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To avoid disappointment, patients should be made aware of this prior to reconstruction. In a previously irradiated patient, scar tissue is likely to be more dense and difficult to release than in a nonirradiated patient, and a vertical releasing incision in the lower mastectomy flap (Figs 5-7 and 5-8; also see chapter 17) is more likely to be required. Dissection of recipient vessels in the axilla may also be more difficult. The surgeon should be prepared for these challenges. Obviously, one way to solve the problem of a difficult dissection in a heavily scarred axilla is to use the internal mammary vessels as recipients; they may well have been irradiated but will not have had previous surgery.

Using jeweler’s forceps with tips that do not meet correctly and will not hold sutures, for example, is frustrating and can lead to poor anastomoses and flap failure. Microsurgical instruments are delicate and can easily be damaged by operating room personnel during cleaning or storage. If the operating room staff is not used to working with microsurgical instruments, the surgeon needs to take a personal interest in the instruments and ensure that they are properly cared for. Instruments used for breast reconstruction should be long enough to reach easily into the axilla (Fig 3-7).

Note that a skin-sparing mastectomy had been done on the right, but not on the left. (B) The same patient after bilateral free TRAM flap breast reconstruction. A vertical releasing incision was required in the left inferior mastectomy flap. 50 C H A P T E R 5 D ELAYED B REAST R ECONSTRUCTION FIG. 5-9 A patient 4 years after bilateral free TRAM flap breast reconstruction. She had been treated previously with mastectomy and radiotherapy on the left side, but there is no apparent difference between the irradiated (left) and nonirradiated (right) sides.