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Background: Component separation techniques (CSTs) have allowed for midline fascial reapproximation in large midline ventral hernias. In certain cases, however, fascial apposition is not feasible, resulting in a bridged repair that is suboptimal. Previous estimates on myofascial advancement are based on hernia location and do not take into account variability between patients. Examination of preoperative computed tomography (CT) may provide insight into these variabilities and may allow for prediction of abdominal closure with CST. Study Design: A retrospective review was conducted of patients who underwent abdominal wall reconstruction from 2007 to 2012 with CST. Preoperative CT was obtained, and specific parameters were analyzed using image analysis software. Logistic regression was used to predict ideal operative closure. Multivariate analyses were adjusted for age and sex. An a priori value was set at P G 0.05. Results: Fifty-four patients met the criteria and had preoperative CT available for analysis. Forty-eight patients had fascial reapproximation achieved, whereas 6 patients had a bridged repair. Age, sex, weight, and body mass index were similar between groups (P 9 0.05). Significant differences were seen between groups in 3 variables: transverse defect size (19.8 vs 10 cm, P G 0.05), defect area (420 vs 184.2 cm 2 , P G 0.05), and percent abdominal wall defect (18.9% vs 10.6%, P G 0.05). Conclusions: Preoperative determination of abdominal wall defect ratios and hernia defect areas may represent a more accurate method to predict abdominal wall closure after CST. Predicting midline approximation after CST is critical because outcomes after bridged repair can result in higher recurrence rates.

Summary: Giant juvenile fibroadenomas are relatively rare, accounting for less than 1% fibroadenomas. Large breast tumors create significant asymmetry and provide unique reconstructive challenges after removal. In this case, we describe a 21-year-old female with delayed presentation of a giant fibroadenoma of the right breast. This represents an unusual presentation of benign breast disease requiring reduction of the skin envelope, extensive glandular resection, lower pole reconstruction, and free nipple grafting to achieve symmetry with the opposite breast. A novel modification of the Goldilocks mastectomy technique is described for partial breast reconstruction. Adaptation of the Goldilocks mastectomy technique provides adequate soft tissue for partial breast reconstruction. Using the lower pole deepithelialization breast skin flap provides autologous vascularized tissue to supplement volume loss after tumor and glandular excision. Benign breast disease can create significant breast deformities. Application and combination of the Goldilocks mastectomy technique allow for partial breast reconstruction without the need for an additional donor site or prosthetic devices.

Reduction mammaplasty can be performed with a variety of incisional patterns as well as variety of pedicle designs to maintain the vascularity of the nipple areolar complex. The inferior pedicle technique using an inverted T skin design was one of the first methods of the modern era of reduction mammaplasty. The technical aspects of this operation are important in order to reduce the incidence of adverse events. In this chapter for operative dictations, the inferior pedicle method will be described with an emphasis on preoperative markings and intraoperative technical details.

The latissimus dorsi musculocutaneous flap was one of the first described autologous options for breast reconstruction. It remains one of the common options for immediate or delayed reconstruction following mastectomy. It is usually performed as a pedicle flap and the success rate is high. It is often combined with an implant for additional volume. Another benefit is its use as a salvage procedure in the event of prior reconstructive failure or radiation therapy or device infection. An appreciation of the technical details of the operation is important in order to minimize the incidence of adverse events. This chapter in operative dictations will review the preoperative markings and the intraoperative details that will facilitate obtaining predictable and reproducible outcomes.

Nipple-sparing mastectomy and prosthetic reconstruction is a frequent option for women considering therapeutic and prophylactic mastectomy. The use of acellular dermal matrices in the setting of prosthetic breast reconstruction has facilitated the ability to achieve full coverage of the prosthetic device and provide additional tissue support. Some surgeons feel that reconstructive outcomes are improved, whereas others feel that they are not. Thus, its use is controversial for a variety of reasons that include cost, risk of adverse events, and questionable benefits. This chapter will review the indications, techniques, and outcomes associated with the use of acellular dermal matrices in the setting of nipple-sparing mastectomy and prosthetic breast reconstruction.

New technologies and innovations are common in the delivery of modern health care. Google Glass is one such device gaining increased attention in medical specialties. The authors surveyed residents and attending physicians in the Department of Plastic Surgery, MedStar Georgetown University Hospital, on their experience using Google Glass in the operating room. Ease of use, quality of images, gaze disruption, and distraction during surgery were measured. Overall, subjects found the device to be comfortable and satisfying to wear and use during surgery to capture images of good quality. Despite some identified weaknesses, Google Glass is a unique technology with a promising plastic surgical application in the operating room.

Conservative mastectomy with preservation of the nipple areolar complex is now considered a safe and effective technique in properly selected patients. Good candidates for this procedure include women with small to moderate breast volume having therapeutic or prophylactic mastectomy. Both autologous and prosthetic options are available; however prosthetic techniques are performed more frequently. Prosthetic approaches include immediate 1-stage (direct to implant) or 2-atge (tissue expander/implant) techniques. Delayed prosthetic reconstruction is also possible with conservative mastectomy. This manuscript will review the 1-stage and 2-stage methods with an emphasis on indication, surgical techniques, and outcomes.

Whole breast reconstruction using autologous tissue is the gold standard in many regions of the world. Reasons include breast replacement with native skin and fat, ability to shape and mold the tissue into a breast, no foreign materials are necessary, and it lasts forever when successful. There are now many options for autologous breast reconstruction and the decision making process regarding which flap to choose will depend on ones experience and comfort, ability to perform microvascular surgery, and the milieu in which one operates. This chapter will review many of the options for autologous breast reconstruction and provide an algorithmic approach for flap and patient selection. J. Surg. Oncol. 2016;113:865-874. © 2016 Wiley Periodicals, Inc.

Prosthetic breast reconstruction using acellular dermal matrix is currently used by many plastic surgeons. As our understanding of these matrices expands, our results and outcomes are becoming more reproducible and predictable. As with most new technologies, there is a learning curve associated with using acellular dermal matrix. There are principles and concepts that should be heeded when considering their use. The purpose of this article is to review some of the important principles and concepts to improve our understanding of how these matrices perform and what can be expected of them.

Component separation (CS) is an effective technique for complex abdominal wall reconstruction (AWR). Reinforcement of the repair with mesh can add durability. The purpose of this study was to evaluate the indications and outcomes following CS combined with a porcine acellular dermal matrix (PADM) for reinforcement.A retrospective review of all patients who underwent complex AWR at the authors' institution was completed between 2007 and 2010. Patients with complex hernias who underwent CS in conjunction with PADM as an underlay were included. The PADM used in this cohort was Strattice (LifeCell Corporation, Branchburg, NJ). Patient demographics, indications, perioperative details, postoperative care, and long-term outcomes were reviewed.A total of 78 patients were identified as having PADM implanted for AWR. Of this cohort, 41 patients met the criteria as having a CS to achieve midline closure, with the PADM placed as reinforcement in an underlay manner. These patients were classified as grade II (33; 80.5%), grade III (4; 9.8%), and grade IV (4; 9.8%). Average patient age was 57.6 years (range, 33-80), and average body mass index (BMI) was 35.8 kg/m2 (range, 21.6-52.1). Patient comorbidities included coronary artery disease (19; 46.3%), diabetes mellitus (14; 34.2%), chronic obstructive pulmonary disease (COPD) (6; 14.6%), and chronic steroid use (2; 4.9%). Previous mesh infection occurred in 9 (28.1%). The mean defect diameter was found to be 14.3 cm. Perforator preservation of the subcutaneous flaps was performed in 34 (82.9%) patients. A concomitant panniculectomy was performed in 9 (22%) patients. A staged approach was used in 3 (7.3%) patients. The overall complication rate was 24.4%. Strattice exposure occurred in 5 (12.2%) patients. All patients went on to heal wounds without explantation.No hernia recurrences or symptomatic bulges were observed in the follow-up period of 474 days (range, 194-1017 days). No significant predictors of complications were identified.Strattice is an effective adjunct to AWR when used as reinforcement during CS for a wide variety of indications. Complication rates remain low in complex patients. In addition, Strattice appears to add durability to midline reconstructions with no recurrences during the follow-up period.

Acellular dermal matrices (ADM) have generated interest for their possible applications in secondary revisions following prosthetic breast reconstruction. These materials can be effective in a variety of situations, including implant displacement, synmastia, capsular contracture, incisional support, and pocket conversion. ADM can also be placed in the setting of delayed breast reconstruction and to augment nipple projection. These biomaterials have demonstrated feasibility and success for many complex deformities. However, there is an associated learning curve that includes an understanding of proper technique and patient selection. The authors review their cumulative experience between 2004 and 2010 with ADM for the correction of secondary deformities following prosthetic breast reconstruction, focusing on the indications for repair, traditional management, and management with ADM.

Background:Oncoplastic reduction mammaplasty offers patients breast conservation with the added benefit of functional improvement in symptoms related to macromastia. The reduction can be performed in the immediate setting with the lumpectomy, in a staged-immediate fashion after final pathology has b

Breast reconstruction has become an important consideration for women after mastectomy. Over the past decade, there have been a variety of technological advancements that have facilitated the ability to deliver reproducible and predictable outcomes with autologous breast reconstruction. This article chronicles many of the technological advancements and reviews the current toolbox that surgeons now have at their disposal when performing autologous reconstruction. It focuses on preoperative, intraoperative, and postoperative tools that have enabled the achievement of more reliable and predictable outcomes, especially in the setting of microvascular breast reconstruction.

LEARNING OBJECTIONS: After reviewing this article, the participant should be able to: 1. Appreciate the diversity of approaches for the correction of breast deformities and mastopexy. 2. Review the salient literature. 3. Understand patient selection criteria and indications.Breast deformities and mastopexy continue to challenge plastic surgeons. Deformities such as Poland syndrome, tuberous breast, gynecomastia, and other congenital conditions are uncommon; therefore, management experience is often limited. Various techniques have been described, with no general consensus regarding optimal management. Mastopexy has become more common and is performed both with and without augmentation mammaplasty. However, a variety of techniques are available, and a thorough understanding of the indications, patient selection criteria, and techniques is important to optimize outcomes. This article will review these and other conditions to provide a better understanding of the current available data and evidence for these operations.

As rates of bilateral prophylactic mastectomy and contralateral prophylactic mastectomy have increased over the past decade, bilateral microvascular breast reconstruction has played an increasing role in breast cancer care. Data on unilateral flap failure in bilateral microvascular breast reconstructions have been lacking, and strategies to address the challenges encountered in this situation are needed.A retrospective review of all simultaneous bilateral microvascular breast reconstructions performed by the senior author (M.Y.N.) from July of 1999 to July of 2008 was conducted. Flap failures were identified and reviewed for operative parameters, causes of flap loss, and techniques used for secondary reconstruction.The authors identified 171 consecutive patients who underwent bilateral microvascular breast reconstruction between July of 1999 and July of 2008. In these patients, 342 flaps were attempted, including 108 free transverse rectus abdominis musculocutaneous flaps, 228 deep inferior epigastric artery perforator flaps, and six superior gluteal artery perforator flaps. Twelve flaps failed or were aborted intraoperatively, yielding an overall failure rate of 3.5 percent. The authors' unilateral microsurgical breast reconstruction failure rate over this period was 2.1 percent (eight of 386). No bilateral failures occurred. Causes of flap failure included venous insufficiency (six of 12), lack of adequate perforator anatomy (three of 12), and perforator injury during dissection (two of 12). Secondary reconstruction with tissue expanders and implants was performed in 11 of 12 patients who underwent an average of 2.25 additional procedures to complete reconstruction.Flap failure is more common in bilateral reconstructions than in unilateral reconstructions, largely secondary to the obligation to use both sides of the abdominal donor tissue. When flap failure does occur, techniques to optimize prosthetic reconstruction can ultimately result in successful bilateral reconstructions despite free flap failure.

The performance of AlloDerm (LifeCell Corp., Branchburg, N.J.) in the setting of prosthetic breast reconstruction, infection, and radiation therapy has not been well documented. The purpose of this study was to review the author's experience with AlloDerm-assisted prosthetic breast surgery and determine the tolerance in the setting of infection and irradiation.A total of 361 women and 476 breasts underwent reconstruction or revision with prosthetic devices. Of these, 76 women and 100 breasts underwent reconstruction using AlloDerm assistance.The incidence of postoperative infection was 5.85 percent (22 of 376) when prosthetic devices were used without AlloDerm and 5 percent (five of 100) when prosthetic devices were used with AlloDerm. Radiation therapy was a factor in 23 of 100 breasts reconstructed with AlloDerm. Adherence of AlloDerm was noted in 100 percent (23 of 23) and infection was noted in 8.7 percent (two of 23). The timing of irradiation (before or after AlloDerm insertion) did not affect the adherence or the infection rate. The overall incidence of seroma was 5 percent, the incidence of skin necrosis was 3 percent, and the incidence of incisional dehiscence was 4 percent.This study demonstrates that prosthetic breast surgery using AlloDerm is safe and well-tolerated. AlloDerm viability has been demonstrated in the setting of infection and radiation therapy. The risk of prosthetic breast infection in the setting with AlloDerm is no different from in the setting without AlloDerm. Local complications such as dehiscence, skin necrosis, and seroma formation can occur in accordance with radiotherapy.

The importance of symmetry after unilateral breast reconstruction is becoming increasingly realized and important. As our reconstructive options have increased and our technical abilities have improved, the expectations of women with breast cancer have been enhanced by virtue of the fact that we are often able to reconstruct a breast with natural volume and contour. When embarking on a unilateral breast reconstruction, the plastic surgeon has several goals and one of which is to obtain breast symmetry. In many circumstances, breast symmetry is achieved without operating on the contralateral breast; however, in some cases, a contralateral operation will be necessary. This is usually based on the volume, contour, and position of the natural and reconstructed breast. Often, the need and/or desire for a contralateral procedure will be evident during the initial consultation. Otherwise, the need for a contralateral procedure will not be evident until after the primary reconstruction has been completed. In either case, it is important for plastic surgeons to be aware of the incidence of these procedures and the options available to them.

Current indications for radiation therapy in women with breast cancer are controversial and continue to be modified. Current indications for breast reconstruction in the setting of radiation therapy are also controversial and poorly defined. The purpose of this study is to analyze oncologic outcomes following various methods of breast reconstruction in the setting of radiation therapy. A retrospective review of 676 women who had breast reconstruction following mastectomy was completed. A total of 146 women had breast reconstruction either before or after radiation therapy and were analyzed. Response variables included tumor recurrence and patient demise for patients having autologous and prosthetic reconstruction. Explanatory variables included patient age, cancer stage, radiation therapy, diabetes mellitus, and tobacco use. Recurrence of tumor occurred in 29 of 146 women (19.8%), of which 27% was when radiation followed reconstruction and 14.9% was when radiation preceded reconstruction. Patient demise occurred in 8.9%, of which 11.9% was when radiation followed reconstruction and 6.9% was when radiation preceded reconstruction. The difference in tumor recurrence in the setting of radiation therapy before or after breast reconstruction was significant for autologous (P = 0.0146) and prosthetic (P = 0.0424) reconstruction. The difference in patient demise was significant for autologous reconstruction (P = 0.0380) but not for prosthetic reconstruction (P = 0.2827). These results imply that tumor recurrence and patient demise may be increased when radiation therapy is performed following breast reconstruction. The need for a prospective inquiry is validated.

The etiology, diagnosis, and management of diastasis recti is now well understood and has demonstrated predictable and reproducible success. Multiparous women are at highest risk for developing diastasis recti. Diagnosis is easily made by clinical examination and symptomology and characterized by a midline abdominal bulge without a fascial defect. Classification systems have been proposed and based on the degree of rectus abdominis separation and myofascial deformity. Management options vary and will depend on the degree of separation between the rectus abdominis muscles. Simple plication has been effective for mild to moderate diastasis. The use of resorbable or nonresorbable mesh places as an onlay or in the retrorectus space has been effective for moderate-to-severe diastasis. The use of laparoscopic or endoscopic techniques can also be considered in select situations.

Background: Secondary operations of the anterior abdominal wall following breast reconstruction with abdominal flaps are sometimes performed to improve outcome. The purpose of this study was to review a single surgeon's experience with secondary abdominal wall operations following breast reconstruction with the deep inferior epigastric perforator (DIEP) and free transverse rectus abdominis musculocutaneous (TRAM) flaps. Methods: Over a 7-year period, 330 women had microvascular breast reconstruction using abdominal flaps. Indications for secondary abdominal operations that were considered necessary included bulge, abdominal skin necrosis (wound), hematoma, neuroma, and seroma. Indications that were considered elective included lateral dog-ear scars and lipodystrophy. Mean follow-up time was 40 months (range, 3 to 84 months). Results: Secondary abdominal operations were performed in 59 women (17.9 percent). The cumulative number of indications was 64. The indications were considered necessary in 33 women (10 percent) and elective in 31 women (9.4 percent). Lower abdominal bulge was the most common necessary indication and was repaired in 9.3 percent of free TRAM flaps and 4.7 percent of DIEP flaps. Dog-ear scars were the most common elective indication and were revised in 29 women (8.8 percent). Neuromas of the anterior abdominal wall were diagnosed in three women (0.9 percent). Secondary procedures for indications with a low frequency included skin necrosis (n = 3), hematoma (n = 3), seroma (n = 1), and lipodystrophy (n = 2). Conclusions: The incidence of secondary procedures of the abdominal wall following microvascular breast reconstruction using abdominal flaps approximates 20 percent, with an equal distribution between necessary and elective procedures. Women considering breast reconstruction using a free TRAM or DIEP flap should be advised of these statistics.

Creation of the nipple-areolar complex is the final and important component of the breast reconstruction process. Various techniques using a variety of local flaps are available. This article covers the pre- and postoperative care of the woman having nipple reconstruction, reviews the author's preferred techniques, discusses the use of supplemental materials for nipple augmentation, and comments on the common complications.

The impact of adjuvant therapy on the surgical outcomes following breast reconstruction is poorly understood. The purpose of this systematic review was to evaluate surgical outcomes following autologous and prosthetic reconstruction in the setting of post-mastectomy radiation therapy (PMRT) and adjuvant chemotherapy.A systematic review of the English literature published from 2000 to 2015 in the Pubmed/MEDLINE database was performed to identify all manuscripts reporting outcome of breast reconstruction in patients receiving PMRT and/or adjuvant chemotherapy.Sixty-two manuscripts met the criteria for inclusion. This included 56 manuscripts (5437 patients) evaluating patients treated with PMRT and 11 manuscripts (820 patients) evaluating patients treated with chemotherapy. Pooled analysis of the PMRT cohort revealed significantly higher weighted incidences of re-operation (P 0.0001), total complications (P 0.0001), and reconstructive failure (P 0.0001) in prosthetic reconstruction compared to autologous. There was little evidence to suggest that postoperative chemotherapy is associated with poorer overall outcomes.PMRT was associated with an increased incidence of adverse events when compared to chemotherapy. There was little evidence to suggest that adverse events following breast reconstruction were related to adjuvant chemotherapy. Manipulating the method and timing of reconstruction may mitigate some of the undesirable outcomes associated with PMRT.

Background: AlloDerm, a human acellular dermal matrix, is available in a ready-to-use (RTU) or freeze-dried (FD) form. A limited number of studies have compared complication rates between RTU and FD in implant-based breast reconstruction. The objective of this report was to conduct a meta-analysis of previously reported complication rates between RTU and FD. Methods: A systematic literature review was conducted from 2010 to 2014 and supplemented by hand searches. Included studies compared both RTU and FD. Odds ratios and relative risks (RRs) with 95% confidence interval (CI), taking into account study heterogeneity, were calculated. Studies reporting patient-level results as opposed to breast-level results were excluded from the primary analysis but included in subsequent sensitivity analyses. Variable follow-up time within and between studies was also considered in a sensitivity analysis. Results: Of the 275 identified studies, 115 studies were eligible for detailed review. Only 5 studies compared RTU with FD, and of these, 2 studies had breast-level data and 1 study had patient-level data appropriate for meta-analysis. The 2 studies included in the primary meta-analysis had a pooled sample size: n = 116 RTU and n = 109 FD patients, or 205 and 186 breasts, respectively. Age and body mass index were similar between groups. Across all meta-analyses, there were no differences in complication rates between RTU and FD: cellulitis (RR = 0.863; 95% CI, 0.272–2.740), seroma (RR = 0.553; 95% CI, 0.026–11.830), and explantation (RR = 0.593; 95% CI, 0.247–1.425). Results remained nonsignificant even after adjustment for variable follow-up time. Conclusion: The results suggest that there are no differences in complication rates between RTU and FD forms.

Background The deep inferior epigastric perforator (DIEP) flap has gained notoriety because of its proposed benefit in decreasing donor-site morbidity but has been associated with longer operative times, higher perfusion-related complications, and increased cost relative to muscle-sparing free transverse rectus abdominis myocutaneous (TRAM) flaps. The authors performed the first cost-utility analysis examining the cost effectiveness of DIEP flaps relative to muscle-sparing free TRAM flaps in women who underwent mastectomy. Methods A comprehensive literature review was conducted using the MED- LINE, Embase, and Cochrane library databases to include studies directly comparing DIEP to muscle-sparing free TRAM flaps in matched patient cohorts. Eight studies were included, examining 740 DIEP flaps and 807 muscle-sparing free TRAM flaps. Costs were derived adopting both societal and third-party payer perspectives. Utilities were derived from a previous cost-utility analysis. Probabilities of clinically relevant complications were combined with cost and utility estimates to fit into a decision tree analysis. Results The overall complication rates were 24.7 percent and 21.8 percent for DIEP and muscle-sparing free TRAM flaps, respectively. The authors' baseline analysis using Medicare reimbursement revealed a cost decrease of $69.42 and a clinical benefit of 0.0035 quality-adjusted life-year when performing DIEP flap surgery relative to muscle-sparing free TRAM flap surgery, yielding an incremental cost-utility ratio of -$19,834.29. When using societal costs, the incremental cost-utility ratio increased to $87,800. Conclusion DIEP flaps are cost effective relative to muscle-sparing free TRAM flaps when patients are carefully selected based on perforator anatomy and surgery is performed by experienced surgeons.

Background Subcutaneous mastectomy for women with advanced breast cancer has been historically controversial because of the increased risk for tumor recurrence. Despite this, some women remain interested in this method of treatment as a means of preserving the appearance of the breast and nipple-areola complex. Several studies have evaluated the feasibility of subcutaneous mastectomy; however, there has been no study that has critically analyzed the aesthetic outcome of the nipple-areola complex following this approach. Methods Over a 14-month interval, 12 women had subcutaneous mastectomy with preservation of the nipple-areola complex. The reconstruction was unilateral in 10 women and bilateral in two women, totaling 14 breasts. The mastectomy was for cancer in 11 and for prophylaxis in three breasts. Outcomes were assessed based on the sensation, appearance, and secondary procedures of the nipple-areola complex, and tumor recurrence and patient satisfaction. Results Of the five parameters, sensation was present in six breasts (42.9 percent), delayed healing was noted in four breasts (28.6 percent), symmetry with the contralateral breast was achieved in five of 10 women (50 percent) following unilateral reconstruction, tumor recurrence was noted in three of 11 breasts (27.3 percent), and secondary procedures related to the nipple-areola complex were necessary in five of the 14 breasts (35.7 percent). Outcome was graded as excellent in three, good in eight, and poor in three breasts. Conclusion This study has demonstrated that aesthetic outcome of the nipple-areola complex is variable following subcutaneous mastectomy and immediate breast reconstruction. However, patient satisfaction was graded as good to excellent in 11 of 14 breasts (78.6 percent). Subcutaneous mastectomy with flap reconstruction results in fewer secondary procedures and improved aesthetic outcome when compared with implant reconstruction.

Microsurgeons currently employ the internal mammary artery and vein as recipient vessels for microvascular reconstruction of the breast with increasing frequency. Recent reports have demonstrated that the perforating branches of the internal mammary artery and vein can also be used as recipient vessels. The purpose of the following cadaver study was to determine the location and diameter of these internal mammary perforators and whether they are suitable as recipient vessels. Ten fresh cadavers were obtained for this project. Using a micrometer under loupe magnification, bilateral measurements were taken of the perforators from the first five interspaces. The largest arterial perforator averaged 1.74 mm in diameter and the largest venous perforator averaged 1.78 mm in diameter. The largest perforators were most commonly found in the second interspace. Based on the results of this study, the internal mammary perforators appear to have suitable diameter for microvascular anastomosis and should be considered.

The surgical management of melanoma continues to evolve. A large body of information serves as a foundation for the oncologic principles, surgical excisions, and reconstructive methodologies that are currently in use. This article serves as a guide for the physician considering surgical management of the melanoma patient.

The etiology of lower abdominal bulge following breast reconstruction with the DIEP flap is uncertain. Most studies report an incidence that ranges from 0.7% to 5%. The purpose of this study was to review a set of factors that may predispose to a lower abdominal bulge. This was a retrospective review of 123 women who had breast reconstruction with the DIEP flap over a 4-year period. The reconstruction was unilateral in 93 women and bilateral in 30 women, totaling 153 flaps. Etiologic factors that were evaluated included patient age, diabetes mellitus, tobacco use, previous abdominal operations, unilateral or bilateral reconstruction, previous childbirth, aponeurotic plication to improve the natural abdominal contour, and use of Marlex mesh. A lower abdominal bulge occurred in 5 of the 123 women (4%), 2 following 30 bilateral reconstructions (6.6%) and 3 following 93 unilateral reconstructions (3.2%). Analysis of the factors for all women demonstrated diabetes mellitus in 1 (0.8%), tobacco use in 9 (7.3%), a prior abdominal operation in 55 (44.7%), previous childbirth in 95 (77%), aponeurotic plication in 49 (40%), and use of Marlex mesh in 4 (3.3%). Statistical analysis did not show any significant association between the explanatory factors and the occurrence of a lower abdominal bulge, except for a weak trend in women who had not been pregnant (P = 0.08). The results of this study demonstrate that the occurrence of a lower abdominal bulge following the DIEP flap is a random event that can occur in anyone. Pregnancy may confer a preventative effect as the collagen fibers strengthen to overcome the stretching forces. Techniques for prevention and treatment include intraoperative assessment of the anterior rectus sheath, use of an adjuvant material for reinforcement if unstable, and vertical plication for bulge repair.

Pregnancy following abdominal flap-based breast reconstruction may cause stress to the abdominal wall. These changes may result in weakness and hernia or bulge. We present two patients who previously underwent unilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction and became pregnant twice. Both patients maintained abdominal contour without bulges or hernias. Subjectively, patients reported minor changes to abdominal strength. Therefore, these two patients had minimal abdominal morbidity following pregnancy after unilateral DIEP flap reconstruction.

Clinical applications for the internal mammary artery include use as an arterial conduit for coronary revascularization and as a recipient artery for microvascular reconstruction of the breast. This study was completed in an attempt to resolve the controversy over which indication should have priority. Five hundred twenty women with breast cancer who underwent breast reconstruction were reviewed. Of these, 240 were 50 years of age or more and were evaluated for cardiac disease. Three components were studied that included analysis of factors related to cardiac function (prior cardiac surgery, specific cardiac disorders, and cardiac medications), analysis of risk factors related to cardiac disease (hypertension, diabetes mellitus, and tobacco use), and analysis of factors related to the reconstruction (selection of recipient vessels, type of reconstruction). The women were stratified based on age-50 to 59 years, 60 to 69 years, and older than 70 years-to analyze trends based on advancing age. Results demonstrated that the incidence of coronary artery disease was 2 in 240 women (0.8%) and that the incidence of factors related to cardiac function and the incidence of risk factors related to cardiac disease appear to increase with advancing age. The internal mammary vessels were used in 35 of 114 free tissue transfers with no adverse sequelae. No woman in whom the internal mammary artery was used has developed coronary artery disease. The 2 women with coronary artery disease were reconstructed with implants. Based on the results of this study, the author thinks that use of the internal mammary artery as a recipient vessel for microvascular reconstruction of the breast is justified. Options for future coronary revascularization would include the opposite internal mammary artery when available, a saphenous vein graft, or angioplasty.

Background: Although many techniques of reduction mammaplasty are currently in use, a prospective study quantitating the sensation of the nipple-areolar complex (NAC) after the performance of specific techniques has not been performed. Objective: The purpose of this study was to quantitate the postoperative sensation of the NAC after reduction mammaplasty and to compare the results on the basis of the orientation of the vascularized pedicle. Methods: We tested 42 patients divided into 4 groups: medial pedicle (9 patients), inferior pedicle (8 patients), free nipple transfer (8 patients), and a control group (17 patients). The specific mammaplasty technique chosen was based on the preoperative assessment and the estimated volume of resection. A Wise pattern approach was used in all cases. NAC sensation was quantified with the use of the Pressure Specified Sensory Device (Sensory Management Services LLC, Baltimore, MD). Results: We detected no significant difference in the volume of reduction between the free nipple group and the medial pedicle group (P =.14). NAC sensation in the free nipple transfer group was significantly lower than either of the pedicle techniques and control group in all areas of testing (P < 0.001), whereas the medial and inferior pedicle groups had no significant sensory differences in NAC sensation (P < 0.001). Conclusions: The medial pedicle technique is safe and reliable and can be used for large-volume reduction mammaplasty to optimize sensation of the NAC.