51
CLINICS IN
Partial Mastectomy Reconstruction
Moustapha Hamdi, MD, FCCPa,*, James Wolfli,
Koenraad Van Landuyt, MD, FCCPa
- Oncologic outcome of partial mastectomy
Why do we need reconstructive
procedures in BCT?
- Partial mastectomy reconstruction
The treatment of breast cancer is an evolving
field. Different modalities are continuously being
developed to maximize patient survival while min-
imizing the treatment’s morbidity [1]. Currently,
the two main options for the management of pri-
mary breast cancer are total mastectomy and partial
mastectomy with radiation. Although partial mas-
tectomies (lumpectomy or quadrantectomy) con-
serve the nipple and areola complex (NAC) and
native breast tissue, asymmetry and distortion of
the breast can still occur. Many methods of recon-
struction have been described. The early and long-
term effects of radiation also contribute to the
complexity of these cases. This article reviews
breast-conserving therapy (BCT), reconstruction
options, and outcomes.
Oncologic outcome of partial mastectomy
Conservative surgery followed by breast irradiation
has replaced modified radical mastectomy as the
preferred treatment for early-stage invasive breast
cancer. The 5-year survival of partial mastectomy
with radiation is not statistically different when
compared with mastectomy alone in patients with
Stage I or II breast cancer [2]. Studies have shown
a
Plastic and Reconstructive Surgery Department, Gent University Hospital, De Pintelaan 185, B-9000, Gent,
Belgium
b
Plastic Surgery Department, Grey Nuns Hospital, 218 Meadowlark Health Centre, 156 Street & 87 Ave.,
Edmonton, AB, T5R 5W9 Canada
* Corresponding author.
E-mail address: moustapha.hamdi@ugent.be (M. Hamdi).
0094-1298/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
PLASTIC
SURGERY
Clin Plastic Surg 34 (2007) 51–62
MD
a,b
,
Delayed reconstruction
Immediate reconstruction
- Summary
- References
that women diagnosed at early stages of invasive
breast cancer have equivalent outcomes when
they are treated with lumpectomy and radiation
therapy or modified radical mastectomy [2–4].
Partial mastectomy includes quadrantectomy
and lumpectomy. In quadrantectomy, a wide exci-
sion is performed, including skin and underlying
muscle fascia. In lumpectomy, the goal is tumor ex-
cision with clear surgical margins. The 5-year inci-
dence of in-breast tumor recurrence was higher in
lumpectomy-and-radiation patients than in quad-
rantectomy-and-radiation patients (8.1% versus
3.1%) [2]. The incidence of local recurrence de-
pends upon the tumor margin, histology, radiation
therapy, and patient age (higher rate of recurrence
in age <60). Most local recurrences occur at the
site of initial tumor excision (57%–88%) or in the
same breast quadrant (22%–28%). Duo novo ipsi-
lateral breast cancer makes up about 10% to 12% of
in-breast tumor recurrences [4]. In general, during
the first 10 years after lumpectomy with radiation
the recurrence rate is 1.4% per year. The treatment
of in-breast tumor recurrence in most patients is
completion mastectomy [5]. A surgical dilemma
in breast cancer treatment arises because, on the
one hand, the surgeon needs a wider excision to
doi:10.1016/j.cps.2006.11.007
52 Hamdi et al
provide clear margins and better local control of
disease; but, on the other hand, the surgeon wants
to spare as much tissue as possible for defect closure
and make the resulting aesthetic outcome as favor-
able as possible [6].
Why do we need reconstructive
procedures in BCT?
Approximately 10% to 30% of patients are dissatis-
fied with the aesthetic result after partial mastec-
tomy with radiation [7]. There are many possible
causes of aesthetic failure. Tumor resection can
produce distortion, retraction, and noticeable vol-
ume changes in the breast. Changes to the position
of the NAC can extenuate asymmetry. Radiation
can also have a profound effect on the native
breast. Initially, radiation causes generalized breast
edema and skin erythema. Long-term effects of ra-
diation to the breast skin include hyperpigmenta-
tion, hypopigmentation, telangiectasia, and
atrophy. In the breast parenchyma, radiation
causes fibrosis and retraction. For most patients, ra-
diation-induced changes plateau 1 to 3 years after
treatment. Unfortunately, it is difficult to predict
who will develop the most severe postradiation
changes [8,9].
Partial mastectomy reconstruction
Reconstruction of partial mastectomies can either
be delayed or immediate. In delayed reconstruc-
tion, the surgeon waits until the postoperative
changes in the deformed breast stabilize (6–12
months). In immediate cases, the goal is to avoid
breast deformity by performing reconstruction con-
currently with the partial mastectomy.
Fig. 1. A 58-year-old patient presented breast asymmetry after BCT on the right breast. Resection of the tumor,
which was located at the junction of superior quadrants, resulted in smaller breast with upward retraction
(grade I in Clough’s classification). A contralateral breast reduction provided adequate matching procedure.
(A) Preoperative view. (B) Postoperative result.
Delayed reconstruction
Classifications of post-BCT deformities
The cosmetic result of BCT depends largely on the
longevity of the follow-up. Edema that occurs
most commonly during the first year after surgery
and irradiation may mask some of the loss of breast
volume. Established scar tissue and progressive
fibrosis will lead to different breast contour defor-
mities and NAC displacement. The original loca-
tion of the tumor is also a significant factor.
Tumors located within the superolateral quadrant
give lateral distortion of the breast gland, or the
NAC, or both. Meanwhile, tumors located centrally
or superiorly lead to retraction and upward disloca-
tion of the whole breast.
Several classification schemes have been devel-
oped to characterize delayed breast deformity and
suggest reconstructive options. Berrino and col-
leagues’ [10] morphologic classification system un-
derscores the importance of analyzing the etiology
of the deformity. In type I, the deformity results
from fibrosis and scar contracture. Displacement
of the NAC is often present. In type II, there is a lo-
calized deficiency of tissue (skin, or parenchyma, or
both). Type III has generalized breast retraction
with normal overlying skin. This is most often sec-
ondary to radiation in patients with large, ptotic
breasts. Finally, type-IV deformity results from se-
vere radiotoxicity. There is significant parenchymal
retraction and distortion, and the skin has dramatic
radiation-induced changes. The NAC is often
displaced.
Clough and colleagues’ [11] classification is based
on response to reconstruction. Patients with a type-
I breast deformity have a normal-appearing breast
with no deformity (Fig. 1A). However, there is
asymmetry in the volume or shape between breasts.
These patients were primarily treated with

contralateral breast surgery (Fig. 1B). Type-II pa-
tients have deformed breasts. The deformity, how-
ever, is deemed correctable primarily via ipsilateral
breast surgery (Figs. 2 and 3) or flap reconstruction
(Fig. 4). Type-III patients have either major defor-
mity or diffuse painful fibrosis of the treated breast.
These patients were treated with total mastectomy
and reconstruction.
Clinical approach to patients with post-BCT
defects
Failure of the BCT is defined by of one or more of
the following:
1. Breast deformity
2. Tumor recurrence
3. Postirradiation pain
Every plastic surgeon has experienced a patient’s
emotional stress and her disappointment after the
BCT. The patient’s cosmetic expectations are usually
higher than during cancer treatment. In approach-
ing post-BCT deformity, several points must be
taken into consideration:
The choices of repair methods and techniques
available in operated–irradiated breasts are
clearly reduced because of the reduced breast
volume and of the scar tissue.
Postradiation sequelae make any salvage proce-
dure technically more difficult with an out-
come that is less predictable.
Fig. 2. A 41-year-old patient who had a BCT left with retro-areolar defect on the right breast with mild breast
deformity (Clough’s grade II). (A and B) Preoperative views. (C) Vertical scar mastopoxy consisted of careful gland
plicature covered with dermal flap to enhance vascularization and skin tightening without skin undermining.
Similar procedure associated with 40-g gland resection was done at the left side. (D and E) Postoperative views
at 1 year after surgery.
Partial Mastectomy Reconstruction 53
Like in any reconstructive method, reoperative
breast surgery has to be more carefully planned
and executed on an individual basis. Before surgery,
records of previous procedures and treatments
should be reviewed. The clinical evaluation should
examine the breast deformity with its several com-
ponents. Skin deficiency may not always be obvious
but some kind of skin correction will be needed due
to skin retraction and scar tissue in almost every
case. Any postradiation skin alternations should
be noted since it reflects the degree of parenchymal
damage. It is difficult though to estimate the re-
quired amount of skin tissue to repair the defect.
Nevertheless, severe NAC distortion is a marker
for the need of a large skin component.
Before considering any treatment, relapse of dis-
ease should be ruled out. A recent general and local
checkup is mandatory to determine the oncologic
status of the patients. Pain may improve after surgi-
cal correction. However, no surgical method can
guarantee total pain relief. Rehabilitation programs
may be necessary to achieve better outcome.
The choice of reconstructive method
Performing extensive surgical manipulation of the
irradiated breast must be considered with great
trepidation. High complication rates have been re-
ported with attempted manipulation of the irradi-
ated breast [12]. Patients who underwent either
local tissue rearrangement or reduction mammo-
plasty of the irradiated breast had complication
54 Hamdi et al
Fig. 3. A 45-year-old patient present lower-pole deformity post-BCT of the right breast (Clough’s grade II). A bi-
lateral matching mammaplasty similar to the procedure described in Fig. 2 was performed. (A, B, and C) preop-
erative views. (D, E, and F) postoperative results.
rates of up to 50% [13]. Complications, including
wound dehiscence, fat necrosis, skin necrosis, and
nipple necrosis, may occur and the risks of such
complications should be discussed with the patient.
In addition, the final aesthetic results of these cases
were also poor, and tended to worsen over time
[12]. Therefore, attempts to correct these defects lo-
cally must be limited to minor asymmetry, which
may be solved by scar correction or Z-plasty
procedure.
The contralateral breast is usually larger and
more ptotic after partial mastectomy with radiation.
When no frank deformity exists on the treated
breast, procedures, such as reduction mammo-
plasty or mastopexy performed on the nonirradi-
ated breast, are excellent options to create
symmetry between breasts (see Fig. 1). When
mild radiation sequelae are observed, a bilateral
matching procedure can be done. Nevertheless,
techniques in mammaplasty should be adapted to
this specific situation. A minimal skin undermining
with a short and wide pedicle must be used (see
Figs. 2 and 3).
The use of implants to reconstruct partial mastec-
tomies after radiation is potentially problematic.
The loss of tissue compliance in the irradiated
breast makes obtaining a satisfactory result with im-
plants more difficult. Secondly, capsular contrac-
ture and infection rates of implant or expander
placement in the radiated sites are very high [14].
Finally, an implant obscures mammography and
thus may decrease the sensitivity of recurrence
surveillance.
Breast reconstruction following partial mastec-
tomy with radiation is best achieved using autolo-
gous, nonirradiated flaps. Pedicled flaps, such as
the latissimus dorsi (LD) and transverse rectus ab-
dominus myocutaneous (TRAM) flaps, have lower
complication rates than the above-mentioned op-
tions [13]. The key step to delayed reconstruction
involves the excision of previous scars and release
of parenchymal tethering. Correct flap size can
then be determined, taking into account that in
the case of musclocutaneous flaps, the muscular
component will atrophy. No large studies evaluate
the aesthetic results of delayed partial reconstruc-
tion with flaps. In general, the shape is improved;
however, this is partially negated by the donor-site
morbidity and ‘‘plugged-in’’ appearance of the non-
irradiated flap skin [12]. Location of the deformity

Fig. 4. A 46-year-old patient with lateral deformity after BCT on the left side characterized by skin and paren-
chymal deficiency and NAC displacement. (A and B) Preoperative views. (C) The defect can be reconstructed
by pedicled flap: muscle-sparing LD musculocutaneous flap. (D) Wound closure at end of surgery.
can influence the choice of flaps. Defects located at
the lateral aspect of the breast are best treated with
loco-regional flaps, such as the LD musculocutane-
ous or thoracodorsal artery perforator (TDAP) flap
(see Fig. 4). However, the thoracodorsal vessels
may be damaged by previous surgery or irradiation
and should first be checked before raising the flap.
Severe scar or postradiation sequelae may preclude
harvesting such flaps. Other defects located in the
superior, central, or inferior quadrants of the breast
can still be approached by LD or TDAP flaps. Defor-
mities of the inferomedian quadrant are better
treated with abdominal flaps (Fig. 5).
When the deformity after partial mastectomy
with radiation is severe, the best option is comple-
tion mastectomy and autologous reconstruction
(see Fig. 4). In these cases the aesthetic outcome
can be expected to be similar to that with delayed
reconstruction for the irradiated mastectomy
patient.
The approach to post-BCT defects is summarized
in Box 1.
Immediate reconstruction
The authors prefer to perform immediate recon-
struction whenever it is indicated and feasible be-
cause operations on irradiated breasts have high
complication rates and frequently poor aesthetic re-
sults. During immediate reconstruction, the breast
Partial Mastectomy Reconstruction 55
can be manipulated before radiation. This poten-
tially decreases complications and improves the
outcome.
Clinical approach to patients with
immediate partial breast reconstruction
Breast-conserving surgery for cancer, associated with
postoperative radiotherapy, has been proven to be
safe as compared with total mastectomy for tumors
up to 3 cm in diameter [2–4]. Larger tumors are still
treated with mastectomy as a first choice. However,
introducing more efficient protocols of neoadjuvant
chemotherapy may allow a more conservative local
approach to advanced tumors. The combination of
a quadrantectomy with an immediate partial breast
reconstruction has been considered a decisive stage
in the evolution of breast cancer surgery. This com-
bination, so-called ‘‘oncoplastic surgery,’’ allows
a wider resection of the tumor with safe margins.
Moreover, good aesthetic results can be achieved be-
cause of the advantage of immediate reconstruction
with supple, malleable nonirradiated tissue. How-
ever, immediate partial reconstruction should be de-
layed if the surgeon is uncertain about the margins
or tumor extension (eg, tumors with a large in situ
component) despite the preoperative radiologic as-
sessment. A delayed immediate reconstruction can
still be performed within a few days after the defini-
tive margins become known.
56 Hamdi et al

Fig. 5. A 47-year-old patient presented for correction of post-BCT deformity on the medial quadrant of left
breast and right prophylactic mastectomy with immediate reconstruction. The microanatomoses were done
to the internal mammary vessels in both sides. (A and B) Preoperative views. (C) Bilateral SIEA flap is planned.
Superficial inferior epigastric vessels are shown with surgical retractors. (D) One SIEA flap harvesting. (E and F)
Results at 2 years show good breast symmetry.

Box 2 summarizes the specific issues that should

preoperatively be addressed with both patient and
the oncologic surgeon.
The choice of the reconstructive method
To determine which reconstructive option is best
for the patient, the size and location of the expected
tumor resection and the ratio of breast volume to
resection volume must be appreciated.
Bilateral rearrangement breast tissue A large na-
tive breast has historically been a moderate contra-
indication for BCT, due to increased rates of
radiotoxicity, as the large breast requires higher
doses of radiation therapy to reach a therapeutic
range. Many surgeons have suggested incorporating
a reduction-mammoplasty–type procedure during
tumor resection. Benefits include a more aesthetic
postoperative breast, a concealed tumor resection
incision within the reduction pattern, and smaller
radiation doses due to decreased breast size.
Box 1: General guidelines for delayed
reconstruction of partial mastectomy
Ensure careful patient evaluation locally and
generally.
Be aware that approach is technically more dif-
ficult with less aesthetic outcome compared
with the immediate approach.
Avoid extensive manipulation of the irradiated
tissue.
Use autogenous tissue to fill the defect.
Usually treat lateral, superior or inferior de-
fects with thoracodorsal-based pedicled flaps
if available.
Abdominal-based flaps are usually the best
treatment for medial defects.
In the case of severe breast deformity, com-
plete the mastectomy with thick skin flap and
consider total breast reconstruction with flaps.

Box 2: Issues that should be addressed
preoperatively with patient and oncologic
surgeon
Incision lines
Nipple–areola preservation
Estimation of defect size after tumor resection
Reconstructive method depending on breast-
size/tumor-size ratio
Consideration of delayed immediate recon-
struction if doubt about margins
Status of contralateral breast: no surgery ver-
sus mastopexy–reduction or prophylactic
mastectomy
The pattern can be rotated laterally or medially to
fit the location of the tumor. The choice of the ped-
icle is related to the tumor location (Table 1). Good
knowledge of the blood supply of the breast is es-
sential to design different potential pedicles to carry
the NAC or to reconstruct the defect.
Tumors involving the lower pole are the most eas-
ily treated because this region is removed during
most reduction techniques (Fig. 6). Other regions
of tumor excision, not normally removed with
reductions, can also be reconstructed using a combi-
nation of breast reduction and creation of a glandular
flap to fill the oncologic defect [7,15–17]. A similar
mammaplasty technique is performed on the contra-
lateral breast to match the size and shape of the tu-
mor-affected breast. However, it is preferred to end
up with a tumor-affected breast 10% larger than
the contralateral remodeled breast because some
shrinking and volume changes of the reconstructed
breast due to irradiation should be expected.
Incorporating a reduction mammoplasty with
partial mastectomy can be a complex procedure. Re-
cent literature, however, suggests that early compli-
cations are similar to those with mere reduction
Table 1: Choice of pedicle related to tumor
location
Location of the defect Choice of pedicle
Inferior, inferomedial, Superior,
or inferolateral superomedial, or
superolateral pedicle
Superior Inferior or
centro-inferior pedicle
Superomedial Superolateral pedicle
with an inferocentral
component to fill the
defect
Superolateral Superomedial pedicle
with an inferocentral
component to fill the
defect
Central Inferior pedicle
Partial Mastectomy Reconstruction 57
mammoplasty. The aesthetic outcome was consid-
ered good or very good in 81% of patients [16]. In
Spear and colleagues’ [17] review, none of the com-
plications significantly interfered with healing,
radiation, chemotherapy, or the quality of the result.
Replacement of the missing part One of the rel-
ative anatomic contraindications for rearrangement
breast surgery is a large tumor/breast ratio. Smaller
breasts require different methods of reconstruction.
If a postoperative deformity is expected due to
a large-volume tumor resection in a smaller breast,
the recruitment of nonbreast tissue is required. De-
pending on the location and the size of the breast
defect, different flaps can be used for partial mastec-
tomy reconstruction (Fig. 7).
A small lateral defect can easily be closed with
a skin rotation flap or lateral thoracic axial skin
flap. However, most of these flaps become unavail-
able when axillary lymph-node dissection is per-
formed. In obese patients, the lateral thoracic flap
can fill large defects at the lateral aspect of the breast
[18]. Lateral breast defects are usually reconstructed
using a flap based on the thoracodorsal system. The
LD musculocutaneous flap is the most commonly
used. It has excellent blood supply and provides
both muscle for filling of glandular defects and
skin for cutaneous deficiencies. Donor-site compli-
cations mainly include seroma and dehiscence.
Flap complications are few, with partial flap loss
seen in <10% of patients [19]. Unfortunately, do-
nor-site morbidity consists of potentially conspicu-
ous scars on the back and loss of some back
musculature function. Avoiding a scar on the back
can be achieved by harvesting the LD without
a skin paddle through the lateral breast incision.
The use of an endoscope can assist in raising the
muscle [20]. A deinnervated and radiated LD will
undergo postoperative atrophy. To compensate for
the expected loss in muscle volume, a flap much
larger than the defect should be harvested.
The advent of perforator flaps has enabled sur-
geons to spare muscle function. A similar skin pad-
dle to the classical LD musculocutaneous flap can
be raised on perforators either from the thoracodor-
sal or intercostals vessels [21]. Harvesting of pedi-
cled perforator flaps is feasible when the
appropriate perforator is chosen and the dissection
is performed meticulously. The technique becomes
more predictable if the surgical algorithm previ-
ously outlined is used to select the most appropriate
flap for the particular defect [22].
The pedicled TDAP flap is ideal for partial
mastectomy reconstruction (Fig. 8). Preoperatively,
a Doppler locates the perforator or perforators at
the lateral border of the latissimus. Introducing
the multidetector CT scan made perforator
58 Hamdi et al

Fig. 6. A 48-year-old patient presented a 15-mm invasive ductal carcinoma in the inferior pole of the left breast.
The tumor was widely excised. (A and B) Preoperative views. (C) Tumor resection lines were incorporated within
a breast-reduction pattern with superior pedicle. (D) Defect after the quadrantectomy. (E and F) Results after
irradiation.

mapping more precise and reliable. The dominant
thoracodorsal perforator can be visualized and its
location is marked directly on the skin [23].
Converting a TDAP perforator flap into a muscle-
sparing LD flap should be performed whenever the
perforators are too small or nonpulsating. Different
LD muscle-sparing techniques, which were previ-
ously described, call for locating a small segment
of LD muscle under direct visualization of the per-
forators so as not to damage them when harvesting
the muscular segment [22].
The authors reported the use of the lateral inter-
costal artery perforator (LICAP) in partial breast re-
construction within a clinical algorithm based on
the location of the defect and the availability of
these perforators [24]. The perforators are located
in front of the anterior border of the LD muscle.
The dissection of the perforators is quite easy and
quick; and it provides adequate perforator length
to rotate the flap 180 without torsion of the perfo-
rator. It is not necessary to extend the dissection
into the costal groove.
The LICAP flap is a good alternative to the TDAP
flap for lateral and inferior breast defects (Fig. 9).
However, the TDAP has a longer pedicle, thus en-
abling the flap to reach most of the breast (except
for the inferomedial quadrant). In addition, the
TDAP flap has a greater arc of rotation, facilitating

Breast defect

Superior Quadrants Lateral Quadrants Medial Quadrant

TDAP Flap LICAP Flap

MS-LD muscle-skin flap Scapular flap Small defect Large defect
LD muscle flap Lateral thoracic skin flap

LICAP or AICAP flap Mastectomy +

thoracoepigastirc flap Free flap

Fig. 7. Algorithm for using flaps for partial breast reconstruction. AICAP, anterior intercostal artery perforator;
LICAP, lateral intercostal artery perforator; MS-LD, muscle-sparing LD.
 Partial Mastectomy Reconstruction 59

Fig. 8. A 51-year-old patient who had a 3-cm tumor in the junction of superior quadrants of the right breast. She
was candidate for quadrantectomy with sentinel lymph-node dissection with immediate partial reconstruction
with a pedicled TDAP flap. Weight of the resected breast gland was 138 g. (A and B) Preoperative views. (C)
TDAP flap markings. The perforators (circled crosses) were marked with unidirectional Doppler. (D) The flap
was based on one perforator. (E) Dissection of the perforator up to the thoracodorsal vessels through the split
LD muscle. The thoracodorsal nerve was completely preserved (blue loop). (F and G) Results at 1 year after ra-
diation. (H) Donor site. The scar is hidden in the bra region.

tension-free folding or plication of the flap when
shaping the breast to achieve good breast symmetry.
Over the last 6 years, 101 pedicled perforator flaps
have been used in the authors’ department at Gent
University Hospital for breast or thoracic recon-
struction. TDAP flaps were converted to muscle-
sparing LD flaps in only 8% of cases. There is
only a minimal decrease in flap volume postopera-
tively as opposed to the LD musculocutaneous flap,
which can lose up to 30% of volume secondary to
muscle atrophy.
Muscle preservation is a sound rationale and is
likely to contribute to reduced donor-site morbid-
ity. Donor-site morbidity after raising a pedicle per-
forator flap is reduced to an absolute minimum
since the LD muscle is left intact with functional
motor innervation. In addition, there was no sero-
ma formation at the pedicled perforator flap donor
site.
Medial defects are more difficult to reconstruct.
Small lower-pole defects can be reconstructed using
an epigastric rotation flap. Because this flap is based
on tissue directly below the inframammary fold
(IMF), donor-site closure may distort IMF contour.
More commonly, the pedicled TRAM flap is used.
The superficial inferior epigastric artery (SIEA) free
flap was also described for immediate partial breast
reconstruction [25]. However, stringent patient se-
lection is essential when considering the harvesting
of abdominal flaps either pedicled or free, since it
excludes the use of abdominal tissue for autologous
reconstruction if completion mastectomy becomes
60 Hamdi et al

Fig. 9. (A) 47-year-old patient with a 2-cm diameter tumor on the junction of the inferior quadrant (oval). (B)
Both TDAP (indicated by TAP) and LICAP flaps were marked on the patient. Note that the LICAP flap is designed
lower and more proximal toward the breast. (C) Intraoperative view. The defect was filled by surgical swab. A
LICAP flap was designed with the marked perforators (circled crosses). (D) The flap was raised on intercostal per-
forators without disturbing the LD vasculature. (E) Close-up view of a LICAP with two branches. (F) Defect closed
with the flap.

indicated. Therefore, in such clinical situations, the
authors prefer to complete the mastectomy and im-
mediately use the abdominal flap for total breast re-
construction. The authors’ first choice is the deep
inferior epigastric artery perforator (DIEAP) free
flap, which produces an aesthetic donor site with
low morbidity [26]. The SIEA flap is an excellent
choice for small to moderate-size breast reconstruc-
tion whenever the superficial inferior epigastric ves-
sels are present.
Complication related to flap irradiation
Postoperative radiation therapy of any flap is a ma-
jor concern. Spear and colleagues’ [27] large review
of pedicled TRAM flap reconstruction in total mas-
tectomies showed no statistically significant in-
crease in complications when the patient received
postoperative radiation, compared with no radia-
tion. Tran and colleagues’ [28] examination of post-
operative radiation on free TRAMs also showed no
increase in early complication rates. However, both
studies showed a significant increase in delayed flap
contracture, pigmentation changes, and volume
loss. As these changes can dramatically lower the
final aesthetic outcome, most surgeons delay total
mastectomy reconstruction until radiation has
been completed. Presently, no large, long-term
outcome studies compare immediate flap

reconstruction in radiated and nonradiated partial
mastectomy patients. However, one would expect
radiation to have less detrimental aesthetic effects
on partial mastectomy patients than on total mas-
tectomy patients. Theoretically, radiating both the
flap and conserved breast tissue should produce
a more homogenous appearance than the
‘‘plugged-in’’ appearance of nonirradiated flaps
following delayed reconstruction.
Summary
Reconstruction after partial mastectomy is an evolv-
ing aspect of plastic surgery. In many centers, imme-
diate reconstruction is commonly performed. The
feeling amongst most reconstructive surgeons is
that immediate reconstruction provides superior
aesthetic outcomes with fewer complications. It is,
however, important to be aware of the rate of reex-
cisions for positive margins by the surgeons per-
forming the tumor resections. If this rate is
unacceptably high, then reconstruction should be
delayed. One option is ‘‘delayed-immediate’’ recon-
struction, where the reconstruction is performed af-
ter final pathology clearance, but before radiation.
The other option is to reconstruct the breast after
the effects of radiation therapy have stabilized. Un-
fortunately, the options for delayed reconstruction
are more limited, and satisfactory results can prove
more difficult to achieve. Thus, the timing and
method of partial mastectomy reconstruction re-
main controversial. However, with the increasing
popularity of partial mastectomy with radiation,
the need for reconstruction will also increase.
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