BREAST

Skin-Reducing MastectomyMaurizio B. Nava, M.D.

Umberto Cortinovis, M.D.Joseph Ottolenghi, M.D.

Egidio Riggio, M.D.Angela Pennati, M.D.

Giuseppe Catanuto, M.D.Marco Greco, M.D.

Guidubaldo Querci dellaRovere, M.D.

Milan, Italy; and London, UnitedKingdom

Background: The authors propose a combined flap technique to reconstructlarge and medium-sized ptotic breasts in a single-stage operation by use ofanatomical permanent implants.Methods: The authors enrolled 28 patients fulfilling criteria for skin-sparingmastectomy and presenting with ptotic breasts whose areola-to-inframammaryfold distance was more than 8 cm. All reconstructions were performed as asingle-stage procedure. After preoperative planning, a large area in the lowerhalf of the breast was deepithelialized according to the conventional Wisepattern. Mastectomy was then carried out. To perform reconstructions, theinferomedial fibers of the pectoralis major muscle were dissected and suturedto the superior border of the inferior dermal flap. An anatomical implant wasthen inserted into the pouch, which was closed laterally with the previouslyharvested serratus anterior fascia. Skin flaps were finally closed down to theinframammary fold.Results: The authors performed 30 procedures on 28 patients. The mediumsize anatomical implants was 433 cc. Twelve women achieved symmetrizationin a single stage ending in a symmetric inverted-T scar. The overall com-plication rate was 20 percent, with four cases (13 percent) complicated bysevere, extensive necrosis of the skin flaps requiring implant removal.Conclusions: Breast cancer treatment must nowadays optimize cosmeticresults. This can be accomplished in selected cases by means of a single-stageoperation that the authors call “skin-reducing mastectomy.” The final scarsimitate those of cosmetic surgery. Careful patient selection and improvementin the learning curve may reduce the complication rate. (Plast. Reconstr.Surg. 118: 603, 2006.)

Skin-sparing mastectomy was introducedinto clinical practice several years ago andis now considered an oncologically safe sur-

gical procedure.1–5 Saving the skin envelope andinframammary fold improves the reconstructiveoutcome of a conventional radical modified orsimple mastectomy and avoids unpleasant scar-ring.

Carlson and colleagues6 classified skin-sparingmastectomy into four categories based on type ofincision used and amount of skin removed.Types I, II, and III of this classification involvemainly small breasts and take into considerationthe position of a previous biopsy scar. In all ofthese cases, mastectomy is carried out through aperiareolar approach. Type IV skin-sparing mas-tectomy involves large ptotic breasts that require

a conspicuous reduction of the skin envelopeand a contralateral mastopexy or reduction.

Reconstruction surgery in this subset of mastec-tomies can be performed by means of totally sub-muscular expanders or permanent prosthesesrather than autologous flaps. Final scarring is sim-ilar to that from cosmetic surgery (inverted T).

This technique has two main limitations. First,the two long superior flaps that close down to theinframammary fold may become ischemic, be-cause of their length and thinness. This could re-sult in healing complications of the inverted-T scar,such as superficial epidermolysis, wound dehis-cence, and implant exposure.7 Second, a perma-nent prosthesis in the lower pole of the recon-structed breast lacks projection, resulting inexcessive upper pole fullness. This inconveniencecan be overcome in part by means of a two-stepoperation initially using tissue expansion.

In this study, we describe an alternative tech-nique to minimize complications and poor cos-metic results in a single-step operation using ana-tomical silicone gel implants and a dermal-muscleflap pocket.

From the Plastic and Reconstructive Surgery and BreastUnits, Istituto Nazionale Tumori, and the Breast Unit,Royal Marsden Hospital, National Health Service.Received for publication March 26, 2005; accepted May 26,2005.Copyright ©2006 by the American Society of Plastic SurgeonsDOI: 10.1097/01.prs.0000233024.08392.14

www.PRSJournal.com 603

PATIENTS AND METHODSWe enrolled 28 patients on behalf of Istituto

Nazionale Tumori, in Milan, Italy, from Septem-ber of 2001 to October of 2004. All patients ful-filled the oncological criteria for skin-sparing mas-tectomy.

We submitted all patients to reconstructive cri-teria and included all women who presented withsagging breasts and an areola-to-inframammaryfold distance of more than 8 cm and a nipple-to-areola distance of more than 25 cm in the trial forthis technique.

Operations were performed by a team madeup of a surgical oncologist and a plastic surgeon.All reconstructions were performed as a single-stage procedure. We used McGhan style 410/510highly cohesive silicone gel anatomical perma-nent implants (Inamed, a Division of AllerganInc., Irvine, Calif.), with full and extra-full projec-tion. Cosmetic and reconstructive results were as-sessed by plastic surgeons comparing preoperativeand postoperative photographs.

All data were collected retrospectively fromthe clinical medical data records.

Surgical TechniqueThe Preoperative ProjectAs with all surgical procedures we perform

for breast reconstruction or reshaping afterwide local excision, our strategy begins with acareful preoperative assessment. With the pa-tient standing in front of us, we first mark theposition of the new nipple along the midcla-vicular line at a distance between 19 and 23 cm.The marking then follows the steps used for anormal breast reduction or mastopexy using aconventional Wise pattern; however, on the mas-tectomy side, we erase the semicircular drawingrepresenting the position of the new nipple-areola complex and we prolong the two verticallimbs up to the new nipple position. The lengthof the two limbs on this side depends on thedegree of reduction we want to achieve and isusually between 5 and 7 cm, plus the 2 cm radiusof the nipple-areola complex. The distal ends ofthe two limbs are then extended medially andlaterally with patient lying in the supine posi-tion, so as to intercept the previously markedinframammary fold (Figs. 1 and 2, above, left).

Surgical ProcedureSkin is incised full thickness along the vertical

limbs of the reduction pattern, including only theepidermis (partial thickness) after the inframam-mary line. A dermal flap is then created by deepi-

thelialization of a large lower area of skin betweenthe inframammary line and the medial and lateralextensions of the reduction pattern.

Before the mastectomy is started, the lowerflap is sculpted down to the inframammary fold,whose anatomy we always identify to allow care-ful preservation. The gland has to be removedwith accurate sparing of the superior flap’s sub-dermal vascularization. We always tend to dissectfollowing Cooper’s ligaments plane, to mini-mize ischemia without compromising oncologicsafety and complete removal of breast tissue.

This access usually allows for easy axillary dis-section or sentinel node identification and biopsy.After the oncologic procedures are completed, westart the reconstruction by incising along the lat-eral border of pectoralis major. The inferior andlower-medial insertions of this muscle are dividedand sutured to the superior border of the dermalflap (Fig. 2, above, right). A large pouch is thencreated to accommodate an anatomically shapedpermanent prosthesis. The pouch is then closedlaterally with the previously raised serratus muscle(Fig. 2, below, left). Before the pouch is closed, asuction drain is placed inside it. Once the viabilityof the cutaneous flaps has been carefully assessed,the skin is sutured by approximating the distal endof the two vertical limbs to the inframammary line.

The nipple is usually reconstructed in a sec-ond step with the patient under local anesthesia.In selected cases, nipple autotransplantation canbe performed, even if it remains unclear whetherthe superior flap can provide adequate vascular-ization to the skin graft. In a few cases, we recon-structed the nipple intraoperatively with local skin

Fig. 1. Preoperative markings for skin-reducing mastectomy onthe left breast and mastopexy on the right breast.

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flaps (Fig. 2, below, right). There is still concernregarding the oncologic safety of nipple preser-vation in cancer patients.7 In this case, we normallyperform frozen section analysis of retroareolarbreast ducts.

RESULTSWe performed 30 procedures in 28 patients.

The median patient age was 47 years (range, 33 to67 years). There was a median follow-up of 13.6months. Six patients (21.4 percent) were smokers.

We subdivided patients into groups accordingto the stage of disease: five patients (17.9 percent)had Tis, one patient (3.6 percent) had Tis(Paget), 13patients (46.4 percent) had T1N0, one patient hadT1N1 with associated extensive ductal carcinomain situ not suitable for conservation, one patienthad T2N0, and two patients (7.14 percent) hadT2N1 disease. One patient presented with bilat-

eral breast cancer (T1N1 on one side and T2N1contralaterally).

A single patient was at high risk because ofgene mutations and had undergone a bilateralprophylactic mastectomy, and two patients (7.14percent), after breast cancer on one side, decidedto undergo contralateral prophylactic mastectomy(Fig. 3). We used this technique for a case ofbenign extensive disease (chronic breast abscess).

In seven patients (25 percent), we performedaxillary dissection; six dissections were performedthrough a mastectomy incision and one dissectionrequired a separated incision in the axilla. Weidentified and excised 15 sentinel nodes (50 per-cent). In no case did we need a new lateral inci-sion.

One patient had bilateral mastectomy for bi-lateral invasive breast cancer. For reconstruction,style 410/510 anatomically shaped, highly cohe-sive silicone gel implants were used; the medium

Fig. 2. (Above, left) Preoperative markings for right skin-reducing mastectomy. (Above, right) The lower border of the pectoralis majormuscle is sutured to the inferior dermal flap. (Below, left) The serratus fascia is raised to close the pouch laterally. (Below, right) Post-operative result.

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size implant was 433 cc, the largest implant was 620cc, and the smallest was 195 cc.

We performed 12 contralateral symmetriza-tion procedures (40 percent) in one stage. Inseven cases, we performed an inferior pediclebreast reduction, and in five cases we performeda mastopexy.

Three patients had one-stage nipple recon-struction in the operating room, one with by localskin flaps and two with nipple-areola skin grafts(one bilaterally). Second-stage nipple reconstruc-tion was performed in six cases 6 months afterimplant allocation.

Six patients developed superficial epidermol-ysis initially treated conservatively by regular dress-ing. Four patients required implant removal be-cause of exposure after necrosis of the superiorflaps. Three of these patients were smokers. Aftercomplete healing of the wound, a new reconstruc-tion was carried out with tissue expansion in all the

cases. None of the uncomplicated cases reportedcapsular contracture (Baker I, 78 percent; BakerII, 28 percent) All patients who had invasive can-cer received adjuvant chemotherapy. No patientreceived postoperative radiation therapy to thechest wall, internal mammary chain, or supracla-vicular fossa.

DISCUSSIONIn 1991, Toth and Lappert introduced,7 for

the first time, the idea of preoperative plastic sur-gery planning and skin-saving techniques in pa-tients undergoing simple or radical modified mas-tectomies. The oncological safety of thisprocedure has recently been demonstrated in sev-eral studies, and skin-sparing mastectomy is thetechnique of choice in some patients.1–5 Small-breasted women can be reconstructed using per-manent prostheses or temporary expanders. Inthese cases, the breast can be easily removedthrough a periareolar approach.

Large or medium-sized breasts are usuallyptotic and require a variable degree of skin re-duction and a contralateral symmetrization for anacceptable cosmetic and reconstructive outcome.This is normally accomplished by removing alarger island of skin, including the nipple-areolacomplex, thereby creating the usual submuscularpocket filled with a temporary expander. A secondoperation is then necessary to reach the final re-constructive result, and it is not really possible tocarefully predict the result from the initial mas-tectomy. Scarring in this case is particularly un-pleasant and asymmetric when contralateralbreast symmetrization is carried out.

Mastectomies in large breasts using the plasticsurgery techniques described by Toth andLappert7 could, in theory, achieve a rewardingoutcome. However, several difficulties need to beovercome.

One limitation is related to the relative lack ofspace in the inferior and medial aspects of thesubmuscular pocket. It is possible to release theinferior fibers of the pectoralis major, but in thiscase, a subcutaneous implant could easily becomeexposed, especially when it is put underneath thelong and possibly ischemic superior mastectomyflap. This length, as Toth and Lappert7 themselvesdescribe, is critical in determining severe compli-cations not rare if the oncologist during dissectionneeds to leave very thin poorly vascularized flaps.

Many authors have tried to overcome necro-sis and poor results using a modified Wisepattern8 rather than a subcutaneous pouch.9 Amuscle-skin combined pocket for permanent

Fig. 3. Prophylactic skin-reducing mastectomy was performedon the left breast due to gene mutation. The patient underwenta two-stage reconstruction on the right breast (above, preoper-ative view; below, 16-month postoperative view).

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implant allocation was described for prophylac-tic and cosmetic purposes by Bostwick in theearly 1990s.10 At that time, there was no infor-mation on the possibility of saving skin duringoncologic procedures. In the technique, apouch made up of pectoralis major and serratusanterior is closed anteriorly by the lower dermalflap deepithelialized before starting mastec-tomy. This allows room for the lower aspects ofthe reconstruction and protects the implant bymeans of a two-layer cover. The nipple-areolacomplex is subsequently grafted in the new po-sition at the top of the inverted T.

Hammond et al.11 introduced Bostwick’s ideain breast cancer treatment. They modified theoriginal technique using temporary expanders inthe large majority of the cases presented, mandat-ing a second operation for permanent implantinsertion. We decided to follow Bostwick’s originaltechnique in our study, and that allowed us toobtain a cosmetically satisfying reconstruction in asingle-step operation.

Use of an anatomical prosthesis when allocatedunder a wide dermal-muscle flap pocket gives animmediate final aspect to the reconstructed breast.Careful saving of the inframammary fold allowed usto obtain an immediate natural ptosis.12 In our in-stitution, mastectomies are conventionally accom-plished by preserving the serratus and pectoralismajor fascia. If a patient is scheduled to undergo askin-sparing mastectomy, she should not have chestwall infiltration diagnosed preoperatively. However,if intraoperatively, for oncological safety, wider ex-cision of fascia is required, we suggest either leavingthe pouch open in the lateral aspect or closing itwith serratus fibers carefully elevated together withthe pectoralis major. An alternative option could beoffered by human acellular tissue matriximplantation.13 This is a rather new skill in breastreconstruction, and we are waiting for further vali-dation from clinical studies before introducing itinto current clinical practice.

By using the combined pouch, we had thechance to allocate large mammary implants (me-dium volume, 433 cc). The large superior access hasgiven us the possibility of identifying sentinel lymphnodes in all cases and avoiding a second scar in thearmpit. Even axillary dissection in the large majorityof cases (85 percent) can be performed through thisaccess. Regardless, it is advisable to avoid strong re-traction to prevent flap problems while exposing theanatomical structures.

The aesthetic purpose of this operation is op-timized by contralateral symmetrization (Fig. 4).In view of this, we decided to extend the indica-

tions of type IV mastectomy to all patients requir-ing a cosmetic procedure with an inverted-T scaron the contralateral breast (Table 1). An 8-cmdistance between the areola and inframammaryfold has been considered the minimum lengthneeded to create a viable dermal flap and a pocketlarge enough to accommodate a prosthesis. In allother cases, skin-sparing mastectomy can be bettercarried out using a periareolar approach. Symme-trization could be easily planned for the sameoperation. However, we gave all of our patients thechoice of having surgery or not on the healthybreast and therefore the chance of a second op-eration whenever they felt it was appropriate. Con-tralateral immediate reduction/mastopexy wasperformed in 11 patients. The inferior pedicletechnique seems to be the most suitable when areduction is needed, whereas for mastopexy weprefer a superior pedicle technique, folding thedeepithelialized inferior pole of the breast intothe retroareolar space as an “auto-prosthesis.”

The nipple-areola complex was usually recon-structed in local anesthesia as a day case proce-dure. We preserved and subsequently grafted thenipple-areola complex in only two patients whohad special concerns regarding cosmesis. Bothwere cancer patients, so we performed a frozensection before grafting. The results showed nocancerous tissue in the retroareolar ducts. Onepatient had a bilateral mastectomy, but because ofa heavy smoking addiction, one graft totally failedand the other survived only partially. The secondgrafted patient had no complications.

In many series describing inverted-T mastec-tomies, a high complication rate is reported (up to27 percent), especially at the T junction6,9,11,14 (Ta-ble 2). Toth and Lappert, in the earliest articleregarding skin-sparing mastectomies, reportedskin problems in four cases of inverted-T proce-dures reconstructed with transverse rectus abdo-minis musculocutaneous flaps.7 Carlson et al., intheir 1997 series, indicated a 27 percent compli-cation rate for type IV mastectomy.6 All patientswere presumably treated with autologous flap re-construction. Further observation from Carlsonon an enlarged population confirmed the previ-ously reported percentage (26.5 percent).14 Ahigher failed reconstruction rate is to be expectedin an implant-based technique. Hammond et al.11

and Hudson and Skoll9 reconstructed the breastmound after inverted-T procedures by using eithertemporary expanders in a two-stage operation or per-manent subcutaneous prostheses. Hammond et al. de-scribed two out of 19 reconstructions with complica-tions, with one case progressing to implant extrusion.

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HudsonandSkoll, allocating implants subcutaneously,reported extrusion in three cases. They provide a thor-oughdescriptionof thecomplicatedcases,andallwererelated to compromised peripheral microcirculationin heavy smokers or diabetics. With our technique, weobserved a 13 percent rate of severe complicationsrequiringimplantremovalandanoverallcomplicationrate of 20 percent (skin problems). Complications inour study began with superficial epidermolysis or mi-

nor wound dehiscence. One-third resolved with con-servative treatment, while the other two-thirds pro-gressedtonecrosisandimplantexposure.Asexpected,catecholamine released due to the effects of nicotinedamaged the vascularity of thin and long skin flaps.15

Carlson et al. correlated tobacco smoking with a sig-nificantly higher rate of necrosis in a subset of smokerswho underwent skin-sparing mastectomy (49 percentversus 19 percent in the nonsmoking group, p �

Fig. 4. Oncologic and cosmetic treatment performed during the same operation. (Above) Preoperative views. (Below) Postoperativeviews.

Table 1. Skin-Reducing Mastectomy: Oncologic and Reconstructive Criteria

Oncologic Criteria Reconstructive Criteria

• Invasive carcinoma unsuitable for breast conservation • Medium-sized or large ptotic breasts• Multicentric carcinoma with no evidence of skin

involvement• Nipple-sternal notch distance �25 cm

• Paget’s disease of the nipple associated with either insitu or invasive carcinoma in peripheral location

• Areola-inframammary fold distance �8 cm

• Extensive ductal carcinoma in situ

• To be avoided in smokers and patients with microvascularproblems (previous radiotherapy, diabetes)

• Prophylactic mastectomy• Post neoadjuvant chemotherapy in which conservation

is still not indicated

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0.001).6 In our series, 75 percent of the implants re-moved were from patients who smoked more than 20cigarettes per day. Some authors suggested intraoper-ative assessment of skin viability with fluorescein toprevent ischemia.11 We, in accordance with Carlson etal., did not find this device to be helpful, relying onlyon clinical observation of skin flap color and red bleed-ing from the edges.14

In view of our report, we advise surgeons toavoid using the described technique in heavysmokers and whenever microvascular disease(e.g., diabetes, postradiation therapy, and so on)is present. In our opinion, the complication ratecan be lowered by accurate patient selection andimproving the learning curve of the technique.

Although the latissimus dorsi flap plays a ma-jor role in repairing failed reconstructions causedby extensive skin necrosis, we never used it as asalvage flap. In all our complicated cases, skin flapswere still large enough to allow expander alloca-tion and a conventional two-stage procedure.Whenever it was not strictly required, we tended topreserve large myocutaneous flaps to reduce bio-mechanical sequelae16 and to keep them availablefor further reconstructions.

A possible option to reduce risks and optimizecosmetic results could consist of using a verticalapproach to mastectomy, with a limited skin take-out followed by a periareolar and vertical skinclosure.14 This is an interesting access to be even-tually endorsed in preoperative plastic surgeryplanning for mastectomy. In our opinion, how-ever, it does not seem to be appropriate in verylarge and ptotic glands (Fig. 4). We would con-sider it for medium-sized ptotic breasts and evento produce symmetrical scars. The decision inthese cases always has to be left to the patient, withthe surgeon possibly offering the patient thechance to undergo a two-stage procedure withcontralateral augmentation. This strategy, accord-ing to our experience, produces extremely satis-fying cosmetic results.

Capsular contracture is one of the main issuesin implant reconstructions affecting the final ap-

pearance of the new breast. Final results werejudged by plastic surgeons and patients as ex-tremely satisfying, especially with regard to theoptimal degree of ptosis and appropriate distri-bution of volume between the superior and infe-rior and medial and lateral aspects of the breast.All of our patients were rated as having Bakergrade I or II contracture (median follow-up, 13.6months). In our opinion, complete release of theinferomedial pectoralis major fibers and the in-ferior dual dermal-adipose plane allowed for avery soft and natural reconstruction.

CONCLUSIONSOncologic procedures in breast cancer nowa-

days must consider accurate preoperative assess-ment to optimize cosmetic results. Large or me-dium-sized breast cosmesis often requires a certaindegree of skin envelope reduction. This can beaccomplished in eligible cases by means of a sin-gle-step operation that we call a “skin-reducingmastectomy.” On the basis of this study, we aregoing to offer all of our patients who meet appro-priate oncologic and reconstructive criteria thiskind of treatment.

Our goal will be to assess accurately in a largeseries the complication rate and cosmetic results.We believe that once the safety of this techniquehas been successfully achieved and demonstrated,it can be adopted extensively. The majority ofwomen who need a mastectomy usually presentwith an excessive skin envelope. All of them can beoffered a skin-reducing mastectomy, and by meansof a single operation, we might be able to mini-mize unpleasant scarring and offer a favorablecosmetic and psychological outcome.

Maurizio B. Nava, M.D.Plastic and Reconstructive Surgery Unit

Istituto Nazionale TumoriVia G. Venezian 120133, Milan, Italy

nava@istitutotumori.mi.it

Table 2. Inverted-T Mastectomy Reconstructive Technique and Complication Rate

Authors (ref.) No. ofCases

Type ofReconstruction

Total No.of Complications

MinorComplications

ImplantExtrusion

Toth and Lappert, 19917 –* TRAM flaps 4* 4* (superficialepidermolysis)

–

Carlson et al., 19976 44 Not reported, presumably TRAM flaps 12/44 (27%) – –Hammond et al., 200211 12 Two-stage implant reconstruction 2/12 (16.6%) 1/12 (8.3%) 1/12 (8.3%)Hudson and Skoll, 20029 19 Single-stage implant reconstruction 3/19 (15.7%) Not reported 3/19 (15.7%)Carlson, 200414 68 Not reported, presumably TRAM flaps 18 (26.5%) – –*Number of Wise pattern mastectomies was not specified. All complicated cases were inverted-T mastectomies.

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risk after skin-sparing and conventional mastectomy: A 6-yearfollow-up. Plast. Reconstr. Surg. 104: 421, 1999.

2. Slavin, S. A., Schnitt, S. J., Goldwyn, R. M., et al. Skin-sparingmastectomy and immediate reconstruction: Oncologic risksand aesthetic results in patients with early-stage breast can-cer. Plast. Reconstr. Surg. 102: 49, 1998.

3. Rivadeneira, D. E., Simmons, R. M., Osborne, M. P., et al.Skin-sparing mastectomy with immediate breast reconstruc-tion: A critical analysis of local recurrence. Cancer J. 6: 331, 2000.

4. Simmons, R. M., Fish, S. K., Osborne, M. P., et al. Local anddistant recurrence rates in skin-sparing mastectomies com-pared with non-skin-sparing mastectomies. Ann. Surg. Oncol.6: 676, 1999.

5. Medina-Franco, H., Vasconez, L. O., Urist, M. M., et al. Fac-tors associated with local recurrence after skin-sparing mas-tectomy and immediate breast reconstruction for invasivebreast cancer. Ann. Surg. 235: 814, 2002.

6. Carlson, G. W., Bostwick, J., III, Wood, W. C., et al. Skin-sparing mastectomy: Oncologic and reconstructive consid-erations. Ann. Surg. 225: 570, 1997.

7. Toth, B. A., and Lappert, P. Modified skin incisions formastectomy: The need for plastic surgical input in preoper-ative planning. Plast. Reconstr. Surg. 87: 1048, 1991.

8. Skoll, P. J., and Hudson, D. A. Skin-sparing mastectomy usinga modified Wise pattern. Plast. Reconstr. Surg. 110: 214, 2002.

9. Hudson, P. A., and Skoll, P. J. Complete one stage, imme-diate breast reconstructions with prosthetic material in pa-tients with large or ptotic breasts. Plast. Reconstr. Surg. 110:487, 2002.

10. Bostwick, J. Total mastectomy with breast skin and volumereduction using an inverted t incision. In Plastic and Recon-structive Breast Surgery. Vol. II. St. Louis, Mo.: Quality MedicalPublishing, 1990. Pp. 1048–1054.

11. Hammond, D. C., Capraro, P. A., Arnold, J. F., et al. Use ofa skin-sparing reduction pattern to create a combinationskin-muscle flap pocket in immediate breast reconstruction.Plast. Reconstr. Surg. 110: 206, 2002.

12. Nava, M., Quattrone, P., Riggio, E., et al. Focus on the breastfascial system: A new approach for inframammary fold re-construction. Plast. Reconstr. Surg. 102: 1034, 1998.

13. Baxter, R. Intracapsular allogenic dermal grafts for breastimplant-related problems. Plast. Reconstr. Surg. 112: 1692,2003.

14. Carlson, G. W. Trends in autologous breast reconstruction.Semin. Plast. Surg. 18: 79, 2004.

15. Chang, L. D., Buncke, G., Buncke, H., et al. Cigarette, smok-ing, plastic surgery, and microsurgery. J. Reconstr. Microsurg.3: 290, 1996.

16. Martino, G., Nava, M., Benson, J., et al. Breast reconstructionwith myocutaneous flaps: Biomechanical aspects. In Onco-plastic and Reconstructive Surgery of the Breast. London: Taylor& Francis, 2004. Pp. 141–149.

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