Incision design: A longitudinal incision is made at the midaxillary line under the armpit, and a length is about 10–15 cm; thus, the incision is completely covered when the upper limbs are sagging, and no surgical scars are left on the chest and back. The incision is near the anterior axillary fold, and it is easy to expose the incision scar when the upper limbs swing (Figs. 15.4 and 15.5).

Surgical methods

Progress in the harvesting of expanded latissimus dorsi muscular flap: The use of subaxillary longitudinal incision for immediate breast reconstruction with the expanded latissimus dorsi muscular flap after the modified radical mastectomy with preservation of the nipple and areola avoids the surgical incision scar on the breast surface. At the same time, how to reduce the scars on the back donor site and shorten the axillary scar has become one of directions for the scholars to explore. With the popularity of endoscopy, the endoscopic harvesting of expanded latissimus dorsi muscular flap can avoid the surgical scar on the donor site, but because the body shows a certain curvature and lacks natural cavities, and the difficulty of surgical operation is increased, some scholars hold adverse opinions. United States Anderson Cancer Hospital reported the application of robot-assisted harvesting of expanded latissimus dorsi muscular flap in 2011, which is likely to be one of the future development directions.

The periareolar incision: If the areola circumference is small, if necessary, the incision can be extended toward the inside or the outside and even the inferior side according to the location of the tumor, which facilitates the exposure (Fig. 15.6a).

The incision at the lateral side of the breast, the incision along Langer’s line above the breast, or the arc incision at the lateral side of the breast: All these incisions are located on the breast surface on the outside of the nipple, along the static tension line of the breast skin, which is conducive to reducing the scar formation (Fig. 15.6b).

The incision at the lower part of the breast: This incision is particularly useful for patients with huge and sagging breasts, and the breast skin can be reduced, and the breast can be shaped during mastectomy, especially in the patients with the breast at the healthy side requiring plastic surgery simultaneously (Fig. 15.6c).

The mastectomy and axillary lymph node dissection are carried out via abovementioned incisions, and it is necessary to retain a certain thickness of the tissue at the bottom of the nipple to prevent papillary necrosis. If necessary, an additional skin incision can be made in the armpit, which is conducive to axillary lymph node dissection. The reconstruction method selectively uses the first-stage prosthesis implantation, dilator-prosthesis implantation, or TRAM flap reconstruction according to the circumstances.

Oncological factors

Cosmetology factors: The significance of breast-conserving treatment is to completely remove the tumor tissue but not destroy or destroy as little as possible the appearance of the female breasts. Therefore, the factors relating to cosmetology should be considered during the treatment process.

Relationship between the tissue resection volume and the breast size: For the patients with medium-sized or smaller-sized breast, the removal of excessive breast tissue volume can cause serious breast deformation, and the fiber contracture due to the postoperative radiotherapy will further aggravate the breast deformation in some patients. It is generally believed that the tissue resection volume in the patients with medium- and small-sized breasts does not exceed 25% of the total volume; the larger tissue resection volume can be removed in patients with larger breasts. If certain principles for breast reduction surgery in plastic surgery are adopted, a good appearance still can be maintained even though 50–60% of the breast is removed. In this type of patients, the appropriate local dissociation after resection of bulk tissue can maintain good blood supply to the breast tissue, but also maintain the good appearance of the breast shape.

The location of the tumor: The breast tissue volume in the upper part within the breast is less and the thickness is thin; thus, the removal of the tumor tissue in this part can cause deformities such as local depression or upper shift of the nipple; on the contrary, the breast tissue volume in upper outer part of the breast is more; thus, the deformation will not easily occur after the tumor in lateral or lower part of breast is resected, and the cosmetic effect is better.

The direction of resection of the breast skin and breast: Any surgical incision of the breast should consider related cosmetic surgery principles. In general, the skin incision should be consistent with the skin tension lines, but the nipple will be easily shifted downward when the transverse incision in the lower half of the breast is made to resect a part of the skin. Therefore, the transverse incision should be made in upper half of the breast, and the radial incision should be made in the lower half of the breast. The glandular part is resected using radial wedge or fusiform resection, so as to reduce nipple displacement. The tumor located in the middle of the breast should be resected through areola margin incision or the transverse incision within the areola. The tumor near the areola should be resected together with the nipple and areola, and the nipple and areola can be reconstructed at a later stage.

Scar contracture after surgery and radiotherapy: The surgery and radiotherapy may cause fibrosis, and the wound hematoma or seroma can further cause scar formation to lead to contractures and even lead to the nipple displacement. The induration can be palpated in local area in some patients, which is softened gradually and disappears over time. The surgical trauma should be reduced as far as possible during surgery; thus, the subcutaneous extensive dissection is avoided; meanwhile, the careful hemostasis is carried out, and the principles of noninvasive surgery are strictly adhered to.

Partial breast resection: Firstly, the methylene blue is used to mark the surgical skin incision and the resection range of the breast; if there is a biopsy incision, the biopsy incision scar should be removed together as far as possible. The skin flap is separated on both sides to fully expose the tumor, then en bloc resection of 1–2 cm of breast tissue surrounding the tumor is performed, and the depth reaches up to the pectoralis major muscle, including part of the pectoralis major muscle fascia. If the bottom is near the pectoralis major muscle, a part of pectoralis major muscle should be removed, and the resection depth is consistent with that of the modified radical mastectomy (see Fig. 15.6). The resection specimen is marked with suture lines. Although in theory, the frozen sections cannot fully reflect the situation in surgical margins; it is still necessary to carry out frozen pathological examination in clinical practice. If the surgical margins are invaded, the resection range should be expanded.

Effects of gravity action: After partial breast resection, the breast tissue defects can be aligned and closed by themselves with the help of gravity action; thus, most of them do not need to be sutured. Due to the gravity action, the incisions in middle upper and lower parts of the breast can’t be closed, and furthermore the incision wound is ripped off. Therefore, the breast tissues in these parts need to be sutured. When the glandular tissue is selectively sutured, it is recommended to use the absorbable suture lines. When the alignment is performed, tight knots or distorted tissues should be avoided; otherwise, the local induration can be palpated after alignment. The patient is placed in the semi-recumbent position during surgery. Whether there is local depression or deformation is observed, and timely adjustments should be made when the deformation is found. Finally, the drainage tube is placed, and the skin is sutured with nylon threads.

Axillary lymph node dissection: In addition to the primary lesions located in the tail of the breast, an additional incision should be selected for the axillary lymph node dissection. S-shaped or axillary fold incision is often used, and specific methods are the same as those of axillary lymph node dissection.

The immediate breast reconstruction after breast-conserving surgery can be divided into two types: one type is the surgery to adjust the original breast tissue, and another type is the tissue augmentation surgery.

Applied anatomy: The rectus abdominis muscle is located on both sides of the abdominal midline, and the upper end is wider and the lower end is narrow. The upper end starts from the xiphoid and the areas of fifth to seventh costal cartilages, and the lower end terminates at the pubic symphysis and pubic crest. The rectus abdominis muscle is located within the sheath of rectus abdominis muscle, with three to four tendinous intersections, and Hunter’s line is located between both left and right sheaths. The anterior sheath of the rectus abdominis muscle is intact, the posterior sheath forms into the semicircular line at 5.8 cm below the umbilicus, and there is no posterior sheath below this line.

The blood supply of the TRAM flap mainly comes from the superior and inferior epigastric arteries and their accompanying veins. The upper one-third of the rectus abdominis muscle is supplied with blood by superior epigastric vessels. The middle and lower parts of the rectus abdominis muscle are supplied with blood by inferior epigastric vessels. There are very big individual differences between superior and inferior epigastric vessels. It is generally believed that there exist direct anastomosis branches between superior and inferior epigastric vessels within muscles.

Single-pedicled TRAM flap is divided into four regions according to the status of the blood supply: region I is located on the surface of the abdominal rectus pedicle, and the blood supply is best; region II is located on the surface of the contralateral abdominal rectus muscle, and the status of blood supply takes second place; region III is located on the outside of the abdominal rectus pedicle, and on the same side of the muscle pedicle, the status of blood supply takes third place; and region IV is located on the outside of the contralateral abdominal rectus muscle of the pedicle and on the contralateral side of the muscle pedicle and is symmetrical to region III, and the blood supply is worst (Fig. 15.7).

Surgical method and indications: The safe blood supply range of TRAM flap pedicled with unilateral superior epigastric vessels is about 60% of the skin flap, namely, regions I and II and part of region III. For patients with scars in the center of the lower abdomen, the blood supply to the contralateral side of pedicle is affected. The appendectomy scar does not affect the blood supply of the skin flap; if there is a transverse incision scar of the rectus abdominis muscle, the pedicled transfer cannot be performed. Therefore, after the modified radical mastectomy with preservation of pectoralis major muscle, in addition to appendectomy incision, the patients without other abdominal scars are suitable for application of single-pedicled TRAM flap.

After radical mastectomy or extended radical mastectomy, the required tissue volume is large, while the tissue volume of the single-pedicled TRAM flap is inadequate; for patients with scars in the center of the lower abdomen, the contralateral blood supply of the single-pedicled TRAM flap is affected, and the surgical methods such as double-pedicled TRAM flap, vertical rectus abdominis myocutaneous flap or combined with additional vascular anastomosis, and free transplantation should be selected. The surgical method combined with additional vascular anastomosis is selected preferably.

Surgical design: The marker line is made in the patient in standing position before surgery – ① the range of tissue defect in the anterior part of chest, a wide range of tissue defects need to be filled from the infraclavicular area; ② the inframammary fold which is symmetrical to that at the contralateral side; ③ the midpoint of the xiphoid process; and ④ the midpoint of the upper pubic hair.

When TRAM flap is designed, it is required to determine the upper margin of the skin flap at first. Since the perforating branches of blood vessels around the navel are thickest and richest; the upper margin of TRAM flap is located at 0.5–1 cm above the navel; the upper margin passes through the slight upper side of the mons veneris, and it should be considered that the donor site can be sutured directly. Especially in younger patients, the abdominal skin is already strained and lacks of sagging; thus, the lower margin of the skin flap should be shifted upward moderately to prevent the donor site wound dehiscence or partial skin necrosis, while the incision in the pubic hair easily leads to necrosis of the middle part of the apron-like flap in upper abdomen. The skin flap presents as fusiform, and the range is limited between bilateral anterior superior spines that is limited within the blood supply range of the epigastric inferior vessels and the superficial inferior epigastric vessels. If exceeding this range, the blood supply area of the superficial circumflex iliac vessel will be brought into the skin flap, which becomes the cause of partial skin flap necrosis. In order to reduce the distortion of the pedicle when the skin flap is transferred, the contralateral rectus abdominis muscle of the reconstructed side is usually selected as the muscle pedicle. Recently, it is reported that the ipsilateral rectus abdominis muscle is also used as the muscle pedicle.

Part of rectus abdominis muscle and its sheath: The blood supply of the skin flap is ensured preferentially for the part above the navel, and the lateral one-third of the rectus abdominis muscle is only retained. A 2–3 cm-wide rectus abdominis anterior sheath in the middle part is harvested, and the medial two-thirds of the muscle is brought into the pedicle. The muscle pedicle is separated upward to the costal margin, then the superior epigastric artery and vein which enter into the body from underneath the costal cartilage are confirmed, and subsequently the skin flap is rotated and transplanted to the chest and is temporarily fixed. Only a part of the rectus abdominis muscle is harvested, and a part of the rectus abdominis muscle and its sheath are retained in the abdomen as much as possible, which is an important measure to prevent the abdominal complications such as abdominal weakness and abdominal wall hernia.

Surgical method: The surgery is performed under general anesthesia; the urethral catheter is placed before surgery. The thoracic scar is removed at first. The skin flap in anterior part of the chest is separated, upward to the infraclavicular area, outward to midaxillary line, inward to the parasternal area, and downward to the inframammary folds. The subcutaneous tunnel is made from the center of the chest to the abdomen, and when the subcutaneous tunnel is made, it is supposed to prevent the excessive separation of inframammary fold at the affected side and the damage to the morphology of the intermammary groove.

The area around the navel is incised, and the navel is separated from the skin flap. Then the upper margin of TRAM flap is incised and obliquely enters into and incises the fat layer toward the head side, which is conducive to bringing more adipose tissue and main periumbilical perforator vessels into the skin flap. The apron-like flap is separated toward the side of the head, the costal arch edge is crossed, and the subcutaneous tunnel in the chest wound is connected to. When the abdominal flap is separated, some adipose tissues are retained on the surface of the sheath of the rectus abdominis muscle, which is conducive to lymphatic drainage. The lower margin of TRAM flap is incised. At the contralateral side of the pedicle and starting from the outside, the separation is performed on the fascia surface to the center of the abdomen. At the ipsilateral side of the pedicle, the separation is performed from the outside to the inside to expose the myocutaneous perforator at the lateral side of the rectus abdominis muscle. The perforating branches of intercostal artery given off at the lateral margin of the rectus abdominis muscle are severed.

At the junction of the middle and lower one-third of the skin flap, the sheath of the rectus abdominis muscle is incised at the outer side of the myocutaneous perforator, and then the rectus abdominis muscle is separated to find the inferior epigastric artery and vein and confirm the running directions of the blood vessels. It is noted that the muscle is brought into the skin flap minimally. In order to prepare vascular anastomosis if necessary, the inferior epigastric vessels are separated to the femoral artery and vein, and they are harvested as long as possible for standby application. The abdominal wall hernia occurs mostly in the lower abdomen; thus, the rectus abdominis muscle and its sheath should be retained on this site as much as possible to prevent the formation of postoperative abdominal wall hernia. Namely, 3 cm-wide rectus abdominis muscle and its sheath below the navel are harvested, and both inner and outer sides of the rectus abdominis muscle and its sheath are retained.

The anterior sheath of rectus abdominis muscle is closed from top to bottom, and eight shaped two-layered sutures are performed using no. 2 silk suture line. The anterior sheath of the contralateral rectus abdominis muscle is also partially sutured, so as to maintain the symmetry of abdominal wall tension. The navel area is fixed with the anterior sheath of rectus abdominis muscle, so that the navel can be located in the center position; or the anterior sheath of the contralateral rectus abdominis muscle is partially incised, and the navel is fixed to the center position (Fig. 15.8). The patient is adjusted in a semi-sitting position. An opening is made in the center of the skin, and the fatty tissue surrounding the opening within the inner face of the skin is cut off, so that the newly formed navel can have deeper depression. A longitudinal incision is made in adipose tissue layer at the center of abdomen above the navel, and the skin flap is turned over, and then a portion of adipose tissue at the margin of the longitudinal incision is cut off to form a subcutaneous depression. The skin flap is put back to original place and is fixed with the anterior sheath by several stitches at the depression site in the center of the abdomen and the bilateral flanks, so as to simulate the morphology of the abdomen in young females. The drainage tube is placed, then the suprapubic wound is adjusted and sutured from the outside to the inside to avoid the formation of “orecchiette” on both sides, and, finally, the periumbilical area is sutured.

At the same time of using TRAM flap to carry out breast reconstruction, the effect of abdominoplasty is also achieved for the donor site in the abdomen, especially for middle-aged women. Therefore, the treatment principles for the abdominal donor site are the same as those for the abdominoplasty. When the anterior sheath of the rectus abdominis muscle is closed, the anterior sheath of the contralateral rectus abdominis muscle is also partially sutured and closed to maintain the symmetry of abdominal wall tension, so that the navel can be located in the middle position. The navel is fixed with the anterior sheath of the rectus abdominis muscle during surgery, and a Y-shaped opening is made in the umbilical area at the middle line of the skin. The fatty tissue surrounding the opening within the inner face of the skin is cut off, so that the newly formed navel can have deeper depression. A portion of adipose tissue at the center of the upper abdomen is removed intraoperatively to form a subcutaneous depression, and the appropriate fixation with the anterior sheath is performed at the depression site in the center of the abdomen and the bilateral flanks, so as to simulate the morphology of the abdomen in young females.

According to methods for resection of breast cancer, the shaping methods of breast are slightly different. The design of skin flap is divided into transverse and longitudinal shape, and single-pedicled TRAM flap is designed mostly as longitudinal shape. Firstly, the upper outer one fourth of skin flap, namely, the region IV of the flap, is incised (see Fig. 15.7), and the upper end of skin flap is fixed and sutured to the upper margin of the lacuna in the anterior chest to simulate the caudate lobe of the breast and the anterior axillary fold; then the medial, lower, and lateral sides of the breast are fixed and the excessive skin is removed; furthermore, the folding and shaping are carried out and the wound margin is sutured. It is noted that the intermammary groove is made, and the breast shape with appropriate sagging and bulging which is symmetrical to that at the contralateral side is ensured. In the patients with modified radical mastectomy, the pectoralis major muscle and the pectoralis minor muscle are retained, and thus the morphology of anterior axillary folds is complete. The skin flap is placed by the inner on the upper part and the outer on the lower part, and the lateral curve of the reconstructed breast is highlighted. In the patients with radical mastectomy or extended radical mastectomy, the pectoralis major muscle is resected, and the tissue defects in the chest are severe. Therefore, it is required to fill the subclavicular and axillary dents and shape the breast ball for the breast reconstruction. The skin flap is placed by the inner on the upper part and the outer on the lower part, and the anterior axillary folds and breast curve are highlighted. In the patients with severe breast tissue defects, it is required to fix the skin flap to the medial upper arm to simulate the stop point and morphology of pectoralis major muscle.

The abdomen is bandaged with a bellyband after surgery, so that the skin flap of donor site is attached to the substrate, while the abdominal wall is strengthened and the formation of abdominal wall hernias is prevented. The pedicle passes through the area of the xiphoid process, and attention should be paid to preventing the local compression, which will affect the blood supply of the skin flap.

The anesthetic technique is particularly important. The aspiration of sputum should be performed before anesthetic awareness. The endotracheal tube is removed timely after anesthetic awareness, and when the extubation is performed, the assistant abdomen should press the abdomen to prevent choking during extubation, which can lead to the burst apart of abdominal wall sutures. The hospital where the authors work in has applied the technique of general anesthesia with laryngeal mask ventilation, namely, the laryngeal mask is used to cover the epiglottis and throat, and no tube is placed in the trachea; thus, the choking during extubation and the tracheal discomfort after surgery can be prevented. In addition, the general anesthesia with tracheal intubation plus the epidural anesthesia can greatly improve the safety of extubation and effectively prevent cracking of abdominal donor site.

The constipation and coughing should be prevented after surgery. The drainage tube is removed 4–5 days after surgery and then the patient can start walking. The stitches are taken out 10 days after surgery, and the patient can be discharged out of hospital if there are no special circumstances.

At the third month after surgery, after the flap swelling subsides and the condition is stable, the star-shaped flap is used to reconstruct the nipple and areola in outpatient clinic, and then, the tattoo coloring is carried out to complete the entire process of breast reconstruction.

TRAM flap: The free transplantation of TRAM flap pedicled with inferior epigastric artery and vein maintains the epigastric inferior vessels as the main supplying vessels of the lower abdominal skin and subcutaneous tissue, and TRAM flap has good blood supply and less fatty degeneration and induration compared to the pedicled transfer. Partial rectus abdominis muscle is merely harvested and included into the flap, which reduces the damage to the abdominal muscles. For surgeons mastering skilled microsurgical techniques, the flap necrosis rate is 1–3%. In the 1990s, the free TRAM flap breast reconstruction had an increasing trend, and compared with pedicle transplantation, the disadvantages are that the operation time is prolonged by 1–2 h and the skilled microsurgical techniques are required, and the result of survival of skin flap is all or nothing.

The surgical operation is basically the same as that of the pedicled transfer. It is required to retain the epigastric inferior vessels as long as possible when the skin flap is separated. The branching blood vessels of the thoracodorsal vessels, the internal thoracic vessels, and the axillary artery and vein are generally selectively used as the blood vessels of the receptor site (Fig. 15.9). It is worth noting that although the required lengths of the inferior epigastric vessels are limited, it is recommended to separate and preserve the inferior epigastric vessels as long as possible for standby application when the internal thoracic vessels are selected for vascular anastomosis. Therefore, they can be anastomosed with the internal thoracic vessels or thoracodorsal vessels at the healthy side when the internal thoracic vessel at the affected side cannot be used due to anastomotic opening occlusion. The internal thoracic vessels are located at 1 cm beside the sternum, closely clinging to the subchondral area. When the internal thoracic vessels are exposed, firstly, the perichondrium in front of the costal cartilage is stripped off with the periosteal elevator, and the costicartilage is bitten off with rongeur forceps, and then the ophthalmology small scissors are used to cut open the costal perichondrium at the underside of the costal cartilage. If the perichondrium around the costal cartilage is stripped and then the costal cartilage is removed according to the general method, this will easily damage the thoracic artery and vein. When the internal thoracic vein is too small and cannot be used, it is required to harvest the saphenous vein of the lower limb to be bridged with the thoracic dorsal vein, or the cephalic vein of the upper limb is reversed and translocated and is anastomosed with the vein of the skin flap.

The blood circulation status of the skin flap is closely observed within 1 week after surgery. The surgical exploration should be timely performed when it is suspected that the anastomotic thrombosis is formed. The embolism area is removed, and the anastomosis should be carried out again.

Inferior epigastric perforator flap: Koshima and Soeda (1989) firstly reported the inferior epigastric perforator flap completely without the rectus abdominis muscle. [18] took the lead in using this flap in breast reconstruction. The inferior epigastric perforator flap is the hypogastric skin flap which takes the inferior epigastric vessels as the vascular pedicle and takes its major vascular branch in periomphalic area as the nourishing blood vessels. Before surgery, the ultrasound or CTA is used to locate the perforating vessels; the shape and design of the skin flap are the same as those of TRAM flap. The major perforator vessels of the inferior epigastric vessels are found at the surface of the rectus abdominis muscle during surgery, and then the rectus abdominis muscle is separated along their traveling direction to look for the main trunk blood vessel. To protect the supplying perforator vessels, a little muscle tissue can be retained around the blood vessels. After the skin flap is formed, the supplying perforator vessels are anastomosed with the blood vessels in chest receptor site under a microscope.

The advantages of this method are that the morphology and function of the rectus abdominis are maximumly retained and the damage degree of the abdominal wall is reduced to a minimum level. The disadvantages are that the surgical operation is relatively cumbersome and the operation time is prolonged. It is easy to damage the perforator vessels during separation of blood vessels, especially when the pectus abdominis muscle is not included completely, and the probability of failure of the skin flap is increased.

The hypogastric skin flap pedicled with superficial inferior epigastric vessels: The hypogastric skin flap pedicled with superficial inferior epigastric vessels refers to that the superficial inferior epigastric vessels are taken as the pedicle during the transfer and the skin flap is located on the surface of the rectus abdominis muscle; thus, the rectus abdominis muscle is not damaged at all, and the abdominal wall function is preserved to the greatest degree. However, the superficial epigastric vessels have more variation. Only about 20% of patients can use this method.

The flap design is the same as that of TRAM flap. Firstly, the lower margin of the skin flap is incised to look for the superficial epigastric vessels carefully. If the vessel diameter is larger than 1.5 mm, the surgery with superficial epigastric vessel flap can be performed; if there are no superficial epigastric vessels of suitable diameter, the inferior epigastric perforator flap can be used as replacement.

Double-pedicled TRAM flap: Double-pedicled TRAM flap is a feasible treatment for the patients with scars in the middle of the abdomen and the need of undergoing reconstruction with the whole TRAM flap after radical mastectomy. Since the double-pedicled TRAM flap needs to harvest bilateral rectus abdominis muscle and the impact on the abdominal wall function is greater, it is particularly important to harvest a part of the sheath of rectus abdominis muscle and use the intramuscular separation techniques during surgery. Attentions are paid to the operation method, and it is not required to synthesize the artificial patch to strengthen the abdominal wall under normal circumstances. For patients with excessive removal of the rectus abdominis muscle and its sheath, it is required to use intraoperatively the autologous fascia, dermal tissues, or artificial patch (polyester mesh) to strengthen the abdominal wall.

Complications: The most common complications after TRAM flap breast reconstruction are flap necrosis and abdominal wall hernia formation in donor site. The complications after breast prosthesis reconstruction depend on the biological characteristics of the prosthesis itself, but the complications after TRAM flap breast reconstruction depend on the patient selection and the operation method and experience of the surgeon. We should be fully aware that the vast majority of complications after TRAM flap breast reconstruction can be avoided.

In earlier application of TRAM flap, the incidence rate of surgical complications was between 20% and 30% [19, 20]. Analyzed the complications in 346 cases of TRAM flap breast reconstruction, and the simple abdominal complication rate was 16% from 1981 to 1984. With the accumulation of surgical experience, the incidence rate of abdominal complications was decreased to 4% from 1985 to 1990. Hartrampf (1987) reported surgical complication rate in more than 300 patients: the partial skin flap necrosis rate was 6%, and the complete necrosis rate was 0.3%, and the abdominal wall hernia rate was 0.3%; in 1991, he reported that the incidence rate of partial skin flap necrosis was 3%, and the complete necrosis rate was 0. The reduction of complications is due to the accumulation of surgical experiences and the full understanding of the risk factors. According to the data from European and American countries, the risk factors related to the complications include obesity, smoking, previously treated with radiotherapy, hypertension, severe systemic disease, etc., with special emphasis on obesity factor. Kroll [21] divided the degree of obesity into four levels: emaciated, standard, obese, and severely obese. Their complication rates of TRAM flap breast reconstruction were 15.4%, 22.7%, 31.4%, and 41.7%, respectively.

After the occurrence of skin flap necrosis, when the necrotic boundaries are obvious, the thorough debridement is performed to remove necrotic tissue, and the reshaping is performed. It is noteworthy that the skin flap should be stretched again during debridement, and the reshaping of the breast after removal of necrotic tissue is carried out. If the necrotic tissue is removed during shaping, the debridement is incomplete often due to misgiving that the pedicle is damaged, and the wound cannot heal for a long time.

After debridement and shaping, the breast volume after reconstruction is slightly reduced, and most patients can accept it. For patients with a large range of necrotic tissue and too small breast volume after reconstruction and shaping, the breast prosthesis can be implanted under the skin flap at the second stage.

When the necrosis boundaries are not confirmed, the debridement should be performed after the necrosis boundaries are confirmed, and the antibiotic ointments such as chlortetracycline ointment and SD-Ag cream are topically applied during the waiting period, so as to prevent aggravation of the tissue necrosis due to secondary infection or the effusion under the scab.

In order to prevent the occurrence of abdominal wall hernia, some authors advocate using the artificial patch (including polyester mesh, nylon mesh, etc.), autologous fascia, and dermal tissue to strengthen the abdominal wall. Hein (1998) transplanted the skin tissue which was removed during skin shaping and then was de-epithelialized to the anterior sheath of the rectus abdominis muscle, so as to strengthen the abdominal wall and make good use of waste materials, which had achieved good results. For selection of reconstruction method, the single-pedicled TRAM flap or free transplantation should be selectively used, and double-pedicled TRAM flap is avoided as far as possible.

After the abdominal wall weakness or abdominal wall hernia occurs, the patient should wear reinforced elastic stretch tight pants until the surgical correction at the second stage is performed. The repair of abdominal wall hernia can be carried out together with other local adjustment surgeries. The area of abdominal wall weakness or abdominal wall hernia is separated through original abdominal surgical incision, and the herniated tissues are put back, and then the tissue patch is used for repair and is fixed onto the surrounding healthy anterior sheath and muscles of rectus abdominis muscle or fixed onto bilateral iliac crests. The patient should wear strictly the elastic stretch tight pants within 3 months after surgery and avoid strenuous exercise abdomen.

Sometimes the isolated fat induration is easily confused with tumor recurrence, and the local biopsy examination is useful in differential diagnosis.

Partition of the fatty tissue surrounding the latissimus dorsi muscle: Delay (1998) divided the available fatty tissue surrounding the latissimus dorsi into five regions (Fig. 15.11):

Preoperative examination and skin flap design: In addition to conventional examinations on systemic recurrence of the tumor, the situations of the breast at the healthy side and the donor site are the examination key points.

Surgical methods: The patient takes the lateral position with the affected side on top, and the chest scar removal and skin flap separation can be carried out in this position. After disinfecting and draping in surgical area, the affected upper limb is bandaged with a sterile sheet, which facilitates the movement during surgery.

The chest scar is removed, and the lacuna is separated within the preoperative marked range on the surface of the pectoralis major muscle under the skin flap. After the bleeding is stopped, the lacuna is filled with saline gauzes for standby application.

The flap incision is made along the back marking line. After the skin is incised, 0.5 cm-thick subcutaneous fat is retained, and the remaining fat is retained on the surface of the muscle; meanwhile, the undermining dissection of the harvesting area of the muscle and the fat flap are performed. In the process of undermining dissection, a certain thickness of subcutaneous fat should be maintained, and the subdermal vascular network is protected to prevent partial skin necrosis in donor site. Separation is performed on the surface of the muscular fascia at the anterior margin of the skin flap to expose the anterior margin of the latissimus dorsi muscle. The running directions of the blood vessels are confirmed at the anterior margin of the skin flap, and the starting point of the latissimus dorsi muscle is cut off according to the required muscle volume. The skin flap is harvested using the method of from far and near. The separation is carried out in deep layer of the muscle, and the thoracodorsal vessels are included. The myocutaneous flap is lifted up and separated toward the direction of the armpit. The thoracodorsal vessels give off a branch to enter into serratus anterior muscle before entering into the latissimus dorsi muscle. Under special circumstances, when the subscapular vessels are destructed, the latissimus dorsi myocutaneous flap relies on the branch to maintain the blood supply. Therefore, it is required to retain the vascular branch of the serratus anterior muscle as far as possible. Under normal circumstances, retaining the branch does not affect the transfer of the latissimus dorsi myocutaneous flap; if necessary, the surrounding tissues of the vascular branch are appropriately dissociated to increase the length of the branch. On the other hand, even if the subscapular vessels are good, retaining the vascular branch of the serratus anterior muscle is also conducive to the blood supply of the latissimus dorsi muscle. The end point of the latissimus dorsi muscle can be kept intact, partially cut off, or cut off to reconstruct the anterior axillary folds. In general case, it should be cut off completely, so as to prevent deformation of the reconstructed breast due to muscle contractions.

Between two incisions before and after the chest, a subcutaneous tunnel near the armpit is made, and the latissimus dorsi myocutaneous flap is transferred to the chest through this subcutaneous tunnel and is temporarily fixed. The negative pressure drainage tube is placed after both sides of the wound margin of donor site are dissociated, and the direct closure and suture are performed in sequence of the subcutaneous area, intradermal area, and skin.

The patient is adjusted in the supine semi-sitting position, and the flap shaping is performed. The latissimus dorsi muscle is placed in separated lacuna in the front chest, and the skin flap is folded, and then the fat flap is placed under the skin flap. Firstly, the myocutaneous flap is placed near the lower part as far as possible and is fixed with chest muscle, costal perichondrium, and inframammary fold flap, and then the end point of the latissimus dorsi muscle is fixed, respectively, with the medial clavicle and the parasternal line. The muscle flap is fixed with lateral chest wall at the anterior axillary line and is sutured on the fascia of the serratus anterior muscle. When there is partial absence of the pectoralis major muscle, the muscle flap is sutured and fixed with the pectoralis major muscle. The adjustment is made to achieve symmetry with the healthy side. The excessive epidermis is removed, and the drainage tube is placed along the inframammary fold, and then the skin incision is sutured. The protection of thoracodorsal nerve during surgery can reduce the denervation atrophy of muscle in a later period. The volume of the reconstructed breast right after surgery should be slightly larger than that at the healthy side. The pedicle compression is prevented during wound dressing. The upper limb is immobilized for 72–96 h after surgery (Fig. 15.13).