technically perfect repair under physiologic tension cannot be achieved with primary closure, it is

preferable to use a more complex surgical option.

Skin Grafting. Skin grafting was one of the foundations on which the specialty of plastic surgery was

established. Skin grafts are classified as either split thickness, where epidermis and a portion of the

dermis are harvested, or full thickness, where the epidermis and the entire dermis are harvested. Both

full-thickness and split-thickness skin grafts can be used to resurface open wounds in cases in which

primary closure is not possible. Skin graft take is contingent on the successful revascularization of the

graft within a narrow time window (48 to 72 hours). Initially, grafts are nourished by a process of

plasmatic imbibition, wherein serum from the wound bed diffuses into the adjacent graft.

Revascularization occurs by the process of inosculation and angiogenesis. Vessels from the wound bed

grow into the graft, forming functional circulatory connections with the vasculature of the graft. For

plasmatic imbibition and inosculation to be successful, two criteria must be met. First, the wound bed

must be appropriately vascularized. Therefore, skin grafts cannot be placed on poorly vascularized

wound surfaces, including bone denuded of periosteum, tendon denuded of peritenon, or cartilage.

Second, a bolster dressing or splint must be used to ensure absolute immobilization of the graft on the

bed to prevent shearing of the nascent vascular connections during inosculation. If either of these

criteria cannot be met, a more complex reconstructive option must be considered. Split-thickness graft

donor sites heal due to epithelial cell growth from the base of remaining hair follicles and skin

appendages. A full-thickness graft donor site must either be closed primarily or reconstructed with a

different technique.

Random Skin Flaps. The use of tissue (usually skin) immediately adjacent to the defect as the tissue

for reconstruction is referred to as a local flap reconstruction. Skin rearrangement can range in

complexity from simple undermining to complex, geometric skin flaps. Which method is appropriate is

dependent on multiple factors, including the etiology of the defect, the desired direction of the scar, the

fragility or mobility of underlying structures, and the need to avoid distortion to adjacent free margins

such as the lip or eyelid. Significant experience is required for the optimal utilization of skin

rearrangement. When plastic surgeons think of “classical” skin flaps, they are referring to random skin

flaps, without an axial blood supply. These skin flaps rely on a dermal plexus of vessels for their

survival, and the perfusion of the distal end of the flap is inadequate to allow tissue survival if the flap

design is inappropriate. It was previously thought that survival of the distal part of random skin flaps

could be ensured by adhering to length-to-width ratios established for various areas of the body. It is

now recognized that these ratios have no basis in circulatory physiology, and the surviving length of a

random skin flap does not depend on flap width.19 In practice, most of the commonly employed skin

flaps have been developed empirically. There are three basic types of random skin flaps: rotation,

advancement, and transposition, depending on how adjacent skin is shifted into the defect. Each type of

flap has specific design criteria and choice of flap design is based on wound location, patient anatomy,

and surgeon preferences. Excellent reviews of the use of skin flaps in reconstructive surgery are

available.20,21

As mentioned, the concern with flap viability limits the utility of random skin flaps. Several strategies

have been developed to circumvent this problem. The first of these is the concept of surgical delay.

Delay is defined as the partial interruption of blood flow to a defined piece of tissue allowing for

preconditioning of the tissue prior to further division or transfer. At present, surgical delay is the only

method available to augment the surviving length of random skin flaps (Fig. 109-1). Another strategy is

the use of tissue expanders. Tissue expanders are implantable balloons that are inserted in a deflated

state and are inflated with sterile saline via percutaneous injection into a self-sealing valve. Except for

the scalp, where expanders are placed in the subgaleal plane, tissue expanders are usually placed

subcutaneously. In fact, the insertion of the tissue expander into a subcutaneous pocket creates a

surgical delay, and the slow expansion has been demonstrated to result in the formation of new skin.

However, the most important strategy to circumvent the use of random skin flaps has been to develop

axial pattern flaps that do not rely on a random blood supply.

3214

Figure 109-1. Example of surgical delay. Because of associated medical problems, the patient was not a candidate for

microvascular tissue transfer. A: Lower-third tibial defect secondary to an open ankle fracture. Note exposed bone, which precludes

use of a skin graft. B: In the first stage, a bipedicle flap was created anterior to the defect. The deep perforators to the skin of the

flap were divided by full undermining. The flap is perfused only from the proximal and distal ends. C: The incisions were

repaired, and the wound was dressed. D: After 5 days, the bipedicle flap was again elevated and part of the distal pedicle was

divided (arrow). The incisions were again closed, and the wound was dressed. This procedure was repeated 10 days after the initial

operation to leave only a small skin bridge at the distal end of the flap. E: Fourteen days after the initial procedure, the remaining

distal skin bridge was divided and the flap transferred. The donor site was skin grafted. This photograph depicts full survival of the

flap and complete take of the skin graft.

Flaps with Axial Blood Supply. Regional flaps are defined as the transfer of tissue that is not

immediately adjacent to the defect without the disruption of blood supply to the transferred tissue. For

this approach to be practical, an axial blood supply to the transferred tissue must be present.

Axial Skin Flaps. The pioneering work of Bakamjian22 and McGregor and Jackson23 identified

longitudinal blood vessels of large caliber traversing a defined region of skin. Their descriptions of the

deltopectoral and groin flaps, respectively, opened a new era of reconstructive surgery. Surgeons were

no longer constrained to the use of random skin flaps; any piece of tissue in the body with an axial

blood supply could be transposed on a vascular pedicle with a high degree of assurance that the tissue

would survive. Taylor and Palmer’s

24 description of the angiosome concept solidified our ability to

design flaps based on a sound knowledge of vascular anatomy. An angiosome is defined as a region of

tissue supplied by an identifiable, and usually named, artery and its venae comitantes. Because of the

ability of choke vessels crossing angiosome boundaries to enlarge, flaps can be designed to encompass

an adjacent angiosome. In practice, there are relatively few axial skin flaps, most being better classified

as fasciocutaneous flaps.

3215

Fasciocutaneous Flaps. Cormack and Lamberty25 further expanded our understanding of the blood

supply to the skin with their description of fasciocutaneous flaps. They pointed out that the dermal

plexus derives its inflow from vertically oriented vessels arising at the level of the deep fascia. The

vessels at the deep facial level have horizontal orientation relative to the skin’s surface and form a

subfacial plexus. This subfacial plexus can form the basis for the design of fasciocutaneous flaps based

on several defined anatomical patterns.25 Several fasciocutaneous flaps have enjoyed widespread use.

The radial forearm flap has become a workhorse for hand reconstruction and as a free flap for head and

neck reconstruction. The anterolateral thigh (ALT) flap has become a common flap for larger

reconstructive needs and is based on septal or muscular perforators from the descending branch of the

lateral femoral circumflex artery. The osteoseptocutaneous fibula free flap has been widely used for

intraoral reconstruction during reconstruction of oromandibular defects and a primary site for

vascularized bone flap harvest.

Muscle and Myocutaneous Flaps. Based on the knowledge that tissue with an axial blood supply can

be reliably transferred, muscle and myocutaneous flaps came into widespread use in the 1980s, thanks

in large part to the classification system by Mathes and Nahai.26 Whole muscles can be transferred as a

pedicled or free flap if a dominant vascular pedicle is present. Segmental muscle transfers are

sometimes possible on minor vascular pedicles. Functional muscle transfer can also occur when

innervation is preserved or the motor nerve is coapted to a different motor nerve.

The rediscovery of the musculocutaneous perforator as a predominant vascular supply to the skin in

many areas of the body has led to the wide use of musculocutaneous flaps. These flaps derive their

inflow from a major muscular artery used to also bring skin along with the underlying muscle.

Perforators emanating vertically from the muscle surface supply the skin overlying the muscle. Table

109-4 lists “workhorse” muscle and myocutaneous flaps. Of particular note is the transverse rectus

abdominis myocutaneous (TRAM) flap, based on periumbilical myocutaneous perforators from the

rectus abdominis muscle has been widely employed for breast reconstruction.27 An extension of this

concept has led to the increasing use of “perforator” flaps. Perforator flaps are based on fasciocutaneous

or myocutaneous perforating vessels. Dissection isolates the skin and subcutaneous tissue to be

transferred on one or more perforating vessels; the underlying muscle is left intact, eliminating the

functional disturbance that would result if a whole muscle was harvested. Because of their robust

vascularity and ability to minimize donor deficit, perforator flaps are often preferred in reconstructions

where muscle is not necessary and preservation of the underlying muscle decreases the morbidity at the

donor site. An example is highlighted in the section on breast reconstruction where the use of the deep

inferior epigastric perforator (DIEP) flap is based on the same donor site anatomy as a TRAM flap, but

preserves the rectus abdominis muscle. In reconstructive surgery a large number of perforator flaps

have been described and are now used as both pedicled and free flaps.28

CLASSIFICATION

Table 109-4 Workhorse Muscle, Myocutaneous, and Perforator Flaps

3216

Microvascular Tissue Transfer. Historically, pedicled flaps were used to reconstruct distant defects.

The distant transfer was accomplished in one of two ways. Flaps could be moved to the defect in a

series of pedicled transfers (waltzing or tumbling flaps). Alternatively, flaps could be attached directly

to the defect with a temporary pedicle to the donor site being maintained temporarily. At a second

stage the flap was detached from the donor site, after it had developed sufficient blood supply from the

recipient bed (e.g., cross leg flaps, pedicled groin flaps). Although the distant transfer of pedicled flaps

still has definitive indications (e.g., the median forehead flap for nasal reconstruction), reconstruction

using distant tissue is now most commonly performed via microvascular tissue transfer, or “free” flaps.

First described clinically by Daniel and Taylor,29 free flaps have revolutionized reconstructive surgery.

Any tissue with an axial blood supply with pedicle vessels 1 mm in diameter or larger can be reliably

transferred microsurgically and improved techniques have opened the door to supermicrosurgery and

the anastomosis of vessels between 0.3 and 0.8 mm in diameter.30 Circulation in the transferred tissue is

established via microvascular anastomoses between the axial flap vessels and vessels in the recipient

site. Microvascular anastomoses are performed with 8-0 or 9-0 suture with the aid of an operating

microscope; success rates for free flap transfers exceed 95%.31 The greatest advantage of free flap

reconstruction is that the surgeon is not restricted to the use of available, local tissues; any flap or

composite block of tissue that has feeding vessels large enough for microvascular anastomoses can be

transferred with this technique. By using composite tissue flaps, massive, complex tissue defects can be

reconstructed replacing “like with like” (Fig. 109-2).32 The transfer of tissue to the site of reconstruction

from another area of the body allows the use of tissue which has not been exposed to the damaging

effects of radiation or scarring. Bowel, skin, bone, muscle, fascia, and composite tissue can be

transferred microsurgically with new flaps continuing to be described clinically. Free flaps are the

primary modality for reconstruction of major head and neck defects after composite resection and for

the reconstruction of traumatic defects in the distal foreleg. As already mentioned, perforator flaps are

increasingly used as microsurgical tissue transfers. The anterior lateral thigh (ALT) perforator flap has

become a workhorse for reconstruction of a diverse array of complex defects, especially after

extirpative surgery of the head and neck. The deep inferior epigastric artery perforator (DIEP) flap

rivals the TRAM as the mainstay for autologous breast reconstruction.33

The future of reconstructive techniques continues to evolve. The use of prelaminated and

prefabricated flaps can now be used to create complex reconstructions elsewhere on the body and then

transfer that reconstruction en bloc to the recipient site.34 Tissue-engineered reconstructions are

emerging with the modification of both biologic and nonbiologic tissues including the modification of

stem cells, generation and cellularization of scaffolds, and three-dimensional (3D) printing for

reconstructive purposes.35 In addition, vascularized composite allotransplantation (VCA) has now been

successfully performed in multiple areas including both hand and facial transplantation.36 Continued

work on immunosuppression modification should continue to shift the risk–benefit ratio toward

standard reconstructive techniques.

3217

RECONSTRUCTIVE AND AESTHETIC SURGERY OF THE BREAST

Plastic surgery of the female breast includes both reconstructive and aesthetic procedures. Breast

reconstruction following mastectomy and reduction mammaplasty for macromastia (oversized breasts)

are the most common examples of reconstructive breast surgery. By contrast, breast augmentation

(enlargement) and mastopexy (breast lift) generally are performed for aesthetic reasons. Although some

surgical approaches may be applicable to both categories of breast procedures, the relative benefits,

risks, and costs of reconstructive versus aesthetic breast surgery may be quite different, particularly as

viewed by patients, providers, and payers.

Before advising women on reconstructive or aesthetic breast procedures, the surgeon should carefully

assess the patient’s current preferences, concerns, history, and physical findings. Initially, any history of

breast disease (as well as familial history of breast pathologies) should be evaluated. On physical

examination, careful linear measurements and preoperative photographs should be taken to document

existing contour deformities, asymmetries, or other findings. A standard breast examination should be

carried out to detect previously undiagnosed masses, nipple discharge, or lymphadenopathy. Finally, it

is also advisable that women age 40 years or older undergo mammography unless this study has been

performed in the previous 12 months.

Preoperative consultation should include a thorough discussion covering the relative benefits and

risks of the various surgical options. The surgeon is well advised to provide comprehensive information

in an understandable format. To enhance patient satisfaction with the eventual surgical result, providers

should elicit patients’ preferences and expectations for surgical outcomes and tailor treatment options

accordingly. Because of the prevalence of breast cancer in North American women, the impact of

reconstructive or aesthetic procedures on breast cancer monitoring also should be discussed.

Reconstructive Breast Surgery

Postmastectomy Reconstruction

1 A variety of operative procedures have been described for breast reconstruction following

mastectomy. These approaches can be categorized as implant-based, autogenous (natural) tissue, and

“hybrid” procedures. For purposes of this discussion, the term hybrid is applied to procedures combining

elements of both implant and autogenous tissue techniques. This overview describes the advantages and

disadvantages of the most common techniques. Ultimately, procedure selection is based on a range of

patient variables, including size and shape of the desired reconstructed breast; availability of local,

regional, and distant donor tissues; coexisting medical problems; and, perhaps most important, patient

preferences.

Implant-Based Techniques. As most commonly practiced, implant-based breast reconstruction is either

performed as a staged tissue expander–implant reconstruction or as a “single stage” implant

reconstruction. The tissue expander–implant approach usually requires two or more operative

procedures to reconstruct the female breast. In the first stage, a temporary tissue expander is placed in a

soft tissue pocket, usually located deep to the pectoralis major muscle. The tissue expander is a deflated

silastic (silicone) envelope with an integrated or remote injection port through which saline solution can

be percutaneously injected. Expanders can be completely covered with a combination of flaps including

the pectoralis major (superior), serratus anterior (lateral), and rectus fascia (inferior). Alternatively,

with the introduction of acellular dermal matrices (ADMs), expanders are now routinely covered with a

pectoralis major muscle flap superiorly and ADM sling inferiorly. Following expander placement and

meticulous closure of the overlying muscle and skin, saline is periodically injected beginning at 10 to 21

days. As the device enlarges, growth is induced in the overlying skin, recreating soft tissue coverage for

the new breast.37

3218

Figure 109-2. Double free-flap reconstruction of a massive, complex defect. A: Squamous cell carcinoma of lip, chin, mandible,

and floor of mouth after resection. Massive tissue defect encompasses skin of the chin, entire lower lip, mandible from midbody to

midbody, and floor of the mouth. B: Fibula free flap. Skin paddle is centered on fasciocutaneous perforators. C: Fibula free flap

elevated but still in situ. Osteotomies have been performed to conform to the mandibular contour. The skin paddle will form the

floor of the mouth. D: Radial forearm free-flap plan. Skin paddle will be harvested along with the palmaris longus tendon. The

tendon will be attached to the modiolus on either side of the lower-lip defect, and the skin paddle will reconstruct the skin of the

chin and lip. For the lip, the skin paddle will be draped over the tendon like a bed sheet on a clothesline. E: Radial forearm flap

elevated but in situ. F: Postoperative result, mouth closed. G: Postoperative result, mouth open. (Reproduced with permission from

3219

Kuzon WM Jr, Jejurikar S, Wilkins EG, et al. Double free-flap reconstruction of massive defects involving the lip, chin, and

mandible. Microsurgery 1998;18:372–378.)

Following completion of expansion, most surgeons delay the second stage of reconstruction for 1 to 4

months to allow for maximal skin growth. At the conclusion of this hiatus, the second procedure is

performed, consisting of removal of the expander and placement of the reconstructive implant.

Currently available breast implants include a range of options, including variations in shape (round vs.

“anatomic” or teardrop configurations), fill material (silicone gel vs. saline), and surface configuration

(smooth vs. textured envelopes). The relative advantages and disadvantages of these options are

discussed in the Breast Augmentation section later in this chapter. As the most common option for

postmastectomy reconstruction in the United States, the expander–implant approach offers several

advantages. The lengths of the surgical procedures associated with this approach usually are relatively

brief (often 1 hour or less) and are technically straightforward. Particularly when employed in bilateral

reconstruction cases, resulting symmetry and aesthetic outcomes are relatively good (Fig. 109-3).

Patients considering implant reconstruction should also be mindful of the disadvantages of these

procedures. The expander–implant approach usually requires at least two surgical procedures, multiple

visits for expansion, and approximately 6 to 12 months to complete. For patients eager to return to a

normal lifestyle following breast cancer treatment, this delay can be particularly frustrating. In

addition, tissue expanders and reconstructive implants have been associated with a number of

complications. Early in the postoperative period, these devices may be troubled by delays in wound

healing, at times resulting in implant exposure and requiring explantation. Implant infections also may

necessitate removal of the prosthetic device. Late complications include expander or implant leakage.

Also, the development of excessive scar tissue surrounding the implant (termed a capsular contracture)

can produce a hard, painful, or deformed breast requiring surgical revision.

3220

Figure 109-3. Staged bilateral tissue-expander based breast reconstruction. A, B: Pre-operative apperance. C, D: After tissue

expansion. E, F: Final result after expande/implant exchange and nipple-areolar complex tattoing.

Figure 109-4. Transverse rectus abdominis myocutaneous (TRAM) flap reconstruction.

The “single stage” approach to implant reconstruction bypasses the tissue expander stage, with

immediate placement of a full-sized silicone or saline-filled implant.38 Similar to the tissue expander–

implant reconstruction, patients will need revision procedures to achieve a complete reconstruction. The

use of ADMs have made this option of reconstruction possible as larger volumes can be placed under an

ADM; complete coverage with muscle limits the intraoperative volume placed in an expander at the

initial reconstruction. Careful patient selection is necessary when considering this option and patients

need to understand the reconstructed breast volume will be about the same size or smaller than their

premastectomy volume. Patients who desire to be larger are better served with tissue expansion.

2 Autogenous Tissue Reconstruction. A variety of autogenous (natural) tissue options have been

3221

described for postmastectomy breast reconstruction. Currently, the most commonly performed of these

procedures are based on the lower abdominal soft tissue. Originally popularized by Hartrampf et al.30

the TRAM (transverse rectus abdominis myocutaneous) flap was the earliest lower abdominal flap

routinely used for breast reconstruction. The flap was commonly performed as a pedicle muscle flap,

with transfer of the rectus muscle which is left partially attached to the costal margin, preserving the

superior epigastric artery and vein as the flap’s blood supply (Fig. 109-4A and B). These tissues are

tunneled subcutaneously into the mastectomy defect, where they are sculpted into the desired breast

size and shape. Meanwhile, the abdominal donor site is closed by reapproximating the anterior rectus

sheath and by advancing the remaining superior skin edge of the donor site as a modified

abdominoplasty (Fig. 109-4C). As harvest of the pedicled TRAM flap requires use of an entire rectus

muscle and a segment of the abdominal wall fascia, occurrences of postoperative abdominal hernias or

(more commonly) abdominal wall laxity are a persistent problem, particularly in patients who undergo

bilateral reconstruction using this technique.39

Microsurgical techniques for soft tissue transfer have allowed for modifications of the TRAM flap and

have also encouraged the development of other alternative flap options. Other lower abdominal flap

options requiring microsurgical free-tissue transfer include the free TRAM, muscle sparing TRAM, DIEP

(deep inferior epigastric perforator) and SIEA (superficial inferior epigastric artery) flaps. Differences

between these flap techniques are based on the amount of rectus muscle and fascia harvested with the

flap, with the DIEP and SIEA flaps avoiding muscle or fascia harvest. Allen and Treece took the free

TRAM flap a step further with their development of the DIEP flap: by meticulously dissecting vascular

perforators from the deep inferior epigastric pedicle into the overlying abdominal fat, avoiding removal

of any rectus abdominis muscle or fascia (Fig. 109-5A and B), thereby minimizing disruption of

abdominal wall structures.40 This consequently decreases the occurrence of abdominal bulges or

hernias.39,41,42 The flap is transferred to the chest where the flap vascular pedicle is anastomosed to

recipient vessels in the chest with the aid of an operating microscope or high-power surgical loupes. The

more common recipients utilized today are the internal mammary vessels (Fig. 109-5C), with the

thoracodorsal vessels serving as a second option.

Abdominal soft tissue flap breast reconstruction offers several benefits. Because the flaps usually

provide a generous amount of lower abdominal adipose tissue for breast bulk, implants are rarely

needed with this approach (Figs. 109-6 and 109-7). The flaps can be inset and sculpted in a virtually

infinite number of ways, giving the reconstructive surgeon considerable latitude in the creation of

breast shapes and sizes. An additional advantage of abdominal-based flaps is their tendency to gain or

lose volume in association with weight changes and body mass, thereby maintaining better symmetry

than implant reconstructions over time. Finally, flap reconstructions avoid long-term problems

encountered with implants such as implant rupture, which may necessitate additional surgical

procedures. Likely based on these benefits, patients tend to be more satisfied with soft tissue flap breast

reconstruction than implants in the long term.43 Despite these advantages, lower abdominal flaps also

are associated with some disadvantages. Compared with implant approaches, flap reconstruction

requires an abdominal scar, longer operations, hospitalizations, and recovery times. Furthermore, flap

procedures can produce a range of complications, including partial and total flap loss as a result of

vascular compromise of the transferred tissue.

3222

Figure 109-5. Deep inferior epigastric artery perforator (DIEP) flap. A: abdominal donor site. B: Flap harvested without muscle or

fascia. C: Microvascular anastomosis to internal mammary vessels.

3223

Figure 109-6. DIEP breast reconstruction. A, B: s/p left mastectomy. C, D: After left DIEP flap reconstruction. E, F: Final result

after tattooing of nipple-areolar complex.

The free flap concept also has been applied to other donor sites for breast reconstruction, most

notably the thighs (transverse upper gracilis and profunda artery perforator flaps) and gluteal region

(superior and inferior gluteal artery perforator flaps).44–47 Although perforator flaps appear to avoid the

functional deficits associated with muscle flap harvest, they (like all free tissue transfers) entail longer,

technically challenging operations requiring special facilities, equipment, and expertise. Also, because

the blood supply for the entire flap depends on two or three microsurgical anastomoses (each usually

involving vessels no more than 2 to 3 mm in diameter), there is the potential for complete flap loss in

the event of anastomotic thrombosis. Flap loss rates are however relatively low at 1% to 2% in highvolume centers.

3224

“Hybrid” Breast Reconstruction Techniques. As an additional alternative for breast reconstruction,

flaps can be used in concert with saline or silicone-gel implants. Most commonly, the ipsilateral

latissimus dorsi and a segment of overlying skin are harvested as a musculocutaneous pedicle flap and

are tunneled anteriorly into the mastectomy defect. Although the latissimus dorsi and its associated skin

island constitute an extremely reliable flap when used for wound coverage, this approach usually

provides insufficient bulk for breast volume. Tissue expanders or implants are often used to address this

volume deficiency. The combination of a latissimus dorsi flap and tissue expansion may be particularly

appropriate for cases in which the remaining mastectomy skin is of insufficient quality or quantity to

tolerate tissue expansion. Following transfer and expansion of a latissimus dorsi musculocutaneous flap,

an appropriately sized breast implant usually can be safely placed in a secondary operation.

Nipple–Areolar Reconstruction. Reconstruction of the nipple–areolar complex (NAC) can be

accomplished at the conclusion of breast mound reconstruction or at a later date. Following recreation

of the mound, many surgeons prefer to allow several months for tissue healing and settling before

proceeding with nipple–areolar reconstruction. To recreate the papule, common options usually rely on

local skin flaps or a segment of redundant contralateral papule. For the areola, a full-thickness skin graft

or tattooing of the surrounding skin can be used. In recent years 3D tattooing of the NAC has been

introduced as an alternative to surgical reconstruction with good aesthetic results (Fig. 109-8).48

Breast Reduction (Reduction Mammoplasty)

Because reduction mammoplasty is intended to alleviate functional problems and symptoms of

macromastia, this procedure is considered a reconstructive rather than an aesthetic operation. In

general, appropriate candidates for reduction mammoplasty are women with macromastia and

associated back, neck, or shoulder pain; limitations in daily work or recreational activities; or

difficulties obtaining proper fit in bras or other clothing. Although reduction mammoplasty usually is a

covered benefit by most health care payers, patients symptomatic and functional concerns must be

carefully assessed and documented before proceeding with surgery. As noted earlier in this section,

patients preferences and expectations regarding postoperative breast size, shape, and functional results

also should be carefully evaluated.

Figure 109-7. DIEP breast reconstruction. A: Pre-operative appearance. B: Post-operative, showing abdominal donor site scars.

3225