Breast Reconstruction with Autologous Tissue

Breast Reconstruction with Autologous Tissue

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Breast Reconstruction with Autologous Tissue Stephen S. Kroll, M.D. M.D. Anderson Cancer Center Department of Plastic Surgery The University of Texas Houston, Texas USA With 621 Illustrations 0 Springer

Stephen S. Kroll, M.D. M.D. Anderson Cancer Center Department of Plastic Surgery The University of Texas 1515 Holcombe Boulevard Houston, TX 77030 USA Cover photo: Marble Amazon, 430 BC/ The Granger Collection, Ltd. Library of Congress Cataloging-in-Publication Data Kroll, Stephen S. Breast reconstruction with autologous tissue / Stephen S. Kroll. p. cm. Includes bibliographical references and index. ISBN 0-387-98670-7 (hardcover alk. paper) 1. Mammaplasty. 2. Flaps (Surgery) I. Title. [DNLM: 1. Mammaplasty methods. 2. Tissue Transplantation methods. 3. Surgical Flaps. WP 910 K93a 2000] RD539.8.K76 2000 618.1 90592 dc21 98-51594 Printed on acid-free paper. 2000 Springer-Verlag New York, Inc. All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer-Verlag New York, Inc., 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use of general descriptive names, trade names, trademarks, etc., in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Production coordinated by WordCrafters Editorial Services, Inc., and managed by Lesley Poliner; manufacturing supervised by Rhea Talbert. Typeset by Matrix Publishing Services, Inc., York, PA. Printed and bound by Maple-Vail Book Manufacturing Group, York, PA. Printed in United States of America. 987654321 ISBN 0-387-98670-7 Springer-Verlag New York Berlin Heidelberg SPIN 10699039

Preface Plastic surgery is a unique specialty that is composed of two parts: engineering and art. The engineering part is concerned with transferring tissues, keeping those tissues alive while they are healing, and minimizing donor site morbidity. This part of plastic surgery is interesting and challenging but is, in many ways, not so different from other surgical specialties. What is unique about plastic surgery is its artistic aspect: turning a flap that used to be a forehead into something that truly looks like a nose, or turning a transverse rectus abdominis myocutaneous (TRAM) flap into a breast. It is this artistry that makes successful plastic surgeons stand out from their peers. It is this artistic aspect of breast reconstruction that this book addresses. Many books already exist about flaps, breast surgery, and breast reconstruction. This book is not meant to replace them. What is unique about this book is its focus on artistry. Before now, very little has been written on the artistic aspects of breast reconstruction. What this book provides possibly for the first time is some basic principles for transferring, shaping, and revising a TRAM (or other autologous tissue flap) so that it really looks like a breast that matches its opposite counterpart. As such, this book is intended to help improve the aesthetic quality of the reader s results, whatever the current level of those results might be. Although this book includes chapters on the fundamentals of breast reconstruction and is therefore suitable for the beginning surgeon, the intended target audience is the more experienced surgeon who seeks superior aesthetic outcomes. The chapters on the free TRAM flap, breast shaping, breast revision, surgery of the opposite breast, and nipple reconstruction will be of special interest to such individuals. Although certain opinions presented here may change in years to come (or be disagreed with by some even today), I believe that everyone who performs breast reconstruction will find something useful here. Who then should read this book? This book is for surgeons who believe in the importance of breast reconstruction and care about aesthetic outcomes. It is for surgeons who believe that they can improve and learn more about their art. It is for surgeons who want to do as much as they can to help their patients. If you are such a surgeon, this book was written for you. Stephen S. Kroll, M.D. M.D. Anderson Cancer Center The University of Texas

Contents Preface v 1 Goals of Breast Reconstruction 1 2 Why Autologous Tissue? 7 3 Why Use Free Flaps? 17 4 Immediate Breast Reconstruction 29 5 Delayed Breast Reconstruction 41 6 Bilateral Breast Reconstruction 53 7 Choice of Technique 69 8 Conventional (Pedicled) TRAM Flap 83 9 Free TRAM Flap 101 10 Deep Inferior Epigastric Perforator Flap 133 11 TRAM Flap Postoperative Care and Complications 143 12 The Extended Latissimus Dorsi Myocutaneous Flap 161 13 The Superior Gluteal Free Flap 179 14 The Inferior Gluteal Free Flap 191 15 The Rubens Fat Pad Free Flap 201 16 Shaping the Breast Mound in Immediate Reconstruction 211 17 Shaping the Breast Mound in Delayed Reconstruction 237 18 Shaping the Breast Mounds in Bilateral TRAM Flap Breast Reconstruction 259 19 Correction of Partial Mastectomy Defects 273 20 Breast Mound Revision Surgery 293 21 The Opposite Breast 313

viii CONTENTS 22 Nipple and Areolar Reconstruction 327 23 Follow-Up of TRAM Flap Breast Reconstruction Patients 347 Index 365