intervening. This
extended interval should allow for adequate settling
of the reconstruction as well as to allow a suitable
period for observation from the oncologic perspec-
tive. Although radiation of the unilateral recon-
struction can be problematic, radiation of one
side of a bilateral reconstruction is untenable and
should be avoided at all costs, because the options
for correction of the deformity are limited.
We have found delayed reconstruction after radi-
ation to be more challenging than immediate re-
construction and to have a higher revision rate.
The interface of the radiated tissue with the flap is
unpredictable and will often have an abrupt transi-
tion. The residual mastectomy flaps will not gener-
ally drape smoothly over the reconstructed breast
mound in the manner of a nonradiated setting. In-
stead, these radiated tissues will appear to have
‘‘shrink wrapped’’ the flap (see Fig. 10). It is imper-
ative to place well-vascularized tissue in the ana-
tomic position of the native breast, even if this
entails initial overcorrection, and commit to revi-
sions. These reconstructive requirements argue for
158 Beahm & Walton
a large flap initially, to provide the volume of tissue
necessary for subsequent revision to adequately
shape (see Figs. 3–7).
Coincident procedures with autologus breast
reconstruction
The application of concurrent procedures with the
breast reconstruction is primarily related to gyneco-
logic procedures in high-risk patients including
BRCA1/2. Patients prefer the idea of completing
all the surgery ‘‘at once.’’ We have combined the
gynecologic procedures (hysterectomy and oopher-
ectomy) in cases undergoing prophylactic bilateral
free TRAM flaps. Review of a series of 26 patients
demonstrated a significant increase in operative
time and length of hospital stay (Beahm EK, Meric
Bernstam F, and Lu K, in preparation, 2006). Al-
though all cases were ultimately successful, we cur-
rently recommend that these procedures be
performed during the secondary/revision stages
and not during free flap transfer for several reasons
(see Fig. 2). The orientation of the operating room
bed needed for the gynecologic procedures will
not adequately permit sitting the patient upright,
and this interferes with shaping of the breast
mound. Flap harvest must proceed before the
oopherectomy and hysterectomy because there is
an approximate 10% or greater chance of injury to
the deep inferior epigastric vessels during these pro-
cedures. These procedures are several hours long
and performed with the patient in extreme Trende-
lenberg position. Immediately after flap harvest
and/or transfer, when the flap is vulnerable, it is dif-
ficult to monitor and the potential for compromise
is significant. Several cases necessitated surgical
exploration and/or intraoperative vascular anasta-
motic revision. Because breast reconstruction is an
elective procedure and is staged, we feel it is more
prudent to perform the elective gynecologic proce-
dures during the second stage of the breast recon-
struction if we are doing a bilateral microsurgical
autolgous reconstruction to minimize the potential
for complications. Although our flap loss rate is
low, any loss is devastating to the individual pa-
tient, and we wish to minimize the potential for
an untoward outcome.
Mastectomy skin flap loss
Loss of the mastectomy skin flaps is highly detri-
mental to the final aesthetic outcome in breast
reconstruction, and every attempt should be made
to avoid this situation. Limiting the application of
a ‘‘reduction pattern’’ flap in the initial flap transfer
will help in this regard. Even without undue
manipulation, there are times in which the vascular
status of the mastectomy skin seems unclear after
the mastectomy. In these cases, it may be most pru-
dent to revascularize and transfer the free flap, but
temporarily inset the mastectomy skin flaps with-
out tension and let them demarcate. A scheduled re-
turn to the operating room on or approximately
postoperative day 4 will then allow definitive inset,
maximize the amount of mastectomy skin pre-
served, and will not prolong the patient’s hospital
stay (Fig. 17). In cases of mastectomy, skin flap
compromise that is not readily apparent intraoper-
atively that results in loss (unfortunately a not infre-
quent event in radiated tissues), a full thickness skin
graft from the abdominal donor site is the best
means to effectively close the wound and salvage
the reconstruction, but does clearly compromise
the ultimate aesthetic result (Fig. 18).
Revision after partial and total flap loss
Loss of free flaps for breast reconstruction at M.D.
Anderson over the preceding 12 years is fortunately
quite rare, averaging approximately 1.4% for total
flap loss and 4% for partial loss [54]. In an exami-
nation of nearly 2000 patients, after partial flap
loss almost all (98%) of the patients completed
their reconstruction. The strategy for restoration of
breast shape and volume was equally divided
between use of a local/region flap (latissimus dorsi,
thoracoepigastric flap), a contralateral balancing
procedure, or augmentation of the reconstruction
with an implant. Recently we have found pedicled
thoracodorsal perforator flaps to be helpful for
the restoration of the breast construct volume with-
out the need to sacrifice a functional muscle, most
especially for those defects in the lateral aspect of
the reconstruction.
In cases of total flap loss, just over half the breast
patients at our institution went on to complete their
reconstruction—the majority with an implant-
based approach. Only one patient underwent a sec-
ond free flap (successfully) after failure of the first
flap, perhaps because of the less critical nature of
breast reconstruction as compared with lower
extremity and head and neck. The dismal number
of secondary attempts at breast reconstruction after
failure suggests an aggressive approach to salvage of
the first flap.
Augmentation of free flaps with breast
implants
Placement of a breast implant can provide volume
and projection, but are deficient in the medial supe-
rior and lateral aspects, and accordingly will not im-
prove the shape of the reconstruction in these areas.
This suggests that implants are often a suboptimal
choice in correction of a partial flap loss. In general,
the introduction of a breast implant on one side of
a reconstruction will necessitate application on the
 Revision in Autologous Breast Reconstruction 159

Fig. 17. Management of mastectomy skin flap necrosis: delayed inset. (A) Intraoperative compromise of mastec-
tomy skin flaps. (B) In cases in which the vascularity of the native skin appears compromised and/or unclear in
extent, maximal preservation of the skin envelope may be accomplished by transferring the free flap but delay-
ing the final inset of the mastectomy skin flaps, returning the patient to operating room once the skin flaps have
declared themselves, approximately postoperative day 4. (C, D) Final result 22 months postoperatively. Patient
deferred NAR (Courtesy of G.P. Reece, MD, Houston, TX).

contralateral side as well. The use of prosthetic aug-
mentation in breast reconstruction is most suited to
a bilateral reconstruction in which the primary con-
sideration is an increase in projection of the recon-
struction, not the correction of a focal deficit.
Implants can and have been used in the initial op-
erative procedure of flap transfer, but their presence
may pose a mechanical risk to the vascular pedicle,
especially in perforator flaps. The placement of
minimally inflated postoperatively adjustable de-
vice will decrease the potential for pedicle or mas-
tectomy flap compromise, but we recommend
delayed subpectoral placement of the implants as
the most reliable means to reduce the potential
for compromise of the flaps. As we usually employ
smooth-walled prosthetics for augmentation, de-
layed insertion affords more accurate positioning
of the implant. It must be noted that the reconstruc-
tive flap, because of the elements of scar and intrin-
sic shape will not drape around an implant in the
same fashion as a native breast. This limitation is
a primary consideration in unilateral breast recon-
struction in which a TRAM is to match an aug-
mented breast. Implants do entail the potential
unfavorable elements of device failure, contracture,
and temporal change. The application of an
implant coupled with the donor morbidities inher-
ent to an abdominal flap requires careful
consideration a clear goal of the desired outcome
and potential complications by both patient and
surgeon. We have found that a well-shaped autolo-
guos flap, provided enough flap volume is present
to afford coning of the flap for increased projection,
to be reasonably efficacious in this regard (see
Fig. 9). The long-term complications and ultimate
failure of implants in the setting of irradiation in
our hands suggest this approach to be a poor
choice.
Fat grafting
Previously considered ineffective and even danger-
ous, the application of free fat grafting in the breast
appears to hold significant promise, particularly for
small areas of contour deformity in a reconstruc-
tion. Several recent reports have demonstrated effi-
cacy in reconstructive and aesthetic application
with conservative staged applications of small
aliquots of fat using multiple passes. Encouraging
reports of improvement of radiated tissues with
fat grafting have prompted speculation of a ‘‘stem
cell’’ mediated process. Clinical efficacy in cases of
breast reconstruction has been empirically
160 Beahm & Walton

Fig. 18. Management of mastectomy skin flap necrosis: full thickness skin grafts. Fifty-four-year-old woman who
had recurrent breast cancer after lumpectomy and radiation underwent immediate breast reconstruction with
bilateral DIEP flaps. (A, B) The free flaps healed nicely, but although all tissues appeared viable in the operating
room, she suffered mastectomy skin flap loss. (C) To avoid loss of breast volume, full thickness skin grafts from
the abdominal wall were used. (D, E, F, G) The 14-month postoperative result after contralateral mastopexy and
NAR with a purse string approach and tattoo is demonstrated.

presented. At present, the quantification and mech-

anism of the efficacy of fat grafting are unknown
and under investigation. Further prospective con-
trolled study seems warranted to address the effects
of fat grafting before widespread application in a na-
tive female breast under surveillance.
Summary
Our standard paradigm for breast reconstruction
incorporates at least one surgical revision for refine-
ment of the breast mound, combined with subse-
quent procedures for symmetry and NAR.
A suitable period of waiting for the reconstruction
to settle—usually about 3 months—is recommen-
ded. This interval may need to be longer if radiation
is involved. NAR is deferred until the reconstructed
and native breast mounds are balanced in terms of
shape and symmetry. Surgical revisions may be
mandated by mastectomy skin flap size or compro-
mise, or the necessity of adjuvant therapy. Proce-
dures for the contralateral breast may be highly
beneficial, but also carry significant surgical risks
demanding consideration. Management of the ab-
dominal wall following autologous flap harvest
must be carefully addressed so as to achieve out-
comes that appropriately address both functional
and aesthetic aspects of the donor site.
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