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Secondary surgery for nipple reconstruction and breast symmetry can be performed after a 3-month period, which allows time for ingrowth of additional blood supply, gluteal muscle atrophy, and settling of the flap. Symmetry procedures may involve mastopexy, reduction, or even augmentation mammoplasty of the contralateral breast.
POSTOPERATIVE CARE
The patient may lie on her buttocks immediately. On the third day, the hemovacs are removed and ambulation is begun; on the fifth day, the patient may sit in a chair with her hips fully flexed; and by the eighth day, the patient is usually walking comfortably and is ready for discharge. A light bra provides gentle support in the early postoperative period. Later, activities are increased as tolerated, with full activity generally expected in three to four weeks.
PLATE XXIV-1
A. Anatomy of Donor Area. The long axis of the flap is horizontal,
centered over the axis of the superior gluteal vessels, about 5 to 6 cm
below the PSIS and 4 cm lateral to the midline of the sacrum.
The superior gluteal vessels and nerve come through the cleft between the piriformis and gluteus medius to reach and arborize over the deep surface of the gluteus maximus. Their presence can be confirmed with a Doppler probe.
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B. Anatomy of Recipient Area. Key recipient areas for vascular hookups
are depicted on the left. A-V fistula from axillary vessels (illustrated
on the right side) would be done on the left if no other vessels are available.
The insert depicts the opening of the perichondrial sleeve around the third and fourth ribs. A 3 cm segment of costal cartilage is removed. The posterior perichondrium is then excised to expose the internal mammary A-V pedicle.
PLATE XXIV-2
A. Flap elevation commences laterally and superiorly at the deep fascia
level toward the medial border of the gluteus maximus. An incision is
made through the upper third of the muscles after one-third of the flap
has been elevated.
B. The plane between the gluteus maximus and gluteus medius is developed
by blunt and sharp dissection medially superficial to the medius. Vessels
from the superior gluteal stalk are seen coming through the left between
the medius and piriformis as one proceeds medially. The pedicle is developed,
clipping numerous branches from the stalk that doe not enter the gluteus
maximus segment, gaining 3 cm of vessel length.
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