SPECIAL TOPIC Shaping the Breast in Aesthetic and Reconstructive Breast Surgery: An Easy Three-Step Principle. Part II—Breast Reconstruction after Total Mastectomy Phillip N. Blondeel, M.D., Ph.D. John Hijjawi, M.D. Herman Depypere, M.D., Ph.D. Nathalie Roche, M.D. Koenraad Van Landuyt, M.D., Ph.D. Ghent, Belgium This is Part II of four parts describing the three-step principle being applied in reconstructive and aesthetic breast surgery. Part I explains how to analyze a problematic breast by understanding the main anatomical features of a breast and how they interact: the footprint, the conus of the breast, and the skin envelope. This part describes how one can optimize results with breast recon- structions after complete mastectomy. For both primary and secondary recon- structions, the authors explain how to analyze the mastectomized breast and the deformed chest wall, before giving step-by-step guidelines for rebuilding the entire breast with either autologous tissue or implants. The differences in shaping unilateral or bilateral breast reconstructions with autologous tissue are clarified. Regardless of timing or method of reconstruction, it is shown that by breaking down the surgical strategy into three easy (anatomical) steps, the reconstructive surgeon will be able to provide more aesthetically pleasing and reproducible results. Throughout these four parts, the three-step principle will be the red line on which to fall back to define the problem and to propose a solution. (Plast. Reconstr. Surg. 123: 794, 2009.) S culpting a flap of autologous tissue into an aesthetically pleasing breast has become the most demanding aspect of breast re- construction, as the technical aspects of flap har- vesting and microsurgery have become routine in most centers. 1–9 There is no question that breast reconstruction is an important component in the final recovery of many breast cancer patients and is a main contributor to the quality of life of the post– breast cancer patient. An unreconstructed mastectomy defect but also a poorly executed re- construction serves as a constant reminder of a cancer diagnosis. Therefore, it stands to reason that the more aesthetic and natural a recon- structed breast appears and feels, the more com- pletely a breast cancer patient will recover. In- deed, in an era where the success rates of elective microvascular breast reconstruction approach 100 percent, a flap that “survives” but fails to recreate an aesthetic breast is appropriately judged a re- constructive failure. Why then does so little literature exist on this critical and challenging aspect of breast recon- struction? Three-dimensional thinking and the ability to manipulate tissue in three dimensions are skills that typically need to be well developed by plastic surgeons. Despite these talents, the mere fact of adequately describing the manip- ulation of an essentially flat structure such as a skin and fat flap into a three-dimensional struc- ture such as a breast is challenging and difficult, particularly in writing. Recreating an aesthetically pleasing breast af- ter partial or total mastectomy is a combination of good measurements and artistic insight. The ex- perience of the surgeon is the final determining factor. Unfortunately, artistic insight and experi- ence are very abstract and ill-defined elements. In this article, we will put forward a very systematic From the Department of Plastic and Reconstructive Surgery and the Division of Gynaecological Oncology, University Hospital Ghent. Received for publication April 27, 2008; accepted August 20, 2008. Copyright ©2009 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e318199ef16 Disclosure: None of the authors has a financial interest to declare in relation to the content of this article. www.PRSJournal.com 794