Immediate and Delayed Autologous Breast Reconstruction with the Peg Flap
Edward W. Knowlton, M.D.

Table of Contents

Abstract   Introduction   Method and Patients
Skin Envelope Necrosis: Avoidance and Treatment   Discussion   References

Abstract

The creation of a symmetrical autologous breast reconstruction that reduces both the recipient site scarring and donor site morbidity can be achieved by enacting a breast care algorithm that places the initial breast biopsy incision within the areola. A composite single stage procedure involving a skin preservation modified radical mastectomy and autologous "Peg" flap reconstruction is then possible for the majority of patients. The procedure is easily adaptable for a variety of breast sizes and shapes. For delayed reconstruction, a two-stage autologous procedure is performed that eliminates the pigmentary demarcation and double-tier flap scar of the recipient breast. Four patients are presented.

Topic presented at the annual meeting of the American Society of Plastic and Reconstructive Surgeons in September 1994

Introduction

A method that combined mastectomy with the use of a latissimus dorsi flap was originally described by Iginio Tansini in 1906.¹ In contrast, the use of the rectus abdominus as an autologous source would not be described for another 70 years. If a rosetta stone of breast reconstruction exists, "sopra il mio nuovo processo di amputazione della mammella" must stand as a cornerstone in the treatment and reconstruction of the breast cancer patient.

Professor Iginio Tansini

The first reported use of a myocutaneous flap

Postoperative results of the Tanzini procedure

After Patey and Dyson modified the Halstead radical mastectomy,² a growing body of studies with comparable tumor staging would demonstrate that routine resection of breast skin is not required unless direct invasion is present.^3,4,5 Skin preservation mastectomy involving the en bloc resection of the circular nipple-areolar complex, glandular breast tissue, pectoralis fascia and axillary lymph nodes have similar local recurrence rates to the standard modified radical mastectomy.⁶ Over several decades, the Tansini procedure has evolved^7-40 and the "Peg" flap⁴¹ is another step in the pedigree of this remarkable operation. In a single stage, the Peg Procedure combines a skin preservation mastectomy with either a Latissimus Dorsi or Rectus Abdominus myocutaneous flap in which a circular cutaneous "Peg" corresponds to the dimensions of the excised nipple-areolar complex. The cutaneous "Peg" is used as a round peg into a round hole for creation of the nipple-areolar complex (Figure 1). Reconstruction of the nipple-areolar complex can be achieved by a variety of techniques and is completed at the initial stage due to the excellent circulation of this myocutaneous territory.⁴² As the patient is no longer "skin short," the frequent requirement of repositioning incisions on the contralateral breast is greatly reduced. Initially, the Latissimus Dorsi "Peg" flap was described with a silicone breast implant. Modification of the flap dissection to include additional subcutaneous tissue can now provide a reliable method of autologous reconstruction for many patients.^43,44 (Figure 2.) The procedure is adaptable for a variety of breast sizes and shapes. Patients with larger and more pendulous breasts may undergo a concurrent reduction or repositioning.

For patients who have undergone a standard modified radical mastectomy, autologous reconstruction is accomplished after expansion of the skin envelope. Creation of the "Peg" flap, including the nipple-areolar complex, is similar to immediate reconstruction (Figure 2).

Method and Patients

As with any treatment regimen, the initial decisions are the most important. A primary requirement for this procedure is that the general surgeon limit the initial biopsy and subsequent skin excision of the mastectomy to the circular nipple-areolar complex. To facilitate this process, J-wire localization of the tumor is performed through the areola. By employing this breast care algorithm, a composite single stage procedure is possible that involves a skin preservation modified radical mastectomy and an autologous "Peg" flap from the abdomen (Rectus Peg) or the back (Latissimus dorsi Peg).

For the Latissimus Dorsi Peg flap, the cutaneous "Peg" is marked behind the anterior border of the latissimus dorsi. The transverse axis of the flap is placed at the level of the infra-mammary fold for smaller breasts and slightly lower for more ptotic breasts to allow for an unrestricted arc of rotation to the recipient site. The chest, back and upper extremities are prepped in a circumferential fashion. The patient is then placed into a supine position on a sterile drape. This arrangement will allow the patient to alternate between the supine and the lateral decubitus positions without redraping. If possible, patients should donate two units of autologous blood. Hypotensive anesthesia monitored with an arterial line has reduced blood loss during the mastectomy and flap elevation. The surgery begins with the patient in the supine position. The nipple-areolar complex is incised circumferentially. The initial periareolar breast biopsy incision is included with the specimen. Sharp dissection without cautery is imperative when raising the skin flap of the breast. As the breast skin exists as a random cutaneous flap, the subcutaneous layer is preserved to avoid damage of the subdermal plexus. The pectoralis fascia is included with the breast specimen. The lymph node dissection is performed through a separate axillary incision. The nipple-areolar complex, breast tissue, pectoralis fascia and axillary lymph nodes are delivered as an en bloc specimen.⁴⁵ The thoracodorsal vessels and nerve are identified and isolated in the axilla. The branch to the serratus anterior is routinely ligated to improve the arc of rotation. Dissection of the thoracodorsal vessels to the axillary vein will provide additional length to the pedicle. The subcutaneous fat over the serratus anterior is included with the flap to provide additional breast volume and reduce the typical "fullness" of the lateral chest due to lymphedema from the axillary lymph node dissection. The patient is then rotated into a lateral decubitus position. Through the flap donor site of the "Peg," most of the latissimus dorsi muscle with the adjacent and overlying subcutaneous tissue is harvested. Additional volume is provided by de-epithelializing a larger skin island. As the flap must exist as an axial island myocutaneous flap, a complete transaction of the insertion of the latissimus dorsi is crucial. Although the preserved skin envelope is the main determinant of breast contour, more projection may be obtained by shaping the autologous flap. Typically, the posterior border of the flap is folded under the deep surface of the muscle. A portion of subcutaneous tissue along the lateral aspect of the breast is preserved as a partition between the mastectomy and the flap donor site (Figure 3). The shaped "Peg" flap is rotated through an arc of 90 degrees and is delivered into the recipient breast defect as an onlay to the chest wall. Hemostasis of the flap donor site is then obtained after the patient is made normotensive. A drain is inserted into the flap donor site for ten days to reduce seroma formation. A second drain is used for the axilla and breast. The flap donor site and axillary incisions are closed. The patient is then rotated to the supine position without redraping. The autologous "Peg" flap can be sutured to the chest wall. However, the circulation of the breast envelope is compromised by suturing to the subcutaneous tissue. The "Peg" flap can be partially inserted into a subpectoral pocket for tumors invading the posterior aspect of the breast. This relationship should not delay the diagnosis of a superficial chest wall recurrence. The nipple-areolar complex is reconstructed at this initial stage and can be created either at the flap donor site or recipient breast. More recently, the superiorly pedicled Quadraped flap has been modified* and incorporated into the "Peg" procedure. The horizontal limbs of the Quadraped are retained as rectangles that extend to the perimeter of the "Peg" flap. The central flap has been redesigned into a semicircle. The nipple is created by the inward rotation of the horizontal limbs under the semicircular flap. The flap donor sites of the reconstructed nipple are closed, reconstituting the perimeter of the "Peg" flap. Using a circular template, the skin outside of the "Peg" flap is de-epithelialized (Figure 3).

*The modified Quadraped flap has now been renamed "the Bowtie flap."

Figure 1 The Peg flap is based on the concept of a "round peg into a round hole"

Figure 2 Concurrent flap transfer and nipple-areolar reconstruction

Figure 3 The nipple-areolar complex is created at the flap donor site of the back

For the Rectus Peg Flap, the circular cutaneous Peg is typically placed inferior and lateral to the umbilicus on the ipsilateral side (Figure 4). Positioning of the cutaneous Peg over a rectus perforator is performed when ever possible. Reconstruction of the nipple-areolar complex can be performed at the flap donor site in a similar fashion to the latissimus dorsi Peg (Figure 5). The rest of the flap is deepithelialized. Non-viable portions on the contralateral side are conservatively resected. For most patients, a unilateral pedicle on the ipsilateral side is used. Patients who require additional breast volume may require a bipedicle flap that may significantly weaken the abdomen. In either circumstance, a muscle sparing dissection of the epigastric system is recommended. The dissection and identification of significant Rectus perforators medially and laterally will avoid the unnecessary removal of the anterior Rectus sheath. The flap is harvested high to preserve fascia and muscle below the semilunar line. However, the subcutaneous fat over the lower abdomen is included within the flap to provide additional volume and to flatten the donor site. Additional flattening of the lower abdomen is achieved with the plication of the anterior rectus fascia from the pubic symphysis to the fascial defect. Closure of the Rectus defect is performed with a narrow inlay of Prolene mesh that is sutured in place between the posterior Rectus sheath and the Rectus muscle remnant. Complete closure of the fascia defect is mandatory. This must include the Internal Oblique component of the Anterior Rectus fascia. For unilateral pedicles, the contralateral fascia is plicated to centralize the umbilicus. If the circulation of the upper skin flap is adequate, additional removal of skin from the lower abdominal incision is performed to correct additional laxity. Closure is facilitated with the retrograde advancement of the lower incision in superior direction. The advanced lower incision is secured with deep subcutaneous sutures to the underlying fascia. Retraction of the reconstructed nipple-areolar complex may be encountered after transfer to the recipient breast. This typically occurs from the 12:00 to 3:00 o’clock position and is corrected with a limited relaxation incision of the deepithelialized dermis in that region. The relaxation incision is only performed if the circulation of the reconstructed nipple-areolar complex is deemed adequate (Figure 6).

Figure 4 The circular skin Peg is placed over a perforator

Figure 5 Donor site creation of the nipple-areolar complex

Figure 6 Correction of nipple-areolar retraction

For a delayed autologous Peg Flap, reconstruction is performed after the expansion of the breast skin envelope. This two stage approach is reserved for patients who have previously had or who are now requiring a standard modified radical mastectomy with skin resection. The initial stage involves the insertion of a temporary submuscular or subcutaneous breast expander.⁴⁷ This may be performed concurrently with the mastectomy or as a delayed first stage. Usually, a textured expander with an incorporated valve is used. More recently, an adjustable Becker expander/implant has been used with good results. Submuscular expansion allows the conversion to an implant method of reconstruction that will not delay the diagnosis of a deeper local recurrence. Repositioning of the contralateral breast is also performed at this initial stage.

Over expansion of the native breast envelope is required, especially along the inferior pole. The second stage involves the removal of the expander with the creation and insertion of an autologous Latissimus Dorsi or Rectus Peg flap. However, the patency of the thoracodorsal or epigastric vessels may be compromised by pre-existing radiation damage. Surgical trauma to the thoracodorsal vessels may have been incurred during a previous axillary lymph node dissection.⁴⁸ Comparison of the Doppler signature to the contralateral thoracodorsal bundle will aid in this analysis. A color duplex scan will provide a more detailed study of flow characteristics of the Epigastric or Thoracodorsal system.⁴⁹

The nipple-areolar complex is created at the flap donor site by the modification of the quadraped technique. A small 3.0 cm circular recipient site on the breast is created. If needed, multiple radial capsulotomies along the inferior pole of the breast are performed for additional ptosis. A segmental capsulectomy at the superior pole provides additional room for postoperative flap edema. Otherwise, a compression atrophy of the flap will occur. The recipient site is stretched to approximately 4.0 cm to receive the reconstructed nipple-areolar complex. Regardless of size, a 1.0 cm differential with the diameter of the reconstructed nipple is required to achieve the desired projection (Figures 7,8). With this method, a net gain in the skin envelope occurs without the pigmentary demarcation or double-tier scar of a standard flap reconstruction.

Figure 7 The circular recipient site of a delayed Peg Flap	Figure 8 Completed right breast reconstruction with a delayed Peg Flap including repositioning of the left breast
Figure 9 Vertically oriented repositioning incisions of the breast skin envelope	Figure 10 Symmetry of the incisions

Four patients are presented to illustrate the various applications of this technique. These cases are a representative sampling of immediate and delayed reconstruction.

Case 1

The patient is a 40-year-old multiparous woman with B-cup size breasts that are moderately ptotic. She presents with a 3.0 cm invasive ductal and multifocal carcinoma in situ of the left breast. The patient underwent a combined single stage skin preservation mastectomy with axillary lymph node dissection and autologous "Peg" latissimus dorsi flap reconstruction. The nipple-areolar complex was reconstructed at this initial stage but required revision at a later date with the modified quadraped technique. The patient's postoperative course was uneventful.

Preoperative

Postoperative mastectomy and reconstruction

After revision of the reconstructed nipple–areolar complex

Case 2

The patient is a 62-year-old, moderately obese female with large pendulous breasts. An extensive ductal carcinoma in situ of the left breast is present. The patient underwent a combined skin preservation mastectomy with lymph node sampling and autologous "Peg" latissimus dorsi flap with nipple-areolar reconstruction. The right breast was reduced with a standard "Wise" keyhole approach. The left reconstructed nipple-areola was repositioned with an excision of a superior semilunar ellipse. An inferior vertical wedge resection reduced the circumference of the breast skin recipient site (Figures 9,10). The entire procedure was performed in a single stage. A donor site seroma resolved after three aspirations.

Preoperative

3 months postoperative

Case 3

The patient is a 42-year-old woman who had a modified radical mastectomy for 3.0 cm ductal carcinoma of the right breast. Reconstruction was deferred at the time of the mastectomy. The patient was reconstructed in two stages. The initial stage included the insertion of a subcutaneous expander with repositioning of the contralateral breast. The patient’s reconstruction was completed with a delayed Rectus Peg flap. A bipedicle flap was employed for additional volume.

Preoperative	Preoperative   3 months after first stage expansion with repositioning of the left breast
Immediately postoperative	Immediately postoperative

Case 4

The patient is a 51-year-old woman who had a modified radical mastectomy for ductal carcinoma of the right breast. A reconstruction with a temporary expander and a permanent saline implant resulted in a contour irregularity that is common with this type of prosthesis. Three years later, the patient's reconstruction was revised in two stages. A temporary expander was reinserted for additional ptosis and the left breast was repositioned. The delayed reconstruction was completed with a Latissimus Dorsi "Peg" flap that included the creation of the nipple-areolar complex.

Preoperative After reinsertion of the breast expander	Intraoperative Completion of the nipple-areolar reconstruction	Immediately postoperative
2 months postoperative	2 months postoperative	4 months postoperative

Skin Envelope Necrosis: Avoidance And Treatment

Patients with skin preservation mastectomies can sustain a higher incidence of breast skin necrosis due to a variety of factors. Avoidance of this complication involves recognition of patients who are at greatest risk. Immediately following a mastectomy, the breast skin is an elongated random cutaneous flap in which survival is determined by length.⁵⁰ Patients with pendulous skin envelopes and large autologous flaps are especially prone to pressure necrosis from postoperative flap edema.

D cup breast with a ductal carcinoma of the right breast

Skin envelope necrosis following an autologous Peg flap to the right breast

Additional risk factors include diabetes, age and smoking.^51,52 Poorly designed repositioning incisions that increase tension or reduce circulation to the skin envelope must be avoided. "Doughnut" or circumareolar mastopexies create significant tension on the breast skin surrounding the reconstructed nipple-areolar complex. The horizontal incision in the infra-mammary fold of a "Wise" keyhole mastopexy is also likely to diminish the circulation of tenuous skin flaps. Moreover, the need for repositioning of the reconstructed breast will be tempered by skin envelope contraction following a mastectomy. When required, repositioning incisions should be limited to superior semilunar excisions to raise the reconstructed nipple-areolar complex. If needed, a vertical wedge of breast skin can be resected without tension along the inferior aspect to reduce the circumference of the nipple-areolar recipient site (Figures 9,10). Suction drains should be used cautiously with the random cutaneous skin of the breast. During mastectomy, the subcutaneous layer should be preserved whenever possible. Careful sharp dissection without cautery is mandatory. Pressure dressings should be avoided, especially at the infra-mammary fold and nipple-areolar recipient site. If a latissimus Dorsi flap is used, patients should not recline on their flap donor site in the immediate postoperative period.

Treatment of breast skin necrosis involves acknowledgment that any vascular compromise will be aggravated by increasing postoperative edema of the autologous flap. Treatment is initiated promptly with a variety of modalities. Breast skin necrosis may be limited with hyperbaric oxygen.⁵³ Intravenous steroids^54,55 and diuretics may reduce interstitial flap edema. Suction evacuation of a hematoma, reduction of flap volume and percutaneous deflation of a saline prosthesis are additional options to consider in the immediate postoperative period.

Discussion

A breast care algorithm should provide the option of a skin preservation mastectomy whenever possible. This process includes J-wire localization of the tumor through the areola to facilitate a periareolar breast biopsy. Restricting the skin excision of the mastectomy to the circular nipple-areolar complex has several important advantages. The mastectomy scar is camouflaged around the perimeter of the reconstructed nipple-areolar complex. Accurate placement of the reconstructed nipple-areolar complex becomes an intrinsic part of the surgery. An intact breast skin envelope most accurately conforms the shape of the reconstructed breast. Without a net loss of skin, repositioning of the contralateral breast is less frequently required. Although postoperative atrophy of the autologous flap occurs, the volume of the reconstructed breast is maintained by the flap edema in the subcutaneous tissues.

Immediate breast reconstruction should not delay adjuvant chemotherapy due to recipient or donor site complications.⁵⁶ The balance between recipient site benefits and donor site deformity and morbidity must be considered when comparing different autologous sources.⁵⁷ Although the latissimus dorsi is a posterior adductor of the upper extremity, other muscles readily compensate for its absence.⁵⁸ Donor site morbidity of the back was minimal and limited to seroma and skin necrosis that resolved in all patients. Rectus flap reconstruction was well tolerated by the majority of patients if careful attention was taken to completely close the rectus donor defect. Careful patient selection is essential for this autologous source.

For patients who require a standard modified radical mastectomy or desire a delayed reconstruction, a two-stage method of autologous reconstruction with the "Peg" flap provides several benefits. Contour irregularities of saline implants can be corrected. The pigmentary demarcation and double-tier scar of a standard flap reconstruction is avoided. The circular recoil of the breast skin projects the entire nipple-areolar complex to an elevated position. This concept of delayed reconstruction can be employed with a variety of autologous sources.^59,60,61,62

Pigmentary demarcation of a standard latissimus dorsi flap reconstruction	The double tier scarring of a TRAM flap	The double tier scarring of a TRAM flap
Completed right breast reconstruction with a delayed latissimus dorsi peg flap	Same patient, 2 months after a delayed latissimus dorsi peg flap	Completed right breast reconstruction with a delayed rectus peg flap

As the incidence of breast cancer approaches 12 percent, the patient and the physician are faced with a myriad of treatment options. "Breast conservation" with radiation therapy will require a continuous evaluation of the patient's residual breast tissue for the remainder of her lifetime. Local recurrence rates after 10 years may be significantly higher than mastectomy in this progressively younger group of patients.^63,64 With the development of techniques that provide immediate and total breast reconstruction the patient no longer must "lose her breast"⁶⁵ in order to have the oncologic benefit of mastectomy.

References

1. Maxwell, G.P. "Iginio Tansini and the origin of the latissimus dorsi musculocutaneous flap." Plast. Reconstr. Surg. 65(5): 686, 1980.

2. Patey, D.H., Dyson, W.H. "The prognosis of carcinoma of the breast in relation to the type of operation performed." Br J Cancer, 2:7, 1948.

3. Dao, T. L., Nemoto, T. "The clinical significance of skin recurrence after radical mastectomy in women with cancer of the breast." Surg. Gynecol. Obstet., 117: 447, 1963.

4. Auchincloss, H., Jr. "The nature of local recurrence following radical mastectomy." Cancer. 11:611, 1950.

5. Deck, K., Kern, W. "Local recurrence of breast cancer." Arch. Surg. 11:323, 1976.

6. Kroll, S., Ames, F., Singletary, S.E., Schusterman, M. "The oncologic risks of skin preservation at mastectomy when combined with immediate reconstruction of the breast." Surg. Gynecol. Obstet., 172: 17, 1991.

7. Olivari, N. "The latissimus flap." Br. J. Plast. Surg. 29:126, 1976.

8. Schneider, W.J., Hill, H.L., Jr., Brown, R.G. "Latissimus dorsi myocutaneous flap for breast reconstruction." Br. J. Plast. Surg. 30(4):277, 1977.

9. Muhlbauer, W., Olbrisch, R. "The latissimus dorsi myocutaneous flap for breast reconstruction." Chir. Plastica. 4:27, 1977.

10. Bostwick, J., III, Vasconez, L.O., Jurkiewicz, M.J. "Breast reconstruction after a radical mastectomy." Plast. Reconstr. Surg. 61(5):682, 1978<

11. Olivari, N. "Use of thirty latissimus dorsi flaps." Plast. Reconstr. Surg. 64(5): 654, 1979.

12. Dowden, R.V., Horton, C.E., Rosato, F.E., McCraw, J.B. "Reconstruction of the breast after mastectomy for cancer." Surg. Gynecol. Obstet. 149:109, 1979.

13. Ohmori, K., Takada, H. "Correction of Poland's pectoralis major muscle anomaly with latissimus dorsi musculocutaneous flaps." Plast. Reconstr. Surg. 65(4): 400, 1980.

14. Pendergast, W.J., Jr., Bostwick, J., III, Jurkiewicz, M.J. "The subcutaneous mastectomy cripple: surgical rehabilitation with the latissimus dorsi flap." Plast. Reconstr. Surg. 66(4):554, 1980.

15. Fodor, P.B., Khoury, F. "Latissimus dorsi muscle flap in reconstruction of congenitally absent breast and pectoralis muscle," Ann. Plast. Surg. 4(5):422, 1980.

16. Vasconez, L.O., Johnson-Giebink, R., Hall, E.J. "Breast reconstruction." Clin. Plast. Surg. 7(1):79, 1980.

17. Biggs, T.M., Cronin, E.D. "Technical aspects of the latissimus dorsi myocutaneous flap in breast reconstruction." Ann. Plast. Surg. 6(5): 381, 1981.

18. Ramming, K.P., Holmes, E.C., Zarem, H.A., Lesavoy, M.A., Morton, D.L. "Surgical management and reconstruction of extensive chest wall malignancies." Am. J. Surg. 144(l):146, 1982.

19. Marshall, D.R., Anstee, E.J., Stapleton, M.J. "Immediate reconstruction of the breast following modified radical mastectomy for carcinoma." Br. J. Plast. Surg. 35:438, 1982.

20. Wolf, L.E., Biggs, T.M. "Aesthetic refinements in the use of the latissimus dorsi flap in breast reconstruction." Plast. Reconstr. Surg. 69(5): 788, 1982.

21. Millard, D.R., Jr. "Breast aesthetics when reconstructing with the latissimus dorsi musculocutaneous flap." Plast. Reconstr. Surg. 70(2): 161, 1982.

22. Tobin, G.R., Mavroudis, C., Howe, W.R., Gray, L.A., Jr. "Reconstruction of complex thoracic defects with myocutaneous and muscle flaps: applications of new flap refinements." J. Thorac. Cardiovasc. Surg. 85(2):219, 1983.

23. Mendelson, B.C. "Latissimus dorsi breast reconstruction: refinement and results." Br. J. Plast. Surg. 70(3): 145, 1983.

24. Nash, A.G., Hurst, P.A. "Central breast carcinoma treated by simultaneous mastectomy and latissimus dorsi flap reconstructions." Br. J. Surg. 70(11): 654, 1983.

25. Broadbent, T.R., Woolf, R.M. "Breast reconstruction: a better skin pattern." Aesthetic Plast. Surg. 7(3):145, 1983.

26. Knowlton, E.W. "Release of axillary scar contracture with a latissimus dorsi flap." Plast. Reconstr. Surg. 74(1):124, 1984.

27. Cohen, B.E., Cronin, E.D. "Breast reconstruction with the latissimus dorsi musculocutaneous flap." Clin. Plast. Surg. 11(2):287, 1984.

28. Larson, D.L., McMurtrey, M.J. "Musculocutaneous flap reconstruction of chest wall defects: an experience with 50 patients." Plast. Reconstr. Surg. 73(5):734, 1984.

29. Marshall, D. R., Anstee, E.J., Stapleton, M.J. "Soft tissue reconstruction of the breast using an extended composite latissimus dorsi myocutaneous flap." Br. J. Plast. Surg. 37(3):361, 1984.

30. Arnold, P.G., Pairolero, P.C. "Chest wall reconstruction: experience with 100 consecutive patients." Ann. Surg. 199(6):725, 1984.

31. Cooper, G.G., Webster, M.H.C., Bell, G. "The results of breast reconstruction following mastectomy." Br. J. Plast. Surg. 37:369, 1984.

32. Lejour, M., Alemanno, P., DeMay, A. "Analysis of 56 breast reconstructions using the latissimus dorsi flap." Ann. Chir. Plast. Esth. 30:7, 1985.

33. Pousset, C., Salmon, R.J., Soussaline, M. et al. "The use of a latissimus dorsi myocutaneous flap for the treatment of recurrent breast cancer." Ann. Chir. Plast. Esth. 31:82, 1986.

34. Hokin, J., Silfverskiold, K. "Breast reconstruction without an implant: results and complications using an extended latissimus dorsi flap." Plast. Reconstr. Surg. 79(l):58, l987.

35. McCraw, J., Arnold, P. "Bibliography: latissimus." McCraw and Arnold's Atlas of Muscle and Musculocutaneous Flaps, pp 693-697. Norfolk: Hampton Press Publishing Co., 1986.

36. McCraw, J., Papp, C.H. "Fleur-de-Lis Breast Reconstruction." Hartrampf’s Breast Reconstruction With Living Tissue, pp 211-248. Norfolk: Hampton Press Publishing Co., 1991.

37. Moore, T., Farrell, L. "Latissimus dorsi myocutaneous flap for breast reconstruction: long-term results." Plast. Reconstr. Surg. 89(4):666, 1992.

38. Slavin, S., Love, S., Sadowsky, N. "Reconstruction of the radiated partial mastectomy defect with autogenous tissues." Plast. Reconstr. Surg. 90(5):854, 1992.

39. Van Natta, B. "Use of the latissimus dorsi myocutaneous flap for immediate breast reconstruction." Plastic Surgical Forum. 15:103, 1992.

40. Kroll, S., Schusterman, M., Reece, G., Miller, M., Smith, B. "Breast reconstruction with myocutaneous flaps in previously radiated patients." Plast. Reconstr. Surg. 93(3):460, 1994.

41. Knowlton, E.W., Gorey, R., Taekman, H. "Total immediate breast reconstruction with 'Peg' latissimus dorsi flap." Contemp. Surg. 41(3):15, 1992.

42. McCraw, J.B., Dibbell, D.G., Carraway, J.H. "Clinical definition of independent myocutaneous vascular territories." Plast. Reconstr. Surg. 60:341, 1977.

43. Knowlton, E.W. "The 'peg' latissimus dorsi flap procedure: a one-stage breast reconstruction." Plastic Surgical Forum. 17:180, 1994.

44. Knowlton, E.W. "The 'peg' latissimus dorsi flap procedure: a one-stage breast reconstruction on video." Medical Media Productions, Mill Valley, CA, 1992.

45. Knowlton, E.W. "Breast reconstruction with the 'peg' latissimus dorsi flap" on video. Medical Media Productions, Mill Valley, CA, 1994.

46. Grossman, P.H., Novack, B.H., Karlan, S.R., Uyeda, R.Y. "An alternative technique for modified radical mastectomy with immediate reconstruction." Contemp. Surg. 38(6):20, 1991.

47. Anton, M.A., Eskenazi, L.B., Hartrampf, C.R. "Nipple reconstruction with local flaps: star and wrap flaps." Perspect. Plast. Surg. 5:67, 1991.

48. Maxwell, G.P., Falcone, P.A. "Eighty-four consecutive breast reconstructions using a textured silicone tissue expander." Plastic Reconstr. Surg. 89(6):1022, 1992.

49. Maxwell, G.P., McGibbon, B.M., Hoopes, J.E. "Vascular considerations in the use of a latissimus dorsi myocutaneous flap after a mastectomy with an axillary dissection." Plast. Reconstr. Surg. 64(6):771, 1979.

50. Rand, Richard P., Cramer, Miles M., Strandness, D. Eugene, Jr. "Color-flow duplex scanning in the preoperative assessment of TRAM flap perforators: a report of 32 consecutive patients." Plast. Reconstr. Surg. 93(3): 453, 1994.

51. Daniel, R.K., Williams, H.B. "The free transfer of skin flaps by microvascular anastomoses." Plast. Reconstr. Surg. 52:16, 1973.

52. Bailey, M.H., Smith, J.W., Casas, L., Johnson, P., Serra, E., de la Fuente, R., Sullivan, M., Scanlon E. "Immediate breast reconstruction: reducing the risks." Plast. Reconstr. Surg. 83(5):845, 1989.

53. Guyuron, B., Raszewski, R. "Undetected diabetes and the plastic sturgeon." Plast. Reconstr. Surg. 86(3):471, 1990.

54. Tan, C.M., Im, M.J., Myers, R.A.M., Hoopes, J. "Effects of hyperbaric oxygen and hyperbaric air on the survival of island skin flaps." Plast. Reconstr. Surg. 73:27, 1984.

55. Woods, J.E., Meland, N.B. "Conservative management in full thickness nipple-areolar necrosis after subcutaneous mastectomy." Plast. Reconstr. Surg. 94(2):258, 1989.

56. Schmidt, J.H., Caffee, H.H. "The efficacy of methylprednisolone in reducing flap edema." Plast. Reconstr. Surg. 86(6):1148, 1990.

57. Noone, R.B., Frazier, T.G., Noone, G.C., Blanchet, N.P., Murphy, J.B., Rose, D. "Recurrence of breast carcinoma following immediate reconstruction: a 13 year review." Plast. Reconstr. Surg. 93(1):96, 1994.

58. Mizgala, C.L., Hartrampf, C.R., Jr., Bennett, G.K. "Assessment of the abdominal wall after pedicled TRAM flap surgery: 5 to 7 year follow-up of 150 consecutive patients." Plast. Reconstr. Surg. 93(5):988, 1994.

59. Grotting, J., Vasconez, L., Urist, M., Song, J., Dachevsky, C., Gamboa, M. "Conventional TRAM versus free TRAM for immediate and delayed breast reconstruction in 278 consecutive patients." Plastic Surgical Forum. 17:134, 1994.

60. Lovaas, M.E. "Immediate pedicled TRAM breast reconstruction and simultaneous nipple reconstruction with a skate flap: a review of 50 patients." Plastic Surgical Forum. 17:136, 1994.

61. Khouri, R., Shaw, W., Ahn, C. "Simultaneous bilateral TRAM flap breast reconstruction: experience with 200 flaps in 100 consecutive patients." Plastic Surgical Forum. 17:138, 1994.

62. Shaw, W., Wong, R., Ahn, C. "Flap selection in autologous breast reconstruction." Plastic Surgical Forum. 17:257, 1994.

63. Laitung, J.K., Peck, F. "Shoulder function following the loss of the latissimus dorsi muscle." Br. J. Plast. Surg. 38(3):375, 1985.

64. Fourquet, A., Campana, F., Zafrani, B., Mosseri, V., Vielh, P., Durand, J., Vilcoq, J. "Prognostic factors of breast recurrence in the conservative management of early breast cancer: a 25-year follow-up." Int. J. Radiat. Oncol. Biol. Phys. 17(4):719, 1989.

65. Fisher, J.C. "Editorial: why we all should be concerned about radiation!" Plast. Reconstr. Surg. 83(6):1039, 1989.

66. "Breast cancer: understanding treatment options." Nat. Cancer Institute Breast Cancer Patient Education Booklet, 1994.

67. "Efficacy of Bilateral Prophylactic Mastectomy in Women with a Family History of Breast Cancer." New England Journal of Med. 2:340, 1999

Illustrations by Meg Bennett and Walter Denn.