History of the Procedure
Tremendous advances in breast reconstruction have occurred in the past 3 decades. Although breast reconstruction with tissue expanders and implants remains the most common form of reconstruction, autogenous tissue has grown more popular. [1, 2] In the past decade, breast reconstruction has advanced because of the popularity of skin-sparing mastectomy.  When immediate reconstruction is performed following a skin-sparing mastectomy in a nonirradiated breast, the demands on the plastic surgeon are reduced and the postoperative result is improved cosmesis. [3, 4, 5, 6, 7]
Refinements and finishing touches are generalized terms. Specificity is needed in addressing these topics. The refinements and finishing touches for breast reconstruction with expanders and implants may be far different than those for a transverse rectus abdominis myocutaneous (TRAM) flap for immediate reconstruction or a delayed latissimus flap in an irradiated mastectomy defect.
The deep inferior epigastric artery and vein (DIEP) flap arguably is a refinement of the TRAM flap; likewise, using the internal mammary vessels for a free TRAM flap procedure arguably is a refinement of the traditional use of the thoracodorsal vessels. The following paragraphs discuss some techniques and planning skills for all types of breast reconstruction with the goal of achieving the best result (see the image below). Although refinements can improve small imperfections in a reconstructed breast, these should not be relied upon to correct improper planning of the initial procedure.
Breast shape varies among patients, but knowing and understanding the anatomy of the breast ensures safe surgical planning. The breast is made up of fatty tissue and glandular, milk-producing tissues. The ratio of fatty tissue to glandular tissue varies among individuals. In addition, with the onset of menopause (ie, decrease in estrogen levels), the relative amount of fatty tissue increases as the glandular tissue diminishes.
The base of the breast overlies the pectoralis major muscle between the second and sixth ribs in the nonptotic state. The gland is anchored to the pectoralis major fascia by the suspensory ligaments first described by Astley Cooper in 1840. These ligaments run throughout the breast tissue parenchyma from the deep fascia beneath the breast and attach to the dermis of the skin. Since they are not taut, they allow for the natural motion of the breast.
Breast reconstruction is rarely considered a 1-stage procedure. Although some surgeons prefer immediate flap and nipple reconstruction during the initial procedure, most separate this into 2 or more procedures. While the initial stage may provide no more than an amorphous mound of soft tissue on the patient's chest wall, refinements and finishing touches may transform this into a breast that can mimic the contralateral breast in contour, symmetry, and projection.
Immediately following mastectomy, the surgeon may close the wound and delay reconstruction, place a tissue expander under the pectoralis muscle,  place an implant beneath a transferred latissimus myocutaneous flap, or perform immediate reconstruction with a large myocutaneous flap. Nevertheless, the surgeon often believes that the most difficult portion of the reconstruction has been achieved, although the breast mound does not resemble the opposite breast. Certain details should be addressed during this initial procedure to improve the final outcome.
- Restore the inframammary crease. Close cooperation with the oncologic surgeon can alleviate problems, since technically no breast tissue lies inferior to this plane. If it has been violated, reconstruct it with sutures before proceeding. Some surgeons prefer placing sutures through the skin at the inframammary fold (IMF), while others simply mark this area with a pen. It is important to mark the IMF and the medial border and lateral slope of the breast.
- Close the axilla. During axillary dissection and dissection of the thoracodorsal pedicle, the lateral border of the latissimus is lifted away from the chest wall. If left alone without closure, the flap or implant often drifts laterally in this area. Suture the latissimus-serratus unit back to the chest wall in an attempt to restore the natural slope of the lateral breast.
- Inspect the mastectomy flaps carefully. If vascular compromise is suspected, intraoperative use of the Wood lamp may help determine this. If uncertainty remains, several options are available, including delaying reconstruction, resecting the questionable skin with immediate reconstruction, and closing the questionable skin over a non–de-epithelialized skin paddle, which allows full demarcation of the questionable skin and definitive surgical repair 2-3 days later.
In reconstruction with expanders and implants (see the image below), address several issues before the initial procedure:
Will the patient's breast be irradiated preoperatively or postoperatively?
Will skin closure over the expander pose a problem?
What is the approximate size of the implant to be used?Expander-implant breast reconstruction. Textured saline expandable implant with built-in port.
Radiation effects and flap reconstruction
Patients who receive either preoperative or postoperative radiation and undergo reconstruction with implants are more likely to develop capsular contracture than those who do not receive irradiation. While a latissimus flap placed over the implant may alleviate some of the effects of radiation on the implant, it also can provide needed skin in patients with delayed reconstructions or large skin resections. The surgeon has more options for revising a breast reconstructed with an implant and a latissimus flap than one with an implant alone, and the additional procedure requiring replacement of the expander for a permanent implant is avoided.
When placed behind a latissimus flap, the implant can be round or anatomic depending upon the desired shape of the breast. Measurements of the base diameter of the breast are important in planning reconstruction. The diameter of the implant should not exceed the diameter of the breast pocket. If the desired implant is too wide for the breast pocket, consider a smaller implant with a contralateral reduction or a different method of reconstruction.
Initial reconstruction with autogenous tissue
Reconstruction with autogenous tissue also requires careful preoperative planning.  Future refinements can be avoided by paying attention to the details of flap orientation. If the free TRAM flap used for breast reconstruction is based on the ipsilateral rectus, it provides more vertical fullness. When the flap is based on the contralateral rectus, it lies in a more transverse orientation; consider this orientation for patients with wider breasts that extend out toward the axilla with minimal superior fullness.
With pedicled TRAM flaps, management of the subcostal innervation to the muscle is controversial.  Some believe the inevitable atrophy of the rectus muscle can be diminished if the nerve is preserved. Conversely, division of the nerve and of the tendon of the rectus muscle superior to the takeoff of the superior epigastric vessels gives the flap more freedom to rotate and helps eliminate the unsightly bulge in the xiphoid region.
When transferring a pedicled TRAM flap, preferably base the flap contralateral to the reconstructed breast and create the subcutaneous tunnel slightly on the opposite side of the sternum in relation to the reconstructed breast. The DIEP flap can be considered a refinement in the abdominal wall closure. Because no fascia is harvested, it is believed that function returns more quickly, hernias and bulges are less frequent, and postoperative pain is less severe. Use of the internal mammary vessels for free-tissue transfer can be considered a refinement in flap orientation. This should help eliminate the problematic lateral drift often observed in free flaps anastomosed to the thoracodorsal vessels. These vessels may be more reliable in delayed reconstructions. See the images below.
Second stage of reconstruction
While the initial reconstruction usually is planned at a stressful point in the patient's life, the second stage is quite different. The patient should have completed her adjuvant therapy, and she can focus more on assisting with improving the cosmesis of her new breast. The second stage should be performed once the breast mound has softened and edema has resolved. During this time, the new breast has already undergone some degree of ptosis. All wounds should be well healed with no evidence of infection. Wait at least 6 weeks after the last course of chemotherapy and at least 8 weeks after the last radiation treatment. Advise the patient to avoid tobacco products for 8 weeks prior to surgery. Although the second stage commonly is associated with nipple reconstruction, the nipple should only be placed once the breast shape is optimal.
Planning second stage
The first step in planning the second stage is comparison of the reconstructed breast with the opposite breast. To obtain symmetry, performing a reduction or a mastopexy on the opposite breast may be necessary. This decision is ultimately the patient's, but fortunately legislation has made reimbursement possible for surgery on the opposite breast to match the reconstructed breast.  Key measurements include nipple-to-sternal notch distance and the nipple-to-IMF distance.
In the reconstructed breast, the key measurements are the distance from the point of maximum projection (PMP) to the sternal notch, the distance from the PMP to the IMF, and the distance from the PMP to the sternal midline. In the initial procedure, placing as much volume as possible behind the PMP is important. If performing reconstruction with a prosthesis, select the projection of the implant accordingly.
In flap reconstruction, overprojection of the new breast is better than underprojection, since it is much easier to reduce and sculpt a breast that is too large than it is to augment a smaller breast. One of the advantages of flap reconstruction is the greater control it provides in shaping the new breast mound.
Management of opposite breast
In management of the opposite breast, do not assume that any large or ptotic breast requires surgery; however, it is much easier to shape the reconstructed breast to match a breast that is neither hypertrophic nor ptotic. The surgeon's preference determines the method of reduction or mastopexy.
Occasionally, more volume is needed to match the other side. The patient may not want a contralateral reduction, or the flap may have some necrosis, requiring a partial resection. As mentioned earlier, a small implant can be placed behind the flap or a latissimus flap can be transferred to fill in the defect.
Reduction of reconstructed breast
When it is necessary to reduce the reconstructed breast, the surgeon has several options. Both direct excision of excess fat and liposuction can achieve the desired result. It may be premature to recommend ultrasonic liposuction. This is an ideal time to resect areas of fat necrosis and to trim both abdominal and breast "dog ears." As previously mentioned, axillary fullness from a wide flap or from improper suture closure of the axilla is a common problem. In mild cases, liposuction and/or excision can correct this problem.
In more severe cases, dissecting the flap off the chest wall and moving it medially may be necessary. Confirm symmetry of the IMF. This often is caused by violation of this boundary during the resection. If the IMF is lower on the reconstructed side, the flap needs to be elevated and suspended along its inferior portion while the new IMF is sutured to the chest wall.
Patients undergoing delayed reconstruction deserve special mention. Because of the nature of delayed reconstruction, the skin envelope is deficient and most of the skin of the new breast consists of the skin paddle of the flap. Many of these patients lack ptosis and superior pole fullness after reconstruction. This can be avoided using a flap that initially is larger than necessary and placing a generous portion of the de-epithelialized flap in the superior pole. In a similar fashion, de-epithelialize the inferior portion of the flap and place it behind the inferior skin flap down to the IMF. If the inferior skin flap remains tight, it can be split vertically to allow the skin paddle of the flap to reach down to the IMF; this often corrects the problem.
Lumpectomy has gained popularity with oncologic surgeons, more patients are referred for evaluation of postoperative breast deformities. Large breasts can easily camouflage a lumpectomy defect with minimal cosmetic deformity, while small breasts need volume replacement. Postlumpectomy deformities can be managed in several ways. If the opposite breast is excessively large, it can be reduced while the lumpectomy deformity can be incorporated into a Wise pattern, and a small reduction can be performed to achieve symmetry.
Conversely, a small implant often can solve the problem. If the patient is opposed to prosthetic material, a latissimus flap can fill in a defect on any quadrant. The flap may use a small skin paddle to replace needed skin, or it can be de-epithelialized and buried to provide more projection. A TRAM flap seldom is needed for this purpose, because it involves too much wasted tissue and precludes a mastectomy reconstruction should the patient develop a recurrence.
Latissimus flap reconstruction
If a large amount of volume is required, the fat adjacent to the skin paddle can be incorporated onto the flap by bevelling away from the flap during the dissection.  Leave enough subdermal fat on the skin flaps at the donor site to ensure adequate wound healing. Placement of the skin paddle depends on the amount of excess skin on the patient's back and the location on the breast where the skin paddle is needed. The surgeon usually has some freedom in planning this portion of the procedure. Maximizing the mobilization of the flap by dividing the branches to the serratus muscle and the latissimus tendon at its origin is recommended.