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Reconstruction of the Breasts
Symposium on Cosmetic Surgery
Reconstruction of the Breasts
John R. Lewis, Jr., M.D.*
Only a generation ago the breast was considered largely a functional organ. True, the breast has been extolled in painting and sculpture through the ages, and perhaps always has been considered a part of the beauty of womanhood. However, only in the last two generations has the breast become an aesthetic appendage in more "cultured" societies. The well-formed, symmetrical, firm breast, well proportioned to the other bodily features, has truly become an important aspect of the feminine ideal. Although, in the opinion of the author, there has been overemphasis on the desirability of the large bust, true inadequacies can be a source of real emotional problems. The "simple" augmentation mammaplastyt has been reasonably perfected through the past few years so that soft, symmetrical, and proportionate breasts can usually be expected from the procedure, with only an insignificant scar in the submammary fold, at the areolar margin, or in the axilla. The ptotic breast can be elevated on the chest wall, the breast skin capsule tightened, and a firm, contoured breast obtained. The hypertrophic breast, which is usually accompanied by a moderate or marked degree of ptosis, is reduced in size and shaped to suit the size and proportions of the patient. Inequalities of the breasts and of the chest wall are corrected to a great extent, and breast resections for benign lesions may be replaced by "nonreactive" implants, with the preservation of breast size and contour. Now there are also procedures available for reconstructing the breast which has been removed by subcutaneous, simple, or radical mastectomy, as well as the breast which has been deformed by trauma. The psychological implications of breast deformities are great. 3 • 7. 8. 27. 28, 31 In fact, the personality change in the patient after breast reconstruction is often greater than the actual physical change. To the plastic surgeon this alone should make the effort worth the doing. ':'Head, Department of Plastic Surgery, Crawford W. Long Hospital of Emory University, and Doctors' Memorial Hospital; Attending Plastic Surgeon, Georgia Baptist Hospital, St. Joseph's Infirmary, Piedmont Hospital, Northside Hospital, Grady Memorial Hospital.
t Augmentation mammaplasty is discussed elsewhere in this issue (p. 441). Surgical Clinics of North America- Vol. 51, No.2, April 1971
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SUB CUT ANEOUS MASTECTOMY When chronic benign breast disease is present and malignancy has been ruled out by mammography or biopsies, subcutaneous mastectomy may prevent total loss of the breast. 4 • to, 12, 18.21, 24, 25. 27 This operation may truly be prophylactic, because malignancy is thought to develop in the chronically diseased breast at least four times as often as in the normal breast. Subcutaneous mastectomy consists of subtotal resection of the breast tissue, leaving only some breast tissue attached to the ducts as they pass into the nipple. It is rarely necessary to leave breast tissue superficially or in the tail of Spence; therefore, adequate resection should be possible throughout. Immediate reconstruction is sometimes carried out at the same stage, unless the overlying skin capsule is very thin. When the overlying skin is thin, or when the breast is large, the prosthesis is inserted at a second stage, several weeks later. As in augmentation mammaplasty, an inframammary incision is used for subcutaneous mastectomy. The incision is somewhat longer. The resulting breast is usually reasonably soft, though not quite so natural to palpation as following augmentation mammaplasty. Many patients claim to have almost normal sensation in the nipple once healing is complete. Certainly the patient is much better off psychologically than she would have been if simple or radical mastectomy had been performed. Subcutaneous mastectomy may be used instead of simple mastectomy in many instances. The use of augmentation implants following subcutaneous mastectomy has been quite successful. The "fillable" prosthesis and the gel-filled prosthesis have both given good results. The newer prostheses of both types have obviated previous problems, and results are much improved. There seems little need to use an overlying capsule of Dacron, or other fibrous tissue-producing material, since in most patients a thin capsule or pseudocyst forms about the implant in a natural manner.
SIMPLE MASTECTOMY Reconstruction of the breast following simple mastectomy is usually not a complicated procedure, though it must be carried out in more than one step.23-28 An implant of conservative size may be inserted through a scar resection incision, if there is an unsightly scar across the breast skin and chest wall (Fig. 1), or through an incision in the proposed submammary fold if the original scar is acceptable (Fig. 2). Undermining is done in a deep plane against the chest wall so as to provide a thick flap. If the skin of the chest wall is tight, a smaller implant is inserted than is ultimately desired. This implant is best inserted without Dacron backing to facilitate later replacement with a larger prosthesis. The incision line is again excised when the larger prosthesis is inserted, and the pocket widened about the periphery after the tissues have been stretched in part by the smaller prosthesis. The final prosthesis may
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Figure 1. Left, Simple mastectomy may leave adequate skin and subcutaneous tissue to allow for a one-stage replacement of breast bulk by a breast prosthesis. The nipple and areola are reconstructed at the same stage or later. Right, Reconstruction of the left breast by repair of the scar, an augmentation implant, and reconstruction of the areola and nipple by a graft of labium minora. Augmentation mammaplasty was performed on the right breast.
Figure 2. A, This patient has had bilateral mastectomy, radical and simple, with removal of all breast tissue and subcutaneous tissue, leaving the skin of the chest wall tight and scarred. B, The second stage of reconstruction of the breast completed. The first step consisted of insertion of small implants for initial stretching of the chest skin, followed a few months later by insertion of larger implants once the skin was adequately stretched. C, Following relaxation of the skin of the chest wall, nipples and areolae were constructed with grafts of labium minora.
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have Dacron plaques posteriorly if the gel-filled prosthesis is desired, or the fillable prosthesis may be used, with or without the plaques. The author believes that Dacron backing is of limited use in most reconstructions or augmentations, except when the breast skin is loose or the breasts are ptotic, in which instance posterior support is needed. The pseudocyst wall which forms about the implant gives its own support very quickly. When there is reasonable support by the overlying tissues at the time of insertion, the Dacron backing is probably unnecessary. The next step in reconstruction of the breast following simple mastectomy is the transfer of a full-thickness graft of labium minora for reconstruction of the areola and nipple (Figs. 1,2, and 4). At a later stage, as an out-patient or office procedure, the center of this graft is puckered in the center to form a nipple (Fig. 5). The resulting color and texture match is excellent, and the patient is usually happy with the appearance. 1. 2. 24-28 Simple mastectomy may leave a relaxed skin envelope over the chest and sometimes an abundance of subcutaneous tissue, making reconstruction simpler. In such cases the implant of desired size is nearly always introduced at the first stage. When the skin is tight and there is a paucity of subcutaneous tissue the staged enlargement of the pocket and stretching of the tissues is usually necessary. When the scar across the chest is relaxed and results in a fine line, the incision for insertion of the implant is made in the proposed submammary crease (Fig. 2). Unfortunately, scars are often hypertrophic, wide, and tight, and crease across the anterior axillary fold. It is better then to resect the. scar and to use this incision for insertion of the prosthesis (Fig. 3). The scar is repaired in layers, and a Z-plasty at the anterior axillary line or a W-plasty repair is carried out.
Figure 3. Left, Conservative radical mastectomy of the left breast has left the upper attachments of the pectoralis muscles in the anterior axillary area. The patient had early carcinoma in situ. Right, Completed first stage reconstruction of the left breast by stretching up the skin of the chest wall and advancing the skin from laterally and inferiorly to allow for insertion of an augmentation prosthesis. The next step consisted of resection of the scars with a W-plasty closure, Z-plasty at the anterior axillary line, reconstruction of nipple and areola, and addition of more fluid to the "fillable" prosthesis.
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After a radical-simple mastectomy the skin of the chest wall is usually thin, tight and inelastic. The skin must then be undermined inferiorly and laterally into the axilla and lateral chest wall to provide relaxation (Figs. 2 and 3). The skin of the posterior chest or axilla may be brought forward as a rotation flap to add further soft tissue. This adds some bulk, and is useful for coverage of a breast prosthesis.
RADICAL MASTECTOMY Radical mastectomy is often psychologically disturbing to the patient. The prospect of losing the breast completely and ending up with a scarred and otherwise deformed chest wall is not a pleasant one. The patient who knows that there is a possibility of reconstructing the breast once healing is complete is usually much better psychologically prepared for the operative procedure, and may face the prospect of the destructive surgery with much more tranquility than the patient who is not aware of the possibilities. 3 • 7, s, 24-28, 31 In my own practice I have had a number of friends whose wives have faced this possibility. Talking to them and showing them before and after pictures has apparently made the prospect of the obliterative surgery much less formidable. In fact, the patient who decides not to have the reconstructive procedures following radical mastectomy still feels much better knowing that the choice is her own. With no choice but to bear the burden of the deformity, the psychologic shock can be great. Reconstructing the breast following radical mastectomy is a multiple-stage procedure. The problem of these stages, the possibilities of complications, and the inadequacies of the final result should be discussed in detail, not only with the patient, but with her husband or family. Obviously a reasonably safe follow-up period should be allowed following the original resection; and the author operates only with the approval of the original surgeon. Methods of reconstructing the breast following radical mastectomy vary according to the condition of the chest wall, the condition of the opposite breast, the availability of skin and fat about the body, and the surgeon's studied opinion. When the opposite breast is large and ptotic, one makes use of a part of it to fashion the missing breast. Though it takes considerable surgical artistry to fashion an acceptable breast from the opposite side without badly deforming the donor breast, it is sometimes justifiable. 3 , 7, 18, 19,32 The author prefers not to destroy a "good" breast in order to fashion a reconstructed breast unless this course of action seems clearly the best choice. If by this method two breasts can be reconstructed with reasonably good shapes, then it is certainly worthwhile. A number of surgeons have reported results by this method which have been quite acceptable. The author's patients always seem to have an inadequate opposite breast for transfer, or have had surgical removal of the opposite breast. A more common method of reconstructing the absent breast is with an abdominal flap (Fig. 4).9,14,15,24,25,29,30,32 Most patients are adequately endowed with skin and fat of the abdomen to provide ample tissue;
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Figure 4. A amd B, This patient had radical mastectomy on the right 5 years previously for carcinoma, and prophylactic simple mastectomy of the left breast one year previously for advanced chronic cystic disease. The patient was emotionally upset at the loss of both breasts much more than by the loss of the first breast. The operating surgeon concurred in advising a reconstruction of both breasts if possible. Subcutaneous mastectomy on the left, rather than simple mastectomy, would have facilitated reconstruction of the breast. C, Abdominal flap raised across the lower abdomen. Note the midline abdominal scar which transects the tube pedicle, making the procedure more precarious and making it absolutely imperative to delay the flap in the center. D, Both ends of the flap had been transferred in stages after appropriate delays, the left end of the flap to the anterior axillary area.
however, all too often, long midline abdominal incisions are present which mitigate against the use of an abdominal flap. One of the author's patients had undergone an abdominoplasty years before; thus the pedicle was of necessity constructed on the flank and hip. The construction of a tubed pedicle or a wide flap backed by a skin graft may be left to the surgeon's discretion. Delays are required in the midline and at one end before transfer. Sufficient time should be allowed between stages to encourage the circulation. Shifting large flaps of tissue to the chest wall and shaping the insert and skin, and possibly the insertion of an augmentation implant, require multiple stages (Fig. 4). The delays of the flap are dictated by the individual case and must be judiciously planned. Reconstruction of the areola and nipple is subsequently carried out by one of the methods to be described, but must be postponed until the breast is properly shaped and the exact location of the nipple and areola determined (Figs. 1-4). In some instances, the skin of the chest wall, though thin and tight, may withstand undermining and the insertion of progressively larger
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Figure 4. (Continued) E, Combining the two limbs of the flap to make a single breast mass, matching the opposite breast size and contour as best possible. Note that an augmentationreconstruction has been performed for the left breast and that a areola and nipple have been reconstructed from a labial graft. F and G, Final photographs of patient following complete right breast reconstruction from an abdominal tube pedicle and left augmentationreconstruction. Nipples and areolae have been reconstructed from two semicircles of labia minora, each of which have been unfolded to form a circle, later being pouched up in the center to form the nipple by the technique described in Figure 5.
implants, or the inflation of balloon type implants with increasing quantities of fluid, so that reconstruction is possible without the use of pedicle flaps (Figs. 2 and 3). The danger of a slough is ever present and, if imminent, pedicle shifts may become necessary. All aspects of the reconstruction of the breast following radical mastectomy should be discussed in great detail with the patient and her family. The limitations of the procedure should be clearly outlined. The author has had no patient who has been disappointed with the result after such frank discussion. Had the patient expected a near perfect breast to result, disappointment would have been inevitable. Occasionally reconstruction of both breasts is necessary. The author has reconstructed both breasts following bilateral simple mastectomies (Fig. 2), following radical mastectomy on one side and simple mastectomy on the other (Fig. 4), and following bilateral radical mastectomy. Results can be acceptable, and one should not stop short of the final result which is obtainable. If there is extensive scarring of the breast and chest wall when surgery is completed, the last step of reconstruction may be an overlay graft to improve extensive cutaneous scarring. Cosmetic skin make-up is also helpful at times to camouflage scars. The possibility of a contralateral malignancy after one breast has been removed makes one hesitant to use this breast for reconstruction. In fact, it may even be desirable to do a prophylactic subcutaneous
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mastectomy on the opposite breast with an immediate reconstructionaugmentation in "high risk" patients.
RECONSTRUCTING THE BREAST FOLLOWING BURNS Third degree burns pose many problems in breast reconstruction, depending on the degree of the injury, the extent ofinvolvement of other areas of the chest, arms, shoulder, axilla, and neck, and especially contractures. 24 • 28 Relaxation of the burned chest skin is required to allow the breast to assume its natural shape. Z-plasties or grafts of the axilla, neck, and supraclavicular area are frequently necessary. Skin grafts placed beneath the breast to restore the submammary fold are also necessary in many cases. When the nipple and areola have been destroyed or badly scarred, they may be reconstructed with one of the methods to be discussed. A full-thickness graft of labium minora is usually the method of choice. If the ducts coming into the nipple proper have not been completely scarred and blocked, the graft may be placed in such a manner as to leave the nipple proper coming through the center of the graft. This provides a functional nipple in instances where the ducts actually open through the nipple. Incisions on the front of the breasts and of the upper chest anteriorly should be avoided whenever possible, since hypertrophic scarring is so common in this area.
RECONSTRUCTION OF THE AREOLA AND NIPPLE Tattooing of brown pigment is the simplest manner of substituting an artificial nipple and areola. Exact color matching with the normal areola is rarely achieved. The central portion of the reconstructed areola can be raised to form a nipple by a number of ways: the excision of several small diamond-shaped trapezoids of skin with the closure of the defects will pouch up the central area of skin between these resections to simulate the nipple; the insertion of a small "nubbin" of plastic sponge (either polyvinyl or Silastic) will also pouch up the central area to simulate a nipple. The contralateral areola may be used for replacing the damaged one. A split thickness skin graft from the opposite areola can be used as an over graft. A fine mesh nonadherent material such as rayon or nylon gauze (Owens gauze, parachute silk, etc.), or a perforated plastic dressing (Telfa, etc.) is used as a dressing. The donor area should be completely healed in 10 days to 2 weeks, and most of the pigmentation should return to the nipple and areola if the graft is not too thick. The grafted nipple and areola provides a reasonable substitute. The central portion may be pouched up later to give more fullness to the nipple proper if desired. The most satisfactory method of reconstructing the nipple and areola is a full-thickness graft from the labium minora. I. 2. 24, 25. 28 A half-
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circle of double-thickness labium minora at the margin of the labium in its central portion is used. This defect is closed with a running suture of 4-0 chromic cat gut. Postoperative discomfort and annoyance is practically nil. The graft is unfolded to form a complete circle. A few nicks in the edges will allow the labia to flatten if it tends to cup. The graft is sutured into the recipient area at the selected site on the reconstructed breast. This circular recipient area should be denuded only of epidermis, leaving the rich vascular bed of dermis to receive the graft- the "overgraft technique." A tie-over dressing is applied for a period of 7 to 10 days. The author has not completely lost any of these grafts. Small losses of tissue will heal by secondary retention. The resulting graft is usually of satisfactory color and texture.!. 2, 28 Simulation of the normal nipple and areola is completed by puckering up the central portion to form a nipple prominence (Figs. 4 and 5).17. 22 ,24-28 This last stage is delayed for several weeks to a few months following the graft to allow for softening and for adequate circulation into the graft. Many of these grafts develop sensation when healing is complete. The color of the graft may be darker than the opposite normal nipple and areola if the normal is fairly light in color, but the result is usually excellent. The author has used various methods for simulation of the nipple proper. The method usually used is one originally described by the author 24 - 28 (Figs. 4 and 5). A buried purse-string suture is inserted into
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Figure 5. The author's method of reconstructing the nipple proper is to use a purse string suture, catching small bites of dermis and subcutaneous tissue in a circular fashion. This puckers up the center of the labial graft to simulate the nipple. The suture enters and exits through the same needle opening, coming out two or three times about the circumference of the nipple area and entering again through the same needle openings so as to make no incision necessary. The final exit is through the point of entrance. A small knot is tied to pucker up the nipple, then the knot slips through the hole made by the needle.
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the subcutaneous tissue and tied just tightly enough to pucker up the central portion of the graft to form the nipple. The needle penetrates and comes out at each side of the proposed nipple, and is then reinserted through the same needle opening to come out again at the next point, until a complete circle has been made; the needle then exits through the original opening through which the suture was inserted. The two ends of the suture are then tied snugly but not tightly, and the suture is clipped at the knot. The small knot slips through the opening made by the needle so that the nipple is "pouched up" in the center and no incision has been made. In order to make the complete circle about the proposed nipple, the needle is reinserted in each instance through the same needle opening to make its progress further around the proposed nipple. The choice of suture material is left to the surgeon, but the author usually uses small braided or twisted white nylon, which has minimal reaction in the tissue and which is tolerated very satisfactorily in this very superficial position.
RECONSTRUCTING THE MALE BREAST The male breast is subject to tumor excision and the correction of gynecomastia. The hypertrophic tissue is removed very satisfactorily through marginal areolar incisions and the residual scar is usually not noticed. Marginal areolar incisions are equally useful in the female breast for biopsy and excision of small masses in the immediate vicinity of nipple and areola. One must keep in mind that breast tumors in the male are occasionally malignant and may require mastectomy. However, gynecomastia is usually the cause of diffuse enlargements of the breast. When the male breast must be reconstructed because of overzealous surgery, tumor resection, or injury, adjacent tissue or distant tissue may be used as in the female. Unsightly chest scars are removed and repaired. If the nipple and areola are removed also, the scars are excised, broken up by a W-plasty, by a Z-plasty at the anterior axillary line, or by multiple Z-plasties. The nipple and areola can be reconstructed with free grafts of scrotal skin which is then repaired as with the female. 24 - 28 Such grafts may undergo pigmentation with time, as in the labium minora grafts. The nipple prominence is created at a subsequent out-patient stage under local anesthesia as previously described. Should the resection of the male breast leave adequate skin coverage but inadequate subcutaneous tissue, one may use thin fat or dermis-fat grafts from buttock or abdomen to the breast area. Since fat grafts can be quite thin for reconstruction of the male breast, they are much more likely to "take" than the thicker fat grafts required for larger bulk reconstructions in the female. Even after shrinkage and absorption, the breast will usually be adequate in size. In the reconstruction of one breast and the removal of tissue from the opposite breast at the same stage, one may use excess fatty tissue from the opposite breast as donor tissue for reconstructing the deficient breast.
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Reconstruction of the nipple and areola in the male was first carried out by the author in 1956. 2 4-28 Without finding any precedence in the literature for such a method, the author utilized a full-thickness scrotal skin graft. The results were very satisfactory and since that time the author has considered this the method of choice for reconstruction of nipple and areola in the male. The center may be "pouched up" to form a nipple by one of the methods described, and the nipple is made somewhat less prominent than for the female. The foreskin is a second choice for donor skin.
CONCLUSION Reconstructive procedures on the female or the male breast can be very adequate aesthetically. Whether the organ functions properly, as does the breast following augmentation mammaplasty, or whether it performs no function, as in the reconstructed breast following radical or simple mastectomy, the patient functions to a higher and happier degree than before the reconstructive procedures. More often than not, the psychological effect is more happy than is the physical one. However, one must remember that adequate surgery in the eyes of the surgeon may not be the same in the eyes of the patient or the patient's mate or family. Therefore, it is important for one to discuss the results to be expected as well as the limitations, and to prepare the patient for extra procedures which may be required and for complications which may mar the final result. If the patient and the patient's family have expectations less than the surgeon feels he can fulfil, he is at a distinct advantage. The happy result is a satisfied patient.
REFERENCES 1. Adams, W. M.: Labial transplant for correction of loss of the nipple. Plast. Reconstr. Surg., 4:295,1949. 2. Adams, W. M.: Mammaplasty with free transplantation of the nipple and areolae. Transactions of the First Internat. Congress of Plast. Surgeons. Baltimore, Williams & Wilkins, 1957, p. 371. 3. Alexander, J. E., and Block, L. I.: Breast reconstruction following radical mastectomy. Plast. Reconstr. Surg., 40:175,1967. 4. Cronin, T. D., and Greenberg, R. L.: Our experiences with the silas tic gel breast prosthesis. Plast. Reconstr. Surg., 46:1,1970. 5. deCholnoky, T.: Breast reconstruction after radical mastectomy: Formation of missing nipple by everted navel. Plast. Reconstr. Surg., 38:577,1966. 6. deCholnoky, T.: Reconstruction of breast following mastectomy. Plast. Reconstr. Surg., 16:226,1955. 7. Edgerton, M. T.: Breast reconstruction after radical mastectomy for cancer. South. Med. J., 60:719, 1967. 8. Edgerton, M. T., Jacobson, W. E., and Meyer, E.: Surgical-psychiatric study of patients seeking plastic (cosmetic) surgery: Ninety-eight consecutive patients with minimal deformity. Brit. J. Plast. Surg., 13:136,1960. 9. Fossati, G. H.: Breast reconstruction. Transactions of the Fourth International Congress of Plast. Surg., Excerpta Medica Foundation, 1967, p. 1046. 10. Fredricks, S.: The subcutaneous mastectomy-A prophylactic and cosmetic operation. Presented to the Mexican Academy of Medicine, Mexico City, March, 1966. 11. Fredricks, S.: Personal communication.
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12. Freeman, B. S.: Technique of subcutaneous mastectomy with replacement: Immediate and delayed. Brit. J. Plast. Surg., 72:161,1969. 13. Gerow, F. J., Spira, M., Moore, J. L., and Hardy, S. B.: One-stage replacement mastectomy for chronic fibrocystic disease of the breast. Transactions of the Fourth Internat. Congress of Plast. Surg. Amsterdam, Excerpta Medica Foundation, 1967, p. 1039. 14. Gillies, H.: Surgical replacement of the breast. Proc. Roy. Soc. Med., 52:597, 1959. 15. Gillies, H. D., and Millard, D. R.: Principles and Art of Plastic Surgery. Boston, Little, Brown and Company, 1957. 16. Griffiths, C. 0.: The submuscular implant in augmentation mammaplasty. Transactions of the Fourth Internat. Congress of Plast. Surg. Amsterdam, Excerpta Medica Foundation, 1967, p. 1009. 17. Grodski, M.: Reconstruction des Mamelous deformies. Rer. de Chir. Struct., June, 1937, 126. 18. Harris, H. R.: Automammaplasty. J. Internat. Coll. Surg., 12:827,1949. 19. Holdsworth, W. G.: A method of reconstructing the breast. Brit. J. Plast. Surg., 9:161, 1956. 20. Horton, C.: Personal communication. 21. Kelly, A. P., Jr., Jacobson, H. S., Fox, J. I., and Jenny, H.: Complications of subcutaneous mastectomy and replacement by the cronin silastic mammary prosthesis. Plast. Reconstr. Surg., 37:438,1966. 22. Letterman, G. S., and Schurter, M. A.: Personal communication. 23. Lewis, J. R., Jr.: Mammaplasty-A current evaluation. J. Med. Assoc. Ga., 53:341,1964. 24. Lewis, J. R., Jr.: Reconstructing the female and the male breast. Presented at the meeting of the Internat. Coll. of Surg., Tokyo, Oct., 1968. To be published in J. Internat. Surg. 25. Lewis, J. R., Jr.: Reconstruction of the Breast. Panminerva Medica, September, 1970. 26. Lewis, J. R., Jr.: Reconstructions of the Breast. Proceedings of Internat. CoIL of Surg., Vienna, 1964. 27. Lewis, J. R., Jr.: The augmentation mammaplasty (with special reference to the use of alloplastic materials). Plast. Reconstr. Surg., 35:51,1965. 28. Lewis, J. R., Jr.: The Surgery of Scars. New York, McGraw-Hill Book Co., voL 1, pp. 132139. 29. Maliniac, J. W.: Breast Deformities and Their Repair. New York, Grune & Stratton, 1950. 30. Pierer, H.: Reconstruction of the breast after carcinoma operation. Transactions of the Fourth Internat. Congress of Plast. Surg. Amsterdam, Excerpta Medica Foundation, 1967, p. 1049. 31. Remecher, R., and Cutter, M.: Psychological problems of adjustment to cancer of the breast. J.A.M.A., 148 :833, 1952. 32. Thorek, M.: Plastic surgery of the breast and abdominal walL Springfield, Illinois, Charles C Thomas, 1942. 33. Trier, W. C.: Complete breast absence. Plast. Reconstr. Surg., 36:430, 1965. 478 Peachtree Street, N.E. Atlanta, Georgia 30308
Reconstruction of the Breasts
John R. Lewis, Jr., M.D.*
Only a generation ago the breast was considered largely a functional organ. True, the breast has been extolled in painting and sculpture through the ages, and perhaps always has been considered a part of the beauty of womanhood. However, only in the last two generations has the breast become an aesthetic appendage in more "cultured" societies. The well-formed, symmetrical, firm breast, well proportioned to the other bodily features, has truly become an important aspect of the feminine ideal. Although, in the opinion of the author, there has been overemphasis on the desirability of the large bust, true inadequacies can be a source of real emotional problems. The "simple" augmentation mammaplastyt has been reasonably perfected through the past few years so that soft, symmetrical, and proportionate breasts can usually be expected from the procedure, with only an insignificant scar in the submammary fold, at the areolar margin, or in the axilla. The ptotic breast can be elevated on the chest wall, the breast skin capsule tightened, and a firm, contoured breast obtained. The hypertrophic breast, which is usually accompanied by a moderate or marked degree of ptosis, is reduced in size and shaped to suit the size and proportions of the patient. Inequalities of the breasts and of the chest wall are corrected to a great extent, and breast resections for benign lesions may be replaced by "nonreactive" implants, with the preservation of breast size and contour. Now there are also procedures available for reconstructing the breast which has been removed by subcutaneous, simple, or radical mastectomy, as well as the breast which has been deformed by trauma. The psychological implications of breast deformities are great. 3 • 7. 8. 27. 28, 31 In fact, the personality change in the patient after breast reconstruction is often greater than the actual physical change. To the plastic surgeon this alone should make the effort worth the doing. ':'Head, Department of Plastic Surgery, Crawford W. Long Hospital of Emory University, and Doctors' Memorial Hospital; Attending Plastic Surgeon, Georgia Baptist Hospital, St. Joseph's Infirmary, Piedmont Hospital, Northside Hospital, Grady Memorial Hospital.
t Augmentation mammaplasty is discussed elsewhere in this issue (p. 441). Surgical Clinics of North America- Vol. 51, No.2, April 1971
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SUB CUT ANEOUS MASTECTOMY When chronic benign breast disease is present and malignancy has been ruled out by mammography or biopsies, subcutaneous mastectomy may prevent total loss of the breast. 4 • to, 12, 18.21, 24, 25. 27 This operation may truly be prophylactic, because malignancy is thought to develop in the chronically diseased breast at least four times as often as in the normal breast. Subcutaneous mastectomy consists of subtotal resection of the breast tissue, leaving only some breast tissue attached to the ducts as they pass into the nipple. It is rarely necessary to leave breast tissue superficially or in the tail of Spence; therefore, adequate resection should be possible throughout. Immediate reconstruction is sometimes carried out at the same stage, unless the overlying skin capsule is very thin. When the overlying skin is thin, or when the breast is large, the prosthesis is inserted at a second stage, several weeks later. As in augmentation mammaplasty, an inframammary incision is used for subcutaneous mastectomy. The incision is somewhat longer. The resulting breast is usually reasonably soft, though not quite so natural to palpation as following augmentation mammaplasty. Many patients claim to have almost normal sensation in the nipple once healing is complete. Certainly the patient is much better off psychologically than she would have been if simple or radical mastectomy had been performed. Subcutaneous mastectomy may be used instead of simple mastectomy in many instances. The use of augmentation implants following subcutaneous mastectomy has been quite successful. The "fillable" prosthesis and the gel-filled prosthesis have both given good results. The newer prostheses of both types have obviated previous problems, and results are much improved. There seems little need to use an overlying capsule of Dacron, or other fibrous tissue-producing material, since in most patients a thin capsule or pseudocyst forms about the implant in a natural manner.
SIMPLE MASTECTOMY Reconstruction of the breast following simple mastectomy is usually not a complicated procedure, though it must be carried out in more than one step.23-28 An implant of conservative size may be inserted through a scar resection incision, if there is an unsightly scar across the breast skin and chest wall (Fig. 1), or through an incision in the proposed submammary fold if the original scar is acceptable (Fig. 2). Undermining is done in a deep plane against the chest wall so as to provide a thick flap. If the skin of the chest wall is tight, a smaller implant is inserted than is ultimately desired. This implant is best inserted without Dacron backing to facilitate later replacement with a larger prosthesis. The incision line is again excised when the larger prosthesis is inserted, and the pocket widened about the periphery after the tissues have been stretched in part by the smaller prosthesis. The final prosthesis may
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Figure 1. Left, Simple mastectomy may leave adequate skin and subcutaneous tissue to allow for a one-stage replacement of breast bulk by a breast prosthesis. The nipple and areola are reconstructed at the same stage or later. Right, Reconstruction of the left breast by repair of the scar, an augmentation implant, and reconstruction of the areola and nipple by a graft of labium minora. Augmentation mammaplasty was performed on the right breast.
Figure 2. A, This patient has had bilateral mastectomy, radical and simple, with removal of all breast tissue and subcutaneous tissue, leaving the skin of the chest wall tight and scarred. B, The second stage of reconstruction of the breast completed. The first step consisted of insertion of small implants for initial stretching of the chest skin, followed a few months later by insertion of larger implants once the skin was adequately stretched. C, Following relaxation of the skin of the chest wall, nipples and areolae were constructed with grafts of labium minora.
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have Dacron plaques posteriorly if the gel-filled prosthesis is desired, or the fillable prosthesis may be used, with or without the plaques. The author believes that Dacron backing is of limited use in most reconstructions or augmentations, except when the breast skin is loose or the breasts are ptotic, in which instance posterior support is needed. The pseudocyst wall which forms about the implant gives its own support very quickly. When there is reasonable support by the overlying tissues at the time of insertion, the Dacron backing is probably unnecessary. The next step in reconstruction of the breast following simple mastectomy is the transfer of a full-thickness graft of labium minora for reconstruction of the areola and nipple (Figs. 1,2, and 4). At a later stage, as an out-patient or office procedure, the center of this graft is puckered in the center to form a nipple (Fig. 5). The resulting color and texture match is excellent, and the patient is usually happy with the appearance. 1. 2. 24-28 Simple mastectomy may leave a relaxed skin envelope over the chest and sometimes an abundance of subcutaneous tissue, making reconstruction simpler. In such cases the implant of desired size is nearly always introduced at the first stage. When the skin is tight and there is a paucity of subcutaneous tissue the staged enlargement of the pocket and stretching of the tissues is usually necessary. When the scar across the chest is relaxed and results in a fine line, the incision for insertion of the implant is made in the proposed submammary crease (Fig. 2). Unfortunately, scars are often hypertrophic, wide, and tight, and crease across the anterior axillary fold. It is better then to resect the. scar and to use this incision for insertion of the prosthesis (Fig. 3). The scar is repaired in layers, and a Z-plasty at the anterior axillary line or a W-plasty repair is carried out.
Figure 3. Left, Conservative radical mastectomy of the left breast has left the upper attachments of the pectoralis muscles in the anterior axillary area. The patient had early carcinoma in situ. Right, Completed first stage reconstruction of the left breast by stretching up the skin of the chest wall and advancing the skin from laterally and inferiorly to allow for insertion of an augmentation prosthesis. The next step consisted of resection of the scars with a W-plasty closure, Z-plasty at the anterior axillary line, reconstruction of nipple and areola, and addition of more fluid to the "fillable" prosthesis.
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After a radical-simple mastectomy the skin of the chest wall is usually thin, tight and inelastic. The skin must then be undermined inferiorly and laterally into the axilla and lateral chest wall to provide relaxation (Figs. 2 and 3). The skin of the posterior chest or axilla may be brought forward as a rotation flap to add further soft tissue. This adds some bulk, and is useful for coverage of a breast prosthesis.
RADICAL MASTECTOMY Radical mastectomy is often psychologically disturbing to the patient. The prospect of losing the breast completely and ending up with a scarred and otherwise deformed chest wall is not a pleasant one. The patient who knows that there is a possibility of reconstructing the breast once healing is complete is usually much better psychologically prepared for the operative procedure, and may face the prospect of the destructive surgery with much more tranquility than the patient who is not aware of the possibilities. 3 • 7, s, 24-28, 31 In my own practice I have had a number of friends whose wives have faced this possibility. Talking to them and showing them before and after pictures has apparently made the prospect of the obliterative surgery much less formidable. In fact, the patient who decides not to have the reconstructive procedures following radical mastectomy still feels much better knowing that the choice is her own. With no choice but to bear the burden of the deformity, the psychologic shock can be great. Reconstructing the breast following radical mastectomy is a multiple-stage procedure. The problem of these stages, the possibilities of complications, and the inadequacies of the final result should be discussed in detail, not only with the patient, but with her husband or family. Obviously a reasonably safe follow-up period should be allowed following the original resection; and the author operates only with the approval of the original surgeon. Methods of reconstructing the breast following radical mastectomy vary according to the condition of the chest wall, the condition of the opposite breast, the availability of skin and fat about the body, and the surgeon's studied opinion. When the opposite breast is large and ptotic, one makes use of a part of it to fashion the missing breast. Though it takes considerable surgical artistry to fashion an acceptable breast from the opposite side without badly deforming the donor breast, it is sometimes justifiable. 3 , 7, 18, 19,32 The author prefers not to destroy a "good" breast in order to fashion a reconstructed breast unless this course of action seems clearly the best choice. If by this method two breasts can be reconstructed with reasonably good shapes, then it is certainly worthwhile. A number of surgeons have reported results by this method which have been quite acceptable. The author's patients always seem to have an inadequate opposite breast for transfer, or have had surgical removal of the opposite breast. A more common method of reconstructing the absent breast is with an abdominal flap (Fig. 4).9,14,15,24,25,29,30,32 Most patients are adequately endowed with skin and fat of the abdomen to provide ample tissue;
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Figure 4. A amd B, This patient had radical mastectomy on the right 5 years previously for carcinoma, and prophylactic simple mastectomy of the left breast one year previously for advanced chronic cystic disease. The patient was emotionally upset at the loss of both breasts much more than by the loss of the first breast. The operating surgeon concurred in advising a reconstruction of both breasts if possible. Subcutaneous mastectomy on the left, rather than simple mastectomy, would have facilitated reconstruction of the breast. C, Abdominal flap raised across the lower abdomen. Note the midline abdominal scar which transects the tube pedicle, making the procedure more precarious and making it absolutely imperative to delay the flap in the center. D, Both ends of the flap had been transferred in stages after appropriate delays, the left end of the flap to the anterior axillary area.
however, all too often, long midline abdominal incisions are present which mitigate against the use of an abdominal flap. One of the author's patients had undergone an abdominoplasty years before; thus the pedicle was of necessity constructed on the flank and hip. The construction of a tubed pedicle or a wide flap backed by a skin graft may be left to the surgeon's discretion. Delays are required in the midline and at one end before transfer. Sufficient time should be allowed between stages to encourage the circulation. Shifting large flaps of tissue to the chest wall and shaping the insert and skin, and possibly the insertion of an augmentation implant, require multiple stages (Fig. 4). The delays of the flap are dictated by the individual case and must be judiciously planned. Reconstruction of the areola and nipple is subsequently carried out by one of the methods to be described, but must be postponed until the breast is properly shaped and the exact location of the nipple and areola determined (Figs. 1-4). In some instances, the skin of the chest wall, though thin and tight, may withstand undermining and the insertion of progressively larger
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Figure 4. (Continued) E, Combining the two limbs of the flap to make a single breast mass, matching the opposite breast size and contour as best possible. Note that an augmentationreconstruction has been performed for the left breast and that a areola and nipple have been reconstructed from a labial graft. F and G, Final photographs of patient following complete right breast reconstruction from an abdominal tube pedicle and left augmentationreconstruction. Nipples and areolae have been reconstructed from two semicircles of labia minora, each of which have been unfolded to form a circle, later being pouched up in the center to form the nipple by the technique described in Figure 5.
implants, or the inflation of balloon type implants with increasing quantities of fluid, so that reconstruction is possible without the use of pedicle flaps (Figs. 2 and 3). The danger of a slough is ever present and, if imminent, pedicle shifts may become necessary. All aspects of the reconstruction of the breast following radical mastectomy should be discussed in great detail with the patient and her family. The limitations of the procedure should be clearly outlined. The author has had no patient who has been disappointed with the result after such frank discussion. Had the patient expected a near perfect breast to result, disappointment would have been inevitable. Occasionally reconstruction of both breasts is necessary. The author has reconstructed both breasts following bilateral simple mastectomies (Fig. 2), following radical mastectomy on one side and simple mastectomy on the other (Fig. 4), and following bilateral radical mastectomy. Results can be acceptable, and one should not stop short of the final result which is obtainable. If there is extensive scarring of the breast and chest wall when surgery is completed, the last step of reconstruction may be an overlay graft to improve extensive cutaneous scarring. Cosmetic skin make-up is also helpful at times to camouflage scars. The possibility of a contralateral malignancy after one breast has been removed makes one hesitant to use this breast for reconstruction. In fact, it may even be desirable to do a prophylactic subcutaneous
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mastectomy on the opposite breast with an immediate reconstructionaugmentation in "high risk" patients.
RECONSTRUCTING THE BREAST FOLLOWING BURNS Third degree burns pose many problems in breast reconstruction, depending on the degree of the injury, the extent ofinvolvement of other areas of the chest, arms, shoulder, axilla, and neck, and especially contractures. 24 • 28 Relaxation of the burned chest skin is required to allow the breast to assume its natural shape. Z-plasties or grafts of the axilla, neck, and supraclavicular area are frequently necessary. Skin grafts placed beneath the breast to restore the submammary fold are also necessary in many cases. When the nipple and areola have been destroyed or badly scarred, they may be reconstructed with one of the methods to be discussed. A full-thickness graft of labium minora is usually the method of choice. If the ducts coming into the nipple proper have not been completely scarred and blocked, the graft may be placed in such a manner as to leave the nipple proper coming through the center of the graft. This provides a functional nipple in instances where the ducts actually open through the nipple. Incisions on the front of the breasts and of the upper chest anteriorly should be avoided whenever possible, since hypertrophic scarring is so common in this area.
RECONSTRUCTION OF THE AREOLA AND NIPPLE Tattooing of brown pigment is the simplest manner of substituting an artificial nipple and areola. Exact color matching with the normal areola is rarely achieved. The central portion of the reconstructed areola can be raised to form a nipple by a number of ways: the excision of several small diamond-shaped trapezoids of skin with the closure of the defects will pouch up the central area of skin between these resections to simulate the nipple; the insertion of a small "nubbin" of plastic sponge (either polyvinyl or Silastic) will also pouch up the central area to simulate a nipple. The contralateral areola may be used for replacing the damaged one. A split thickness skin graft from the opposite areola can be used as an over graft. A fine mesh nonadherent material such as rayon or nylon gauze (Owens gauze, parachute silk, etc.), or a perforated plastic dressing (Telfa, etc.) is used as a dressing. The donor area should be completely healed in 10 days to 2 weeks, and most of the pigmentation should return to the nipple and areola if the graft is not too thick. The grafted nipple and areola provides a reasonable substitute. The central portion may be pouched up later to give more fullness to the nipple proper if desired. The most satisfactory method of reconstructing the nipple and areola is a full-thickness graft from the labium minora. I. 2. 24, 25. 28 A half-
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circle of double-thickness labium minora at the margin of the labium in its central portion is used. This defect is closed with a running suture of 4-0 chromic cat gut. Postoperative discomfort and annoyance is practically nil. The graft is unfolded to form a complete circle. A few nicks in the edges will allow the labia to flatten if it tends to cup. The graft is sutured into the recipient area at the selected site on the reconstructed breast. This circular recipient area should be denuded only of epidermis, leaving the rich vascular bed of dermis to receive the graft- the "overgraft technique." A tie-over dressing is applied for a period of 7 to 10 days. The author has not completely lost any of these grafts. Small losses of tissue will heal by secondary retention. The resulting graft is usually of satisfactory color and texture.!. 2, 28 Simulation of the normal nipple and areola is completed by puckering up the central portion to form a nipple prominence (Figs. 4 and 5).17. 22 ,24-28 This last stage is delayed for several weeks to a few months following the graft to allow for softening and for adequate circulation into the graft. Many of these grafts develop sensation when healing is complete. The color of the graft may be darker than the opposite normal nipple and areola if the normal is fairly light in color, but the result is usually excellent. The author has used various methods for simulation of the nipple proper. The method usually used is one originally described by the author 24 - 28 (Figs. 4 and 5). A buried purse-string suture is inserted into
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Figure 5. The author's method of reconstructing the nipple proper is to use a purse string suture, catching small bites of dermis and subcutaneous tissue in a circular fashion. This puckers up the center of the labial graft to simulate the nipple. The suture enters and exits through the same needle opening, coming out two or three times about the circumference of the nipple area and entering again through the same needle openings so as to make no incision necessary. The final exit is through the point of entrance. A small knot is tied to pucker up the nipple, then the knot slips through the hole made by the needle.
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the subcutaneous tissue and tied just tightly enough to pucker up the central portion of the graft to form the nipple. The needle penetrates and comes out at each side of the proposed nipple, and is then reinserted through the same needle opening to come out again at the next point, until a complete circle has been made; the needle then exits through the original opening through which the suture was inserted. The two ends of the suture are then tied snugly but not tightly, and the suture is clipped at the knot. The small knot slips through the opening made by the needle so that the nipple is "pouched up" in the center and no incision has been made. In order to make the complete circle about the proposed nipple, the needle is reinserted in each instance through the same needle opening to make its progress further around the proposed nipple. The choice of suture material is left to the surgeon, but the author usually uses small braided or twisted white nylon, which has minimal reaction in the tissue and which is tolerated very satisfactorily in this very superficial position.
RECONSTRUCTING THE MALE BREAST The male breast is subject to tumor excision and the correction of gynecomastia. The hypertrophic tissue is removed very satisfactorily through marginal areolar incisions and the residual scar is usually not noticed. Marginal areolar incisions are equally useful in the female breast for biopsy and excision of small masses in the immediate vicinity of nipple and areola. One must keep in mind that breast tumors in the male are occasionally malignant and may require mastectomy. However, gynecomastia is usually the cause of diffuse enlargements of the breast. When the male breast must be reconstructed because of overzealous surgery, tumor resection, or injury, adjacent tissue or distant tissue may be used as in the female. Unsightly chest scars are removed and repaired. If the nipple and areola are removed also, the scars are excised, broken up by a W-plasty, by a Z-plasty at the anterior axillary line, or by multiple Z-plasties. The nipple and areola can be reconstructed with free grafts of scrotal skin which is then repaired as with the female. 24 - 28 Such grafts may undergo pigmentation with time, as in the labium minora grafts. The nipple prominence is created at a subsequent out-patient stage under local anesthesia as previously described. Should the resection of the male breast leave adequate skin coverage but inadequate subcutaneous tissue, one may use thin fat or dermis-fat grafts from buttock or abdomen to the breast area. Since fat grafts can be quite thin for reconstruction of the male breast, they are much more likely to "take" than the thicker fat grafts required for larger bulk reconstructions in the female. Even after shrinkage and absorption, the breast will usually be adequate in size. In the reconstruction of one breast and the removal of tissue from the opposite breast at the same stage, one may use excess fatty tissue from the opposite breast as donor tissue for reconstructing the deficient breast.
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Reconstruction of the nipple and areola in the male was first carried out by the author in 1956. 2 4-28 Without finding any precedence in the literature for such a method, the author utilized a full-thickness scrotal skin graft. The results were very satisfactory and since that time the author has considered this the method of choice for reconstruction of nipple and areola in the male. The center may be "pouched up" to form a nipple by one of the methods described, and the nipple is made somewhat less prominent than for the female. The foreskin is a second choice for donor skin.
CONCLUSION Reconstructive procedures on the female or the male breast can be very adequate aesthetically. Whether the organ functions properly, as does the breast following augmentation mammaplasty, or whether it performs no function, as in the reconstructed breast following radical or simple mastectomy, the patient functions to a higher and happier degree than before the reconstructive procedures. More often than not, the psychological effect is more happy than is the physical one. However, one must remember that adequate surgery in the eyes of the surgeon may not be the same in the eyes of the patient or the patient's mate or family. Therefore, it is important for one to discuss the results to be expected as well as the limitations, and to prepare the patient for extra procedures which may be required and for complications which may mar the final result. If the patient and the patient's family have expectations less than the surgeon feels he can fulfil, he is at a distinct advantage. The happy result is a satisfied patient.
REFERENCES 1. Adams, W. M.: Labial transplant for correction of loss of the nipple. Plast. Reconstr. Surg., 4:295,1949. 2. Adams, W. M.: Mammaplasty with free transplantation of the nipple and areolae. Transactions of the First Internat. Congress of Plast. Surgeons. Baltimore, Williams & Wilkins, 1957, p. 371. 3. Alexander, J. E., and Block, L. I.: Breast reconstruction following radical mastectomy. Plast. Reconstr. Surg., 40:175,1967. 4. Cronin, T. D., and Greenberg, R. L.: Our experiences with the silas tic gel breast prosthesis. Plast. Reconstr. Surg., 46:1,1970. 5. deCholnoky, T.: Breast reconstruction after radical mastectomy: Formation of missing nipple by everted navel. Plast. Reconstr. Surg., 38:577,1966. 6. deCholnoky, T.: Reconstruction of breast following mastectomy. Plast. Reconstr. Surg., 16:226,1955. 7. Edgerton, M. T.: Breast reconstruction after radical mastectomy for cancer. South. Med. J., 60:719, 1967. 8. Edgerton, M. T., Jacobson, W. E., and Meyer, E.: Surgical-psychiatric study of patients seeking plastic (cosmetic) surgery: Ninety-eight consecutive patients with minimal deformity. Brit. J. Plast. Surg., 13:136,1960. 9. Fossati, G. H.: Breast reconstruction. Transactions of the Fourth International Congress of Plast. Surg., Excerpta Medica Foundation, 1967, p. 1046. 10. Fredricks, S.: The subcutaneous mastectomy-A prophylactic and cosmetic operation. Presented to the Mexican Academy of Medicine, Mexico City, March, 1966. 11. Fredricks, S.: Personal communication.
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12. Freeman, B. S.: Technique of subcutaneous mastectomy with replacement: Immediate and delayed. Brit. J. Plast. Surg., 72:161,1969. 13. Gerow, F. J., Spira, M., Moore, J. L., and Hardy, S. B.: One-stage replacement mastectomy for chronic fibrocystic disease of the breast. Transactions of the Fourth Internat. Congress of Plast. Surg. Amsterdam, Excerpta Medica Foundation, 1967, p. 1039. 14. Gillies, H.: Surgical replacement of the breast. Proc. Roy. Soc. Med., 52:597, 1959. 15. Gillies, H. D., and Millard, D. R.: Principles and Art of Plastic Surgery. Boston, Little, Brown and Company, 1957. 16. Griffiths, C. 0.: The submuscular implant in augmentation mammaplasty. Transactions of the Fourth Internat. Congress of Plast. Surg. Amsterdam, Excerpta Medica Foundation, 1967, p. 1009. 17. Grodski, M.: Reconstruction des Mamelous deformies. Rer. de Chir. Struct., June, 1937, 126. 18. Harris, H. R.: Automammaplasty. J. Internat. Coll. Surg., 12:827,1949. 19. Holdsworth, W. G.: A method of reconstructing the breast. Brit. J. Plast. Surg., 9:161, 1956. 20. Horton, C.: Personal communication. 21. Kelly, A. P., Jr., Jacobson, H. S., Fox, J. I., and Jenny, H.: Complications of subcutaneous mastectomy and replacement by the cronin silastic mammary prosthesis. Plast. Reconstr. Surg., 37:438,1966. 22. Letterman, G. S., and Schurter, M. A.: Personal communication. 23. Lewis, J. R., Jr.: Mammaplasty-A current evaluation. J. Med. Assoc. Ga., 53:341,1964. 24. Lewis, J. R., Jr.: Reconstructing the female and the male breast. Presented at the meeting of the Internat. Coll. of Surg., Tokyo, Oct., 1968. To be published in J. Internat. Surg. 25. Lewis, J. R., Jr.: Reconstruction of the Breast. Panminerva Medica, September, 1970. 26. Lewis, J. R., Jr.: Reconstructions of the Breast. Proceedings of Internat. CoIL of Surg., Vienna, 1964. 27. Lewis, J. R., Jr.: The augmentation mammaplasty (with special reference to the use of alloplastic materials). Plast. Reconstr. Surg., 35:51,1965. 28. Lewis, J. R., Jr.: The Surgery of Scars. New York, McGraw-Hill Book Co., voL 1, pp. 132139. 29. Maliniac, J. W.: Breast Deformities and Their Repair. New York, Grune & Stratton, 1950. 30. Pierer, H.: Reconstruction of the breast after carcinoma operation. Transactions of the Fourth Internat. Congress of Plast. Surg. Amsterdam, Excerpta Medica Foundation, 1967, p. 1049. 31. Remecher, R., and Cutter, M.: Psychological problems of adjustment to cancer of the breast. J.A.M.A., 148 :833, 1952. 32. Thorek, M.: Plastic surgery of the breast and abdominal walL Springfield, Illinois, Charles C Thomas, 1942. 33. Trier, W. C.: Complete breast absence. Plast. Reconstr. Surg., 36:430, 1965. 478 Peachtree Street, N.E. Atlanta, Georgia 30308