Oncoplastic breast surgery__a_guide_to_clinical_practice

Florian Fitzal, Peter Schrenk (Eds.)

ONCOPLASTIC BREAST SURGERY

A Guide to Clinical Practice

Univ.-Prof. Dr. Florian FitzalMedical University ViennaDepartment of Surgery, Breast Cancer Health CenterVienna, Austria

Univ.-Doz. Dr. Peter SchrenkDirector, Breast Unit, AKH Linz – LFKK, AKH Linz, Linz, AustriaSecond Surgical Department – Ludwig Boltzmann Institute for Surgical Laparoscopy, AKH Linz,Austria

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The initial idea to write a book on oncoplastic techniques was raisedthrough a meeting on breast cancer treatment in Saalfelden, Aus-tria two years ago. Contrary to the rather minor role breast surgeryis conceded today compared to other treatment modalities the sur-geons role on the further outcome of the disease is crucial and nevercompensated by radiation or adjuvant therapy.

Whereas surgery a decade ago was merely excision of the cancer and closure of the wound leaving behind a mutilated breast in many women, the advent of oncoplastic surgery completely changed the modern surgical approach to breast cancer.

The concept of oncoplastic breast surgery combines oncologic tu-mor resection - either breast conservation or mastectomy - with tra-ditional or less traditional plastic surgical techniques.The primary goal is to achieve an optimal cosmetic result withlong time local tumor control. Some (non – randomized) studiesavailable in patients following breast conservation oncoplasticsurgery showed tumor resection to be associated with wider freemargins, less patients needing re-operation surgery for involved orclose margins, a widening of the indications for breast conserva-tion surgery, a low complication rate and at least an equal localrecurrence rate.

There is no doubt that oncoplastic breast surgery experienced a rap-id rise with more patients demanding this kind of surgery. However, a profound knowledge of the different oncoplastic techniques is es-sential for the outcome.

This book describes various common oncoplastic techniques used inbreast conservation surgery and mastectomy with immediate recon-struction. Surgeons experienced in a particular technique provide a

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step by step description of oncoplastic surgical techniques and aspecial emphasis was put on to outline indications and contraindi-cations for a technique.Furthermore tips and tricks are provided at the end of each chapter which help to avoid common mistakes by surgeons learning a technique.

Re-shaped breasts constitute a diagnostic challenge for the radi-ologist with several postoperative changes not seen after standardquadrantectomy and mastectomy. This prompted us to include achapter on this topic in a book primarily written for surgeons.

We hope that this book will assist breast surgeons in a better understand-ing of oncoplastic principles and encourage them to use techniques we are convinced that will turn out to be beneficial for their patients.

The editors want to thank all the contributing authors for theirdedicated work and Bernard Ammerer for his artistic drawings that largely contribute to further understanding. Without their help wewould have never been able to accomplish this book.

We would also like to thank the staff at Springer, Mag. Heller andMrs. Stakemeier, for their support and guidance during publishing.

And last but not least we thank our families for their support and understanding, that time will always be too short.

Florian Fitzal, Peter Schrenk

Breast Surgery has developed greatly since its beginnings. What wassimple and unfortunately often mutilating removal of the cancerouslesion often has become a sophisticated and quality-of-life-orientedpart of the multi-disciplinary process in the treatment of a disease that nowadays affects 1 out of 8 women during their lifetime in thewestern world.

In parallel with this observation, surgeons have been the triggersof innovation. Going back for more than a century, it was a surgeonwho developed the concept of locoregional cancer growth and the

Preface

development of a radicality that eventually revolutionized cancer treatment. Likewise, procedures aimed at minimalizing morbid-ity and avoiding unnecessary harm and burden to patients were developed by surgeons, as where concepts of adjuvant and neo-adjuvant treatment strategies. While it appeared for a while that surgery may have lost its key role in the concert of multimodality therapy, it is now again realised that the way when and how we remove the tumour, greatly affects outcomes and the quality of lifeof our patients.

Oncoplastic surgery takes this development to the next level. This concept combines both oncologic and tumour biology awareness with modern technical aspects of surgery, trying to combine both principles for optimal outcome. This is not only a matter of surgical technique – it also demonstrates the strive of surgeons for continu-ing progress, and our empathy for those affected by the disease.

It is important for all of us that we have guidance and summaries of the background and state-of-the-art of such rather new fields. This isthe great value of this wonderful book, where Florial Fitzal and Peter Schrenk, two of the most pronounced experts and innovators in the field, have managed to assemble a great group of authors to provide exactly that guidance and education. The book will be of interest to both experts and novices alike, and may provide interesting yet un-known little details to many experienced breast surgeons as well asthose who intend to become experts in the field.

I hope that in addition to the natural focus of this overview on surgical technique, the readers will be able to sense the un-derlying greater concept – that optimising surgery has to finda balance between the intentions of cure and the preserva-tion of an aesthetical shape of the breast, and that these con-cepts have to be embedded in a multidisciplinary concept in the treatment of breast cancer. It is more than satisfying that again sur-geon take the effort and enthusiasm to improve the overall results, but are also willing to share their knowledge and achievements in an attempt to continue innovation and improvement that will eventu-ally serve our grateful patients.

Michael Gnant Professor of SurgeryMedical University of ViennaAustrian Breast & Colorectal Cancer Study Group

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The oncoplastic approach in surgery interlaces concepts of breast surgical oncology with the principles underlying reconstructiveprocedures in an endeavor to enhance both oncologic results andcosmetic performance. Having made substantial progress since the early 1990s, oncoplastic techniques today are refining the role of breast-conserving surgery in an accelerating number of breast can-cer patients who are ineligible for conventional organ conservation.

Overall, oncoplastic breast surgery is well evidenced and clearly war-ranted to facilitate wide excision and clear margins without compro-mising esthetic outcome. While today’s operative settings increas-ingly include specialist oncoplastic surgeons involved in both simple manipulations and sophisticated reconstruction - applying even to immediate intervention following skin-sparing mastectomy -, tradi-tional collaboration between oncologic and plastic surgery in somesituations would remain a viable and valuable treatment option.

The investigations compiled in the present volume, authored byoncologic, reconstructive and plastic surgeons in association, are guided by the evolving oncoplastic principle that any curative onco-logic approach should incorporate its esthetic consequences - andthat any cosmetic procedure should also allow for dilligent oncologicconsiderations.

Raimund JakeszProfessor of Surgery Medical University of Vienna

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1 GENERAL SURGERY1.1 Surgical Anatomy

Würinger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1.2 Breast Cancer Surgery: Standard PrinciplesFitzal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1.3 Oncoplastic Breast SurgerySchrenk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

2 ONCOPLASTIC SURGERY (OPS)2.1 OPS and Breast Conserving Surgery (BCS)

2.1.1 BCS and Immediate Reconstruction –Local Techniques = Local in Breast Tissue Flaps

2.1.1.1 Reconstruction of Partial Mastectomy Defects:Superior Pedicle Reduction MammaplastySchrenk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

2.1.1.2 Inferior Pedicle Mammaplasty for Reconstructionof Partial Mastectomy DefectsSchrenk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

2.1.1.3 Medial or Lateral Pedicle Vertical Breast Reduction(Hall-Findlay or Snowman Technique)Hall-Findlay, Fitzal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

2.1.1.4 Round Block Technique (Doughnut Mastopexy)Fitzal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71

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2.1.1.5 Superior Pedicle Mammaplasty and Reconstructionof Quadrantectomy Defects With Inferior Pedicle FlapsSchrenk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

2.1.1.6 Batwing TechniqueFitzal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

2.1.1.7 S-Shaped Oblique Reduction Mammaplasty forReconstruction of Partial Mastectomy DefectsSchrenk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

2.1.1.8 Immediate Reconstruction of CentralQuadrantectomy Defects with a Rotation Flap –The Grisotti TechniqueGrisotti, Casella, Calabrese . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

2.1.1.9 Intramammarian Flap TechniqueRageth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

2.1.1.10 B-Plasty for Reconstruction of Partial Mastectomy DefectsSchöndorf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ff 107

2.1.2 BCS and Immediate Reconstruction - Flaps2.1.2.1 Partial Mastectomy / BCS and Reconstruction

With LatissimusRainsbury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .y 115

2.1.2.2 Partial Mastectomy: Breast ReconstructionWith the Pedicled Thoracoepigastric FlapHuemer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .r 127

2.2 OPS and Mastectomy

2.2.1 Resection Techniques2.2.1.1 Nipple and Skin Sparing Mastectomy

Carlson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

2.2.2 Implant Reconstruction2.2.2.1 Immediate Breast Reconstruction With Implants

De Lorenzi, Rietjens, Manconi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .141

2.2.2.2 Immediate Reconstruction After Mastectomy:Reconstruction With Tissue ExpandersFriedrich, Salehin, Krämer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .r 149

2.2.3 Autologous Reconstruction2.2.3.1 Breast Reconstruction With the Latissimus Dorsi

Muscle FlapHoch, Benditte-Klepetko, Bartsch, Gösseringer, Deutinger . . . .r 157

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2.2.3.2 Immediate Breast Reconstruction:The Pedicled TRAM FlapSchrenk, Huemer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

2.2.3.3 Reconstruction After Mastectomy:DIEP and Muscle-/ Fascia-Sparing TRAM FlapMunder, Andree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

2.2.3.4 Transverse Myocutaneous Gracilis Flap for ImmediateSkin-Sparing Mastectomy Breast ReconstructionSchoeller, Pülzl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187

2.3 Special Considerations2.3.1 Breast Cosmetic Analyses

Fitzal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

2.3.2 Nipple Reconstruction and Contralateral AdaptationKoller, Gärner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .r 197

2.3.3 Radiological Findings Following Breast ConservingOncoplastic SurgeryGrafinger-Witt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207

2.3.4 Lipofilling of Tissue Defects Following Breast ConservationRietjens, De Lorenzi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

2.3.5 Oncoplastic Breast Conserving Surgery forLate Reconstruction of Partial Breast DefectsSchrenk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223

2.3.6 Defect Reconstruction After Partial Mastectomy With FlapsKoller, Gärner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .r 231

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List 0f Contributors

XIII

Priv. Doz. Dr. Christoph AndreeSana Hospital Gerresheim, Department of Plastic and Aesthetic SurgeryGräulingerstraße 120, 40625 Düsseldorf, GermanyEmail: [email protected]

Dr. Rolf Bartsch Department of Plastic and Reconstructive Surgery, Krankenanstalt RudolfstiftungJuchgasse 25, 1030 Vienna, AustriaEmail: [email protected]

Dr. Heike Benditte-KlepetkoDepartment of Plastic and Reconstructive Surgery, Krankenanstalt RudolfstiftungJuchgasse 25, 1030 Vienna, AustriaEmail: [email protected]

Dr. Claudio CalabreseBreast Unit, Azienda Ospedaliero, Universitaria Careggi50100, Florence, ItalyEmail: [email protected]

Grant W. Carlson, MDProfessor of Surgery, Division of Plastic Surgery, Winship Cancer Institute1365C Clifton Road, Emory University School of Medicine, Atlanta GA USA 30322Email: [email protected]

Dr. Donato CasellaBreast Unit, Azienda Ospedaliero Universitaria Careggi50111, Florence, ItalyEmail: [email protected]

Univ. Prof. Dr. Maria Deutinger Head of the Department of Plastic and Reconstructive SurgeryKrankenanstalt RudolfstiftungJuchgasse 25, 1030 Vienna, AustriaEmail: [email protected]

Univ. Prof. Dr. Florian Fitzal, FEBS (Oncology)Department of Surgery, Breast Cancer Health Center, Medical University Vienna Währinger Gürtel 18-20, 1090 Vienna, AustriaEmail: [email protected]

Prof. Dr. Michael FriedrichHead: Department of Obstetrics and Gynaecology, HELIOS-HospitalLutherplatz 40, 47805 Krefeld, GermanyEmail: [email protected]

List of Contributors

Dr. Beatrix MunderSana Hospital GerresheimDepartment of Plastic and Aesthetic SurgeryGräulingerstraße 120, 40625 Düsseldorf, GermanyEmail: [email protected]

Dr. Petra PülzlKH der Barmherzigen Brüder SalzburgDepartment for Plastic SurgeryKajetanerplatz 1, 5020 Salzburg, AustriaEmail: [email protected]

Doz. Dr. Christoph RagethBrust-ZentrumSeefeldstraße 214, CH-8008 ZürichEmail: [email protected]

Prof. Richard M. RainsburyDirector, Oncoplastic Breast UnitRoyal Hampshire County HospitalWinchester SO22 5DG, UKEmail: [email protected]

Dr. Mario RietjensEuropean Institute of OncologyDepartment of Plastic and Reconstructive SurgeryVia Ripamonti 435, 20141 Milan, ItalyEmail: [email protected]

Dr. Darius SalehinDepartment of Obstetrics and Gynecology, HELIOS-HospitaLutherplatz 40, 47805 Krefeld, GermanyEmail: [email protected]

Univ.-Prof. Dr. Thomas Schoeller, M.Sc.Medical University InnsbruckDepartment of Plastic and Reconstructive SurgeryAnichstraße 35, 6020 Innsbruck, AustriaEmail: [email protected]

Prof. Dr. Norbert K. SchöndorfHinter den Gärten 11, 66740 Saarlouis, GermanyFormer Head of Gynecological Clinic and Breast CenterSt. Elisabeth-KlinikKapuzinerstraße 4, 66740 Saarlouis, GermanyEmail: [email protected]

Doz. Dr. Peter SchrenkDirector Breast Unit, AKH Linz – LFKKLudwig Boltzmann Institute for Surgical LaparoscopySecond Surgical DepartmentKrankenhausstraße 9, 4020 Linz, AustriaEmail: [email protected]

Doz. Dr. Elisabeth WüringerEmail: [email protected]

Dr. Stefan GärnerDepartment of Plastic and Reconstructive SurgeryKrankenanstalt RudolfstiftungJuchgasse 25 , 1030 Vienna, AustriaEmail: [email protected]

Dr. Nina GösseringerDepartment of Plastic and Reconstructive SurgeryKrankenanstalt RudolfstiftungJuchgasse 25 , 1030 Vienna, AustriaEmail: [email protected]

Dr. Elisabeth Grafinger-WittInstitute for Radiology, Breast Unit, AKH Linz – LFKKKrankenhausstraße 9, 4020 Linz, AustriaEmail: [email protected]

Dr. Andrea GrisottiPlastic Surgery UnitCasa Di Cura S.Pio X20100 Milan, ItalyEmail: [email protected]

Elizabeth J. Hall-Findlay, MD, FRCSC340-317 Banff Avenue, Box 2009Banff, Alberta, Canada, T1L 1B7Email: [email protected]

Dr. Daniela HochDepartment of Plastic and Reconstructive SurgeryKrankenanstalt RudolfstiftungJuchgasse 25, 1030 Vienna, AustriaEmail: [email protected]

Doz. Dr. Georg M. Huemer (EBPRS)Plastic, Reconstructive and Aesthetic SurgeryBreast Unit, AKH Linz – LFKKKrankenhausstraße 9, 4020 Linz, AustriaEmail: [email protected]

Prim. Doz. Dr. Rupert KollerHead: Department of Plastic and Reconstructive SurgeryWilhelminenspitaMontleartstraße 37, 1160 Vienna, AustriaEmail: [email protected]

Dr. Stefan KrämerLuisen-HospitalDegerstraße 8, 40235 Düsseldorf, GermanyEmail: [email protected]

Francesca De Lorenzi, MD PhDEuropean Institute of OncologyDepartment of Plastic and Reconstructive SurgeryVia Ripamonti 435, 20141 Milan, ItalyEmail: [email protected]

Andrea Manconi, MDEuropean Institute of OncologyDepartment of Plastic and Reconstructive SurgeryVia Ripamonti 435, 20141 Milan, ItalyEmail: [email protected]

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GENERAL SURGERY

3

A rich nervous and vascular supply to the mammary gland and to the nipple areola complex has long been known (Cooper 1840a; Marcus1934). In turn, the location of the neurovascular structures within thebreast has always been unpredictable and appeared to be distrib-uted in a haphazard, randomized pattern. A practical approach to lo-cate these structures is desirable in order to ensure safe viability andsensibility of the nipple in breast surgery.

Our investigations of the mammary gland showed a definite rela-tionship between the course of the nerves and vessels and a coher-ent, strong suspension apparatus in the breast which can reliablybe predicted and which displays a constant morphology (Würinger,Mader et al. 1998; Würinger, Tschabitscher 2003; Würinger 2009).The ligamentous suspension consists of a horizontal fibrous sep-tum originating from the pectoralis fascia at the level of the fifth rib heading toward the nipple and its vertical ligamentous extensionswhich provide a medial and lateral line of fixation on either border of the septum (Fig. 1 – 4).

The medial vertical ligament stretches from the sternum along thesecond to the fifth rib, while the lateral vertical ligament attachesalong the lateral border of the pectoralis minor muscle. Cranially, thevertical ligaments are connected along the second rib by the super-

Surgical Anatomy

Elisabeth Würinger

1.1

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General Surgery

ficial fascia and in this way form a circle of fibrous attachments. The line of fixation of this circle fol-lows the borders of the pectoralis major muscle or-igin to a great extent. In an anterior direction, thevertical ligaments merge into the capsule of the breast. Thus, the ligamentous suspension also con-nects with the ligamenta suspensoria as describedby Cooper (Cooper 1840b) as stretching from the anterior sheet of the superficial mammary fascia into the skin.

Arising from the same origin at the thoracic wall, the ligamentous suspension also has a superficial cuta-neous component that merges into the overlying skin, thereby defining the actual bounds and shapeof the breast. A rather weak medial cutaneous liga-ment stretches into the skin overlying the sternum.The superficial lateral ligament builds a strong con-nection between the pectoralis minor muscle andthe skin and fascia of the axilla, thus producing anaxillary hollow by the suspensory ligament of the axilla (Fig. 4). The superficial cutaneous part of the horizontal septum stretches from the same origin at the level of the fifth rib into the submammarycrease by densifications of Cooper’s ligaments (Fig. 2); it thereby forms the submammary crease.

The main importance of the ligamentous suspen-sion lies in the fact that it acts as a guiding structure for neurovascular supply. The deep component of the ligamentous suspension, which attaches the breast to the thoracic wall, has a predictable relationship to the main vessels and nerves of the breast and thenipple-areola complex. It resembles the mesentery of the intestine both in its thin, pliable structureand in functional terms. The remaining parts of thebreast receive no distinct vessels from the thoracic wall, as mentioned in previous descriptions of the hypervascular and hypovascular zones of the ante-rior chest wall (Palmer, Taylor 1986).

The horizontal septum is covered cranially and caudally by two dense layers of vessels runningtoward the nipple (Fig. 2, Fig. 3). The very distinct

Fig. 1:Craniomedial view of the right breast in anatomical dis-section, showing the horizontal septum and the medialligament after blunt separation along the retromammaryspace.

Fig. 2:Schematic vertical sectional view of the left breast, show-ing the horizontal septum guiding cranial and caudal vas-cular layers.

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Surgical Anatomy

cranial layer consists of branches of the thora-coacromial artery, emerging from the pectoralis major at the level of the fourth intercostal space, and a branch of the lateral thoracic artery. The caudal vascular layer is built by cutaneous perfo-rating branches from anastomoses of the fourthand fifth, rarely also the sixth intercostal arteries,which together run in a cranial direction to attach to the horizontal septum.

The residual part of the fibrous circle also acts asa guiding structure for the main vascular supply,continuing to run subcutaneously along the cap-sule of the gland and finally building a subdermalperiareolar network (Fig. 4). These are the perforat-ing branches from anastomoses of the internal thoracic artery, which follow the medial vertical ligament, arising from the second to the fourth intercostal spaces, and branches of the lateral tho-racic artery arising at the same level, which follow the lateral vertical ligament. These vessels run subcutaneously, protected within channels built by the fibrous structures of the ligaments, which merge into the superficial fascia. At the subdermalperiareolar plexus, they anastomose with the ves-sels which come along the horizontal septum.

Both the large vessels and the large nerves run alongthe ligamentous suspension (Würinger, Mader et al. 1998). To the extent that they are developed, the an-terior cutaneous branches of the second to fourthintercostal nerves are guided along the medial ligament and the corresponding lateral cutaneous branches along the lateral ligament (Fig. 4). Most importantly, the main nerve to the nipple, the deepbranch of the lateral cutaneous branch of the fourthor sometimes the fifth intercostal nerve, always runs along the horizontal septum (Fig. 3).

Understanding the course of the main neurovascular supply along the horizontal septum is of avail in preserv-ing viability and sensitivity to the nipple in operations of the breast, e.g. in breast reductions (Würinger 1999,2005, 2010; Deventer et al. 2008; Hamdi et al. 2009).

3)

4)

Fig. 3:Schematic anteromedial view of the left breast, showing the neurovascular supply along the horizontal septum.

Fig. 4:Same view, showing the neurovascular supply guided sub-cutaneously along the medial and lateral ligaments to the NAC.

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General Surgery

According to previous investigations, the lymphat-ics also follow the path of the blood vessels (Rom-rell, Bland 2006) and their main course therefore is likely to follow the ligamentous suspension, as well. The ability to locate the lymphatic drainagewithin a defined layer may have some impact onradical tumor surgery.

Clinical access to the horizontal septum is straightforward. It can be accessed by blunt preparation along the retromammary space af-ffter cutting the posterior sheet of the superficialfascia (Fig. 5). The retromammary space is opened up in a caudal direction to the level of the fourth intercostal space where it changes its direction.Here it merges into a horizontal areolar tissue plane which heads to the nipple. The areolar tis-sue plane can be opened bluntly toward the nip-ple (Fig. 2). The horizontal septum with its vascu-lar layers is situated below this cleavage plane (Würinger, Mader et al. 1998).

The nipple is divided horizontally by the horizontal septum. Therefore, the lactiferous ducts also emp-ty themselves into the mammary sinuses along a cranial and a caudal layer. They can be seen ashorizontal planes with the duct openings into thenipple lying at the same levels, separated by thehorizontal septum. They thus represent two sepa-rate anatomical units.

The breast is an ectodermal gland, enveloped by the superficial fascia which spreads into a superfi-cial and a posterior sheet to embed the breast. Thedeep pectoralis fascia envelops pectoralis major and attaches medially to the sternum and laterallyto the fascia of pectoralis minor. The vertical liga-ments and the origin of the horizontal septum can together be seen as a fusion of the superficial anddeep pectoralis fascia.

The preexisting bipartition of the breast can be understood embryologically as the fusion of two mammary buds along the mammary ridges as is

Fig. 5:In clinical breast reduction the horizontal septum (shiningthrough behind the hook) can be found by blunt dissectionalong the retromammary space.

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Surgical Anatomy

seen e.g. in artiodactyls (Starck 1975). On the other hand, the bipar-tition by the nerve- and vessel-guiding septum can be seen as aninvagination of the ectoderm which forms the ducts and alveoli cra-nially and caudally from the inductive vascularized connective tissuederived from the mesenchyme along the mammary ridges (Hinrich-sen, 1990).

Cooper, A.P. (1840a). “Of the arteries of the breast”. In: On the anatomy of the breast. (ed. A.P. Cooper) London: Longman, Orme, Green, Brown and Longmans,pp 60-62.

Cooper, A.P. (1840b). “Of the internal parts of the breast or mammary gland”. In: On the anatomy of the breast. (ed. A.P. Cooper),London: Longman, Orme, Green, Brown,and Longmans, pp 48-58.

Hamdi M, Van Landuyt K, Tonnard P, Ver-paele A, Monstrey S (2009) “Septum based Mammaplasty: A surgical Technique basedon Würinger´s Septum for Breast Reduc-tion” Plast. Reconst. Surg 123: 443-454.

Hinrichsen, K.V. (1990). “Entwicklung derHautanhangsgebilde“. In: Human Embry-ology. Springer Verlag, p 869.

Marcus, G.H. (1934). “Untersuchung überdie arterielle Blutversorgung der Mamilla“.Wiener Med Wochenschr 179: 361-9.

Palmer, J.H., G.I. Taylor. (1986). “The vascularterritories of the anterior chest wall”. Brit JPlast Surg 39: 287-99.

Romrell, I.J., K.I. Bland. (2006). “Anatomyof the breast, axilla, chest wall and relatedmetastatic sites”. In: Bland K I Copeland EM (eds.) The Breast: Comprehensive Management of Benign and Malignant Disor-ders. St Louis, Saunders.

Starck, D. (1975). “Entwicklung der Mam-maorgane“. In: Vergleichende Embryologie,Stuttgart: Thieme, pp 440-441.

van Deventer PV, Page BJ, Graewe FR (2008)“ The safety of pedicles in breast reductionand mastopexy procedures”. Aesth. Plast.Surg 32: 307-12.

Würinger, E., N. Mader, et al. (1998). “Nerveand vessel supplying ligamentous suspen-sion of the mammary gland”. Plast Recon-str Surg 101: 1486-93.

Würinger, E. (1999). “Refinement of thecentral pedicle breast reduction by application of the ligamentous suspension. PlastReconstr Surg 103: 1400-10.

Würinger, E., M. Tschabitscher. (2003).“New aspects of the topography of themammary gland regarding its neurovas-

cular supply along a regular ligamentoussuspension”. Eur J Morphol 40: 181-9.

Würinger, E. (2005). “Vertical scar mamma-plasty with the inferocentral pedicle”. In: Ham-di M, Hammond D, Nahai F (eds.). Vertical Scar Mammaplasty. Berlin, Springer Verlag, 75-82.

Würinger, E. (2009). “Nerves, ligamentsand vessels of the chest and breast”. In:Shiffman M (ed.) Breast Augmentation.Berlin, Springer Verlag, 25-26.

Würinger, E. (2010). “The Central Septum inBreast Reduction and Mastopexy” in Hall- Findlay E. and Evans G (eds) Aesthetic and Reconstructive Surgery of the Breast. Else-vier, Chapter 14, pp 215-22.

References

9

Local therapy in breast cancer patients is of highest importance andinfluences overall survival. A 15% reduction in local recurrence rates 5 years postsurgery will yield a significant 5% increase in overall sur-vival 15 years after surgery (EBCTCG 2005). Local therapy consistsof breast and axillary surgery with or without radiotherapy. While breast-conserving therapy (BCT) should imperatively be accompa-nied by local radiotherapy, mastectomized patients rarely need ad-juvant radiotherapy. There are several excellent reviews about breastcancer surgery (Morrow 2005; Fitzal and Gnant 2006; Fitzal, Nehrer et al. 2007; Fitzal, Riedl et al. 2008). This review briefly summarizesthe most important facts about breast and axillary surgery.

1. History

In the early 20th century, several retrospective studies demonstrat-ed good local control in stage I breast cancer patients with BCT in Europe. The first prospective study by Atkins (Atkins, Hayward et al. 1972) demonstrated no difference for stage I breast cancer patients while stage II patients had a significantly worse oncologic outcomewith BCT.

Breast Cancer Surgery: Standard Principles

Florian Fitzal

1.2

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General Surgery

Six prospective trials (Blichert-Toft, Rose et al. 1992; Arriagada, Le etal. 1996; van Dongen, Voogd et al. 2000; Fisher, Anderson et al. 2002;Veronesi, Cascinelli et al. 2002; Poggi, Danforth et al. 2003) demon-strated no difference in either local and distant control or overall sur-vival comparing BCT and mastectomy. However, several therapeutic implications are to be mentioned.

2. Resection margins

There is still a dispute surrounding the definition of negative and close margins. While European physicians have required larger distances from cancer cells to the margin in referring to negativemargins, Americans are satisfied with at least 1mm of free margin(Taghian, Mohiuddin et al. 2005). However, most authors define apositive margin as less than 1 mm and a close margin as less than2 mm of normal breast tissue between the resection margin and the next cancer cell (Freedman, Fowble et al. 1999; Park, Mitsumoriet al. 2000; Horst, Smitt et al. 2005). Recently, authors demonstrat-ed that a negative resection margin below 3mm is no guaranteefor having entirely eliminated cancer cells in the breast (Zavagno,Goldin et al. 2008). This supports data according to which radio-therapy improves local recurrence-free and overall survival after R0 resections (EBCTCG 2005).

Three prospective trials comparing BCT with mastectomy showed that an R1 resection significantly increases the risk of local recur-rence after BCT (van Dongen, Voogd et al. 2000; Veronesi, Cascinelliet al. 2002; Poggi, Danforth et al. 2003), while trials including pa-tients with resection-free margins only (Blichert-Toft, Rose et al. 1992; Arriagada, Le et al. 1996; Fisher, Anderson et al. 2002) failed to showsignificant differences between BCT and mastectomy regarding lo-cal control.

Several retrospective analyses indicated that a resection-free marginis crucial for any kind of BCT (Horst, Smitt et al. 2005). Positive mar-gins increased the 5- to 10-year local recurrence rates significantly by 2 to 5 times, with annual recurrence rates ranging from 2 to 3 % as compared with annual recurrence rates of 0.2 to 0.4 in patients withresection-free margins (Veronesi, Salvadori et al. 1995).

The definition of a resction free margin is crucial. While most studies demonstrated that a margin of 1mm seems to be enough, several others suggested larger resection free margins. This is based on the

11


fact that there are several other important co-factors which have tobe taken into account regarding the resection free margin.

Recently Morrow et al demonstrated that in patients with a in situcancer margin has to be above 2mm to reduce the local recurrencerate (Dunne, Burke et al. 2009). More over, several other studiesshowed that young age is an independent predictor for a worse localrecurrence free survival and extensive involvement is also increas-ing local recurrence compared with only minor involvement at 1mmaway from the margin.

Thus we suggest to define a resection free margin with 1mm for in-vasive components and >2mm in case of any other cofactors (youngage, e.g. <40, extensive involvement of the resection margin at 1mm and in situ lesions)

3. Radiotherapy

Several prospective trials clearly demonstrated that BCT without ra-diotherapy significantly increases local recurrence rates (Veronesi, Luini et al. 1993; Veronesi, Marubini et al. 1995; Fisher, Anderson etal. 2002). Additionally, recent data also suggest that this increase in local recurrence rates significantly impairs overall and breast cancer-related survival (EBCTCG 2002; Clarke, Collins et al. 2005; EBCTCG2005). Thus, adjuvant radiotherapy is a standard procedure for allpatients following BCT. However, the question is still unresolved asto whether radiotherapy may be omitted in some patients with low-risk disease.

In 2004, the New England Journal of Medicine published two relevantprospective trials. First, Fyles and coworkers reported on patients 50years or older under tamoxifen after BCT with or without radiother-apy (Fyles, McCready et al. 2004). The local recurrence rate increasedfrom 0.6 to 7 %, corresponding to a reduced 5-year survival of 91 %compared with 84 %. Second, Hughes and collaborators compared radiotherapy with no radiotherapy in patients 70 years or older after BCT (Hughes, Schnaper et al. 2004). Radiotherapy improved the localrecurrence rate significantly from 1 to 4 %. Patients with early breast cancer under 74 years of age were randomly assigned to receive ei-ther radiotherapy or not (Malmstrom, Holmberg et al. 2003). Simi-larly, this randomized trial demonstrated significantly improved local recurrence-free survival from 4 to 14 % with adjuvant radiotherapy. Local recurrence was 23 % after a median follow-up of 86 months,

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General Surgery

even in very low-risk patients (stage I) with resection-free marginsof at least 1 cm without extensive intraductal component (EIC) ornodal involvement (Lim, Bellon et al. 2006). The Austrian Breast andColorectal Cancer Study Group (ABCSG) presented two prospectivetrials at the San Antonio Breast Cancer Symposium (SABCS) in 2005 (Gnant, Poetter et al. 2005). Tumor size lesser than 3cm, postmeno-pausal status and lymph node-negative breast cancer were inclusion criteria. Their data showed that radiotherapy significantly reduced local recurrence-free survival from 3.19 to 0.24 % (p=0.0008). There-fore, even in low-risk patients with resection-free margins of more than 1cm, radiotherapy has proven to effectively ameliorate local recurrence-free survival.

3.1 Age

Age has been demonstrated to be a predominant risk factor for lo-cal recurrence (Kurtz, Spitalier et al. 1988; Kurtz, Jacquemier et al. 1990; Kurtz, Jacquemier et al. 1990; Kurtz 1992). Several authors de-scribed an increase in local recurrence rate with ages younger than45, 40 or 35, however, there is no clear cut-off (van Dongen, Bartelink et al. 1992; Borger, Kemperman et al. 1994; Dewar, Arriagada et al.1995; Leborgne, Leborgne et al. 1995; Veronesi, Marubini et al. 1995;Pierce, Strawderman et al. 1997; Kini, White et al. 1998) (Table 2). Af-ffter multivariate correction with other factors such as margin status,age remained a significant prognostic factor for local recurrencedevelopment. This may be due to an increased rate of EIC or other aggressive tumor biological characteristics in young patients, result-ing in increased risk of positive resection margins (Kurtz, Spitalier et al. 1988; Kurtz, Jacquemier et al. 1990; Kurtz, Jacquemier et al. 1990;Kurtz 1992).

Other investigators indicated that the increased risk of local recur-rence is not associated with age but rather with menopausal status(Mansfield, Komarnicky et al. 1995; Dubsky, Gnant et al. 2002) and found no difference in known prognostic factors between younger and older patients despite the fact that survival was poorer in young-er patients. As chemo-oophorectomy compared with chemotherapyreduces the risk of local recurrence by 50 %, circulating estrogensmay be adversely related to local relapse in young patients support-ing the menopause hypothesis (Jakesz 2002).

Although retrospective analyses suggested an increased risk of lo-cal relapse, the data are inconclusive. Prospective studies compar-

13


ing BCT with mastectomy in fact did find an increased risk for local recurrence in younger patients after BCT but not after mastectomy(van Dongen, Voogd et al. 2000; Arriagada, Le et al. 2002; Veronesi, Cascinelli et al. 2002). Keeping in mind that younger patients bear anincreased risk of having EIC and that resection-free margins were not required in these two prospective studies, the increased local failurerate may actually be based on increased rates of positive resection margins in younger women. However, age below 35 was seen to bea risk factor for local recurrence in other prospective trials includingonly patients with resection-free margins (Fisher, Wickerham et al.1992; Fisher, Anderson et al. 1992). In contrast to these studies, the Eu-ropean Organisation for Research and Treatment of Cancer (EORTC)study by van Dongen showed no increase in risk for local recurrencein younger patients after BCT (van Dongen, Voogd et al. 2000). Theincreased risk for local recurrence in these women did not yield anincreased risk of death, as shown in a retrospective analysis of 9000women with 700 patients < 45 years of age. The increase in local recurrence rate was similar for invasive and intraductal carcinoma(Cutuli 2004; Bijker, Meijnen et al. 2006). A recent analysis of womenyounger than 50 years comparing BCT with mastectomy showed nosignificant difference in local, distant recurrence and overall survivalfor this selected group (Coulombe, Tyldesley et al. 2007).

To prevent the increased risk for local failure after BCT in youngerwomen, a resection-free margin of at least 2mm should be war-ranted since in this population, the increased risk for local recurrencewas not statistically significantly different as compared with older patients (Neuschatz, DiPetrillo et al. 2003). Also, a boost dose of radi-ation and tamoxifen in women with ductal carcinoma in situ (DCIS) reduces the risk, indicating that mastectomy is not necessary if adju-vant treatment is appropriate.

4. Size

The six prospective studies comparing BCT with mastectomy includ-ed patients with tumor diameters of up to 5cm (Blichert-Toft, Roseet al. 1992; Arriagada, Le et al. 1996; van Dongen, Voogd et al. 2000;Fisher, Anderson et al. 2002; Veronesi, Cascinelli et al. 2002; Poggi,Danforth et al. 2003). Retrospective analyses indicated that tumor diameter is not a predictive factor for local recurrence-free survival(Borger, Kemperman et al. 1994) (Eberlein, Connolly et al. 1990; vanDongen, Bartelink et al. 1992; Leborgne, Leborgne et al. 1995; Hei-mann, Powers et al. 1996; Pierce, Strawderman et al. 1997; Park, Mit-

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sumori et al. 2000). Thus, tumor size up to 5cm may be treated withBCT.

Only two retrospective analyses showed that even in patients withtumor diameters beyond 5cm, BCT may be oncologically feasible if cosmetic outcomes are satisfactory (depending on breast/tumor size relation) (Khanna, Mark et al. 1992; Fitzal, Riedl et al. 2007). However, resection-free margins and adjuvant radiotherapy are imperative.The introduction of neoadjuvant systemic therapy and the increased early detection rate reduced the number of T3 cancers, thus, only aminority of patients will have to face this issue. Prospective studies will not be performed due to ethical reasons.

5. Intraoperative frozen section analyses

Frozen section analysis (FSA) guides the surgeon during BCT to per-form primary tumor resection with clear margins and yields an ac-curacy of 97 % (Fessia, Ghiringhello et al. 1984; Ferreiro, Gisvold et al.1995). Furthermore, “core cut” FSA results may inform the surgeon immediately about the necessity to perform surgical axillary lymph node dissection in cases of an intraoperatively diagnosed invasive breast cancer. Subsequently, a second operation (two-stage proce-dure) may be avoided in a considerable number of patients (Sauter, Hoffman et al. 1994; Weber, Storm et al. 1997). The false-negative rate and the number of two-stage procedures, respectively, have been re-ported to range between 0% and 19% after FSA (Fessia, Ghiringhello et al. 1984; Sauter, Hoffman et al. 1994; Ferreiro, Gisvold et al. 1995;Niemann, Lucas et al. 1996; Cendan, Coco et al. 2005). Without the use of FSA, a two-stage procedure may become necessary in up to38% to 54% of patients undergoing simple lumpectomy (Schmidt-Ullrich, Wazer et al. 1989; Huston, Pigalarga et al.). Multiple re-exci-sions during BCT do not increase the local recurrence rate (O’Sullivan, Li et al. 2007).

While the accuracy, sensitivity and specificity rates range between 95 % and 99 % (Bianchi, Palli et al. 1995; Ferreiro, Gisvold et al. 1995; Weber, Storm et al. 1997), several authors raised concerns regarding the use of FSA for non-palpable lesions, tumors smaller than 1cm in diameter, and pure microcalcifications (Fechner 1988; Fechner 1995). As a consequence, physicians were concerned about a reduced diag-nostic accuracy particularly in such lesions. In addition, pathologists have reported on freezing artifacts, which may cause difficulties in determining both final tumor staging and the smallest free resec-

15


tion margin, thus obstructing measures to tailor adequate adjuvant therapy and imparing oncological outcome. Other arguments suchas economic and logistic considerations have also been addressed.Thus, several breast cancer units have been shifting their policy notto apply FSA on a routine basis.

Intraoperative FSA of breast specimens reduces the need for second-ary surgery in 20% to 40% (Sauter, Hoffman et al. 1994; Weber, Stormet al. 1997; Pinotti and Carvalho 2002; Chagpar, Yen et al. 2003; Balch, Mithani et al. 2005; Cabioglu, Hunt et al. 2007) and rapidly achieves optimal oncologic results with clear margins (Klimberg, Harms et al. 1999). These results suggest a reduction of two-stage procedures by the use of FSA as compared with reports on BCT without the use of FSA (Schmidt-Ullrich, Wazer et al. 1989; Huston, Pigalarga et al.).

Unpublished data of a retrospective multivariate analysis at our in-stitution regarding the use of FSA demonstrated that the use of neo-adjuvant therapy, the absence of preoperative sure cut biopsy, andthe necessity of preoperative stereotactic-guided breast biopsy may reduce the accuracy of intraoperative FSA. However, small tumor size or low-grade differentiation were not independent variants for afalse-negative FSA. The use of FSA resulted in a two-stage operationin only 9% of all patients (submitted to Eur J Surg Oncol 2008).

6. Biopsy

Diagnostic breast biopsy is indicated in Breast Imaging Reporting and Data System (BIRADS) IV lesions and assists the surgeon in plan-ning surgery in BIRADS V lesions (Sickles 1989). The concern about needle track seeding during core needle biopsy of breast cancer is not completely unfounded. In the literature, several case reports in-dicated needle track seeding after core biopsy (Harter, Curtis et al.1992; Grabau, Andersen et al. 1993; Thurfjell, Jansson et al. 2000;Chao, Torosian et al. 2001; Hoorntje, Schipper et al. 2004). Histologicalproof has been reported recently of tumor cell displacement within the needle track after fine needle biopsy in six patients (Hoorntje, Schipper et al. 2004).

Available data demonstrate that the local recurrence rate in patientswith preoperative fine needle biopsy or core biopsy is between 2%and 6% with a median follow-up of 5 years. This recurrence rate issimilar to that reported in many clinical studies for breast cancer pa-tients without preoperative core needle biopsy. Chen et al. showed

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no difference in the rates of local recurrence-free survival betweenbreast cancer patients with or without preoperative core biopsy. An-other study with 398 patients supported this hypothesis. In a retro-spective analysis at our institution, the use of preoperative core nee-dle biopsy did not increase the local recurrence rate (Fitzal, Sporn et al. 2006). Thus, displaced tumor cells seem to play no critical role forlocal recurrence after BCT and adjuvant radiotherapy.

7. Neoadjuvant therapy

The use of neoadjuvant therapy has been introduced as standardtreatment for locally advanced breast cancer patients, since pro-spective trials demonstrated that breast conservation rates were improved with this treatment option, while yielding similar overall survival rates when compared with adjuvant treatment (Veronesi, Bonadonna et al. 1995; Mamounas 1998; Mamounas and Fisher 2001; Wolmark, Wang et al. 2001).

However, some prospective and retrospective data suggested that patients with BCT after neoadjuvant therapy may have an increasedrisk for the development of a local recurrence (Rouzier, Extra et al.2001). Van der Hage and coworkers (van der Hage, van de Velde et al.2001) demonstrated that BCT after neoadjuvant therapy significant-ly impaired overall survival in patients primarily planned for mastec-tomy. Thus, there is evidence that resection margins after neoadju-vant therapy are to be of the same magnitude as before therapy. If this were true, there would be no further advantage of neoadjuvanttherapy and this treatment option could be questioned altogether. Recent meta-analyses support these data (Mauri, Pavlidis et al. 2005).

The reason for an increased local recurrence rate may be the possibil-ity of cancer cells remaining in the breast after BCT due to a scatter-ing rather than a concentric shrinkage of the primary cancer subse-quent to neoadjuvant therapy. Singletary et al. demonstrated thatthere are several risk factors for the presence of scattered residual cancer cells after neoadjuvant therapy such as skin edema, persist-ent tumor size >4cm, and intramammary lymphatic invasion (Single-tary, McNeese et al. 1992).

In view of the meta-analyses of 9 prospective trials suggesting thatBCT is related to an increase in local recurrence rate after neoadju-vant therapy, (Mauri, Pavlidis et al. 2005) it becomes evident thatseveral trials included patients with resection-positive margins after

17


BCT or even patients not given surgery after neoadjuvant treatment(Mauri, Pavlidis et al. 2005). Excluding these patients, locoregional re-currence is similar between BCT with or without neoadjuvant ther-apy.

Fisher demonstrated that local recurrence rates after neoadjuvant therapy followed by BCT did not differ significantly as comparedwith local recurrence rates in patients after BCT and adjuvant chem-otherapy (10% versus 7% after a median follow-up of 9.5 years) (Fish-er, Bryant et al. 1998). However, for patients initially considered formastectomy and treated with BCT after neoadjuvant therapy, localrecurrence rates were significantly increased compared with those who initially were candidates for BCT (15.9% versus 9.9% p=0.04).This compares well with the above-mentioned data by van der Hage and collaborators (van der Hage, van de Velde et al. 2001). However,the worse outcome may be attributed to a difference in tumor stagebetween the two groups and may thus, in fact, reflect worse tumor biology in the group with initially planed mastectomy (Buchholz, Le-hman et al. 2008). In a retrospective analysis from Milan of 195 pa-tients treated with BCT after neoadjuvant therapy, the local recur-rence rate was 6% after a median follow-up of 41 months which is similar to the rate seen in patients without neoadjuvant therapy andBCT (Gentilini, Intra et al. 2006).

Predictors for local failure after neoadjuvant therapy include lymphnode status, lymphovascular invasion, multifocal pattern of disease, and residual disease larger than 2cm after therapy (Chen, Meric-Bernstam et al. 2004). Zero or two of these factors were associatedwith 3% to 12% of 5-year local recurrence rate, whereas the presenceof three factors was associated with an 18% local recurrence rate at5 years. Clinical response did, and initial tumor size did not correlate with the local recurrence rate. In this regard, BCT is indicated follow-ing neoadjuvant therapy after careful selection. Risk factors and re-sponse to therapy by magnetic resonance imaging (MRI) should beevaluated before surgery. Improved MRI techniques should be evalu-ated to assess whether the cancer decreased concentrically or in ascattered pattern.

8. Axillary surgery

Knowledge of the existence of lymph node metastases in patients with invasive breast cancer is mandated to evaluate their progno-sis, tailor adjuvant therapy, and improve locoregional recurrence-free

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survival. Axillary staging is necessary in this respect. The anatomy of lymphatic mapping was published by Estourgie et al. in 2004 in 691patients applying radionucleid dye. Between 88% (inner quadrant)and 97% (outer quadrant) are drained through the axillary lymph nodes while 14% (outer quadrant) to 37% (inner quadrant) drain via the mammary lymph nodes. Patients with a positive axillary lymphnode need to undergo level I and II axillary dissection. The followingsections will discuss only the axillary staging procedure by sentinel lymph node biopsy (SNB).

SNB has replaced axillary dissection of level I and II in breast can-cer patients with clinically and pathologically negative lymph nodes.The first SNB for breast cancer patients was performed in the early 1990’s (Giuliano, Jones et al. 1997). A meta-analysis by Kim et al. dem-onstrated an accuracy of 92% with a median false-negative rate of 7 % (Kim, Giuliano et al. 2006). Radionucleid (Gallowitsch, Konstan-tiniuk et al. 2002) and/or methylen blue dye (Blessing, Stolier et al.2002) may both be used for sentinel node detection.

8.1 Detection method of SNB

Although their seems to be no significant difference, some investi-gators showed that the radionucleid method has an accuracy of 89 % while the methylen blue dye method reaches 83 % (p=0.007). Thecombination of both increases the detection rate up to 92 % (Alber-tini, Lyman et al. 1996; Kim, Giuliano et al. 2006) with a false-negative rate of 5 % for dual-agent injection versus 11 % for single-agent in-jection (McMasters, Tuttle et al. 2000). The advantage of the radio-nucleid technique is the possible detection of extra-axillary lymph nodes which may be seen in 7 % (Gallowitsch, Konstantiniuk et al.2002). However, time consumption, the necessity of a nuclear medi-cal department and costs are disadvantages associated with thismethod. Thus, blue dye detection is still preferred in several breastcancer centers. A recent report in Lancet Oncology based on 5536 pa-tients demonstrated an overall accuracy of 97 % and a false negativerate of 9 % for the blue dye method (Krag, Anderson et al. 2007) and 0.7 % of all patients showed an allergic reaction.

8.2 Injection site

The correct dye injection site has been investigated in several trials. While some authors show the highest detection rate with peritu-

19


moral injection or dermal injection, others show that not the tech-nique but rather the surgeon performing the technique is crucial(Klimberg, Rubio et al. 1999; Haid, Schrenk et al. 2002). The impor-tance of a trained surgeon rather than the injection site or the tech-nique used has been demonstrated by others (Morrow, Rademakeret al. 1999).

In this regard, advanced experience reduces the number of false-negative findings after SNB while increasing the accuracy of thistechnique (Cody, Hill et al. 1999; Martin, Chagpar et al. 2005). Thirtycases should be performed under the observation of a senior sur-geon until a false-negative rate of 5% and an accuracy of 90% has been reached (Tafra, Lannin et al. 2001). Other authors demonstratedthat 4 to 6 cases may be enough (Cody, Hill et al. 1999).

8.3 Oncologic safety

8.3.1 Prospective data

Oncologic safety was demonstrated by Veronesi et al. in the first pro-spective trial comparing SNB with axillary dissection (Veronesi, Pa-ganelli et al. 2003) with two year’s follow-up. There were no axillary recurrences in either arm, while morbidity was improved in patientsafter SNB. A second randomized trial was published in 2008 by Zav-agno et al., showing a similar disease-free survival rate (87% versus89%) in patients after SNB compared with axillary dissection aftera follow-up of 56 months (Zavagno, De Salvo et al. 2008). The dataof the National Surgical Adjuvant Breast and Bowel Project (NSABP)B-32 study comparing SNB with axillary clearance have not yet beenpublished (Krag Lancet Oncol 2007).

8.3.2 Retrospective data

With a follow-up of 37 months, a Swedish multicenter cohort study with 3534 patients demonstrated that patients after a negative SNB(n=2246) had an axillary recurrence rate of 0.6% (Bergkvist, de Boni-face et al. 2008). A 7-year follow-up of 953 patients after SNB demon-strated that only 3 developed axillary metastases and were treatedwith axillary dissection. The 5-year overall survival rate was 98% inthis population (Veronesi, Galimberti et al. 2005). The Minneapoliscancer registry data published in 2005 demonstrated an axillary re-currence rate of 0.6% in 700 node-negative patients after SNB with a

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General Surgery

median follow-up of 33 months (Swenson, Mahipal et al. 2005). Simi-lar results were published by the Roswell Park Cancer Institute in Buf-fffalo (Palesty, Foster et al. 2006). Interesting overall survival data froma Dutch group in Nijemen demonstrated an improved outcome for 880 node-negative SNB patients compared with 1681 node-negative axillary dissection patients with a hazard ratio of 1.2 after correctionfor other confounding factors (Kuijt, van de Poll-Franse et al. 2007).Four thousand and eight patients were followed up for 31 months showing only 0.25% of axillary recurrences at the Memorial Sloan-Kettering Cancer Center (Naik, Fey et al. 2004). The most recent pa-per from Korea demonstrated an 0.4% axillary recurrence rate afternegative SNB in 720 patients with a median follow-up of 40 months and a median harvest of 2 sentinel nodes (Kim, Son et al. 2008).

8.4 Predicting positive lymph nodes

Lymphovascular invasion has been demonstrated to be the strong-est single predicting factor for a positive sentinel lymph node in mul-tiple analyses of two studies with more than 4000 patients each (Vi-ale, Zurrida et al. 2005; Julian, Fourchotte et al. 2006).

8.5 Morbidity data

Improvements in morbidity have recently been demonstrated in aprospective trial carried out by Mansel et al. (Mansel, Fallowfield et al. 2006), showing a reduced number of lymphedema, drain usage,length of hospital stay, and time to resumption of normal everydayactivities after surgery in the SNB group. This finding has been sub-stantiated by others (Veronesi, Galimberti et al. 2005; Zavagno, De Salvo et al. 2008). However, morbidity improved with SNB seemsto be abrogated with longer follow-up (Purushotham, Upponi et al. 2005).

8.6 Number of nodes

Jeruss showed that by harvesting a median number of two sentinelnodes, the axillary local recurrence rate in node-negative patients was 0.32%. Others suggested that three lymph nodes should at least be harvested, as authors demonstrated a reduced false-negative rateas compared with one or two harvested lymph nodes (Krag, Ander-son et al. 2007). In a retrospective study with 1287 patients, the false-

21


negative rate was reduced from 14% to 4% after SNB by harvestingmore than one node (Wong, Edwards et al. 2001). The number of lymph nodes examined in node-negative breast-conserved patients with adjuvant radiotherapy had no impact on disease-free survival. In the mastectomy cohort, on the other hand, the number of lymphnodes in node-negative patients significantly correlated with dis-ease-free survival (Salama, Heimann et al. 2005), suggesting an un-derstaging in this particular patient cohort. Still, the numbers weretoo small to draw a definitive conclusion. At the MD Anderson Can-cer Center, 99% of positive nodes were found in the first five nodes sampled from more than 4000 patients, as reported at the SABCS in2006 and published in 2008 (Yi, Meric-Bernstam et al. 2008). Schrenk et al., however, demonstrated an accuracy of 99% by harvesting twonodes (Schrenk, Rehberger et al. 2002).

8.7 Multifocality and multicentricity

Multifocal and multicentric breast cancers are no exclusion criteria,although there is only little evidence to support the role of SNB inthese patients. In Austria, Schrenk et al. were the first to demonstrate that 19 patients with multicentric cancer had no false-negative senti-nel node (axillary dissection-controlled) (Schrenk and Wayand 2001). A 96% rate of accuracy and a 8% false-negative rate in 70 multicen-tric/multifocal breast cancer patients was published by Tousimis etal. (Tousimis, Van Zee et al. 2003). Korean data on 127 multifocal breast cancer patients yielded accuracy and false-negative rates of 97% and 7%, respectively (Kim, Hong et al. 2006), with a mean number of 2.6 sampled nodes which did not differ from patients with unifocalbreast cancer (Kim, Lee et al. 2008). In Milan, 42 multicentric breastcancer patients had a 100% sentinel node identification rate with-out any axillary metastases after 24 months (Gentilini, Trifiro et al. 2006). Another axillary-controlled trial of 31 multifocal/multicentricpatients demonstrated an accuracy of 96% and a false-negative rate of 7%, which was similar to patients with non-multicentric disease (Ferrari, Dionigi et al. 2006).

8.8 SNB and neoadjuvant chemotherapy

Several studies addressed the question whether SNB is viable afterneoadjuvant chemotherapy. A meta-analysis of these studies was published in 2006 (Xing, Foy et al. 2006). Twenty-one studies inves-tigating SNB with axillary surgery as control including 1273 patients

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were analyzed. The reported pooled detection rate was 90% with 89% pooled sensitivity and an accuracy rate of 94%. These investiga-tors concluded that SNB may be an accurate method to detect axil-lary lymph node metastases in clinically node-negative breast cancerpatients after neoadjuvant therapy.

8.9 Micrometastasis

The use of SNB has enhanced the detection rate for small cancer cellsin the lymph nodes due to increased histological sections. In this re-spect, cancer cells visualized with hematoxylin/eosin (HE) smaller than 0.2mm are termed isolated tumor cells and cells between 0.2and 2mm are referred to as micrometastases which may be detected with HE or immunohistochemistry. A remarkable overview by Rut-gers at the SABCS in 2006 can be downloaded from the internet (http://209.196.53.174/2006_webcast/ day 3, plenary lecture 3). In general, there is substantial risk (20%) of having additional lymph node metastasis in HE-detected micrometastases, yet with less risk in immunohistochemistry-detected micrometastases (9%) (Cserni, Gregori et al. 2004). The occurrence of a micrometastasis does not impair disease-free or overall survival. In this regard, other prognos-tic factors such as lymph vessel invasion, young age and grading are to be addressed in the question as to whether axillary dissection should be performed in patients with micrometastases. Veronesi et al. started a randomized trial comparing axillary dissection versus nil in this patient subgroup. The results should be available in some years’ time. Until then, cancer cells in the lymph node should be fol-lowed by axillary dissection, regardless of the detection rate (Lyman, Giuliano et al. 2005). Isolated tumor cells, in turn, should be regardedas pN0.

8.10 Re-SNB after SNB

Prior breast and/or axillary surgery are still a contraindication forSNB. However, there are several interesting articles that report verylow local recurrence rates after the use of a re-SNB in locally recur-rent breast cancer and prior breast and/or axillary surgery (Port, Fey et al. 2002; Cody 2006; Newman, Cimmino et al. 2006; Newman 2007; Port, Garcia-Etienne et al. 2007). Port et al.f reported on thelargest series with 117 recurrent breast cancer patients. While SNB was successful in only 55%, the use of dye failed to help detect thesentinel lymph node (dye detection rate 6%, isotope detection rate

23


45%; dye and isotope detection rate 44%). A positive re-SNB was seen in 16% and in 91% of these patients, the sentinel node was the only site of cancer spread. Previous axillary clearance in lieu of SNB re-duced the success of re-SNB from 74% to 36%. After two years, there were no local recurrences in the patients undergoing a re-SNB. Theseauthors concluded that a re-SNB may be feasible. However, prospec-tive studies are still to be performed to further investigate this issue. So far, it may be said that blue dye should not be used and re-SNB after axillary clearance may not be feasible.

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29

1. Introduction

Breast Conserving Surgery (BCS) followed by radiation therapy iscomparable to total mastectomy with respect to local recurrence and survival (Veronesi et al. 1995).

The major drawback of BCS is unfavorable cosmetic results whichmay be found in up to 30 % of patients (Petit, Rietjens 1991; Clough,Cuminet et al. 1998). Breast tissue deformities are seen immediatelyafter surgery or develop over time. They are due to the amount of breast tissue excised, the size of the breast (tumor to breast size ratio), whether or not skin is resected with the tumor, the localiza-tion of the tumor in the breast, orientation of surgical incisions, andpostoperative radiation therapy (Petit, Rietjens 1991; Cochrane, Vala-siadiou et al. 2003).

Whereas tumor-involved surgical margins are generally accepted to be detrimental to local recurrence, the impact of the width of freemargins on local recurrence or survival is still a matter of debate (Horiguchi, lino et al. 1999, Di Biase, Komarnicky et al. 1998; Meric, Mirza et al. 2003). The extent of local excision therefore remains a controversial issue in BCS. In any case, the greater the amount of tis-sue removed, the higher the risk for an inferior cosmetic result.

Oncoplastic Breast Surgery

Peter Schrenk

1.3

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General Surgery

2. Definition

Oncoplastic surgery (OPS) (other terms used are: tumor-specific im-mediate breast reconstruction, coupled surgery (Audretsch, Rezai et al. 1998)) refers to resection of the tumor (either partial or total mas-tectomy) and immediate reconstruction of the defect using plasticsurgical techniques (local parenchymal/muscle flaps or free flaps).

OPS includes:�� Excision of the cancer with adequately wide free margins to

achieve locoregional control � Immediate remodeling of the defect to improve the cosmetic result � Contralateral breast symmetrization and reconstruction of the

nipple -areola complex (NAC), when needed � Immediate and late reconstruction after mastectomy

3. Possible indications

1. After standard BCS a. Who need re-excision for involved margins and OPS – BCS

avoids total mastectomyb. With free margins but who seek correction of defects for cos-

metic reasons

2. Scheduled for BCS:Patients with primary breast cancera. Who consider reduction mammaplasty / mastopexy due to

breast hyperplasia / ptosis (a cosmetic reduction mamma-plasty performed after BCS and radiotherapy is associatedwith increased morbidity due to radiation)

b. When a poor cosmetic result is expected after standard BCS:i. Unfavorable tumor to breast size ratio: defects are expect-

ed when >10-20 % of the breast volume is removedii. Unfavorable tumor location, e.g. medial, inferior, central

quadrants

3. Scheduled for mastectomyPatients with primary breast cancer scheduled for total mastec-tomy who seek immediate breast reconstruction

31


4. Contraindications

4.1 Contraindications for OPS combined with breast conservation:

� No tumor-free margins obtained � Inflammatory breast cancer � Multicentric carcinoma (relative) � When unfavorable tumor to breast size ratio results in an inferior

cosmesis � No adjuvant radiotherapy (relative) � No change or progression after neoadjuvant therapy

4.2 Contraindications for OPS after totalmastectomy immediate reconstruction

� Inflammatory carcinoma � Postoperative radiation therapy required (relative) � Concomitant physical, psychological illness � No free margins can be obtained (palliative resection)

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General Surgery

5. Techniques

5.1 Scheduled for BCS

Breast tissue defects following tumor resection may be prevented in some patients following sim-ple basic surgical guidelines (e.g. mobilization of the gland, NAC re-centralization, choice of inci-sion, mirror biopsies) at the time of primary sur-gery (Petit, De Lorenzi et al. 2007) (Fig. 1). A variety of remodeling techniques have been described formore complex defects.

Partial mastectomy defects can be reconstructed by volume displacement or volume replacement techniques. Volume displacement techniques rear-range breast tissue by bringing local (dermo)glan-dular flaps into the defect (advancement, rotation or transposition flaps) (Galimberti, Zurrida et al.1993; Anderson, Masetti et al. 2005; Benelli 2006). Inferior and superior pedicle mammaplasty tech-niques are preferable in patients with large or ptot-ic breasts. They facilitate reconstruction of defectslocated in any breast quadrant when the skin inci-sion patterns are rotated according to the locationof the tumor in the breast (Schönegg, Keppke et al.1987; Daher 1993; Clough, Lewis et al. 2003). Some reduction techniques retain breast tissue usually discarded with cosmetic reduction mammaplasty to cover quadrantectomy defects (Clough, Kroll et al. 1999; McCulley, Macmillan 2005; Schrenk, Hue-mer et al. 2006; Fitzal, Nehrer et al. 2007) (Fig. 2, Fig. 3). Centrally located carcinomas require resec-tion and reconstruction of the NAC using eithervolume displacement techniques or mastectomy with immediate reconstruction (Huemer, Schrenk et al. 2007; Fitzal, Mittlböck et al. 2008).

Fig. 1:Patient with tumor in the upper outer quadrant of theright breast. Preoperative anterior (a) and lateral (b) viewand postoperative result (c) following quadrantectomy,mobilization of the gland and re-centralization of the nip-ple-areola complex.

1a)

1b)

1c)

33


2a) 3a)

2b) 3b)

2c) 3c)

Fig. 2:Postoperative result following breast conservation and ra-diation of a tumor in the upper inner quadrant. Postopera-tive view following standard quadrantectomy (a), and pr-eoperative (b) and postoperative view (c) after oncoplastic reduction mammaplasty with an inferior pedicle.

Fig. 3:Postoperative result following breast conservation and radia-tion of a tumor in the upper outer quadrant. Postoperative view after standard quadrantectomy (a) and preoperative (b)and postoperative view (c) after oncoplastic reduction mam-maplasty with a superior pedicle and defect remodeling using an inferior pedicle.

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General Surgery

Volume replacement techniques use distant au-tologous tissue flaps or implants to substitute fortissue loss. The most commonly used flap after BCS is the latissimus dorsi myocutaneous flap (with orwithout an island of overlying skin) (Raja, Straker 1997). Autologous flaps to cover partial mastecto-my defects bear the disadvantage of having fewerreconstruction techniques available should the patient require total mastectomy due to involvedmargins or local recurrence.

5.2 Scheduled for total mastectomy

Immediate reconstruction is facilitated by skin-spar-ing mastectomy (SSM), nipple-sparing mastectomy (NSM) or skin-reducing mastectomy techniques(Carlson, Bostwick et al. 1997; Malata, McIntosh et al. 2000; Gerber, Krause et al. 2003; Nava, Cortinovis et al. 2006). They allow removal of the breast while preserving the skin envelope and the inframam-mary fold and thus ease breast reconstruction andprovide a better cosmetic result without compro-mising the oncological result (Fig. 4).

Reconstruction using expanders or prostheses is less time-consuming than autologous tissue reconstruction and does not result in donor-sitemorbidity (Cordeiro, McCarthy 2006). Implant re-construction may be applied in women with smallor medium-sized and non-ptotic breasts but pro-vides an inferior long-term cosmetic result while requiring a greater number of re-operations overthe years (Kroll 2000). Radiotherapy is contraindi-cated after prosthesis reconstruction.

Fig. 4:Nipple-sparing mastectomy and immediate reconstruc-tion with a latissimus dorsi flap in a patient with local tumor recurrence in the lower outer quadrant followingbreast-conserving surgery and radiation. Preoperative view(a) and postoperative view (b).

4a)

4b)

35


6. Comparison of standard BCS andOPS – BCS

6.1 Advantages of OPS – BCS:

� Resection of larger breast volumes (Kaur, Petit et al. 2005; Schrenk, Huemer et al. 2006, Giacalone, Roger et al. 2007): The amount of breast tissue resected largely depends on the size of the breastand more volume excised does not automatically result in widerresection margins

� Wider free margins (level III evidence) (Kaur, Petit et al. 2005; Schrenk, Huemer et al. 2006, Giacalone, Roger et al. 2007)

� Free margins are obtained more frequently (level III evidence)(Kaur, Petit et al. 2005; Schrenk, Huemer et al. 2006, Giacalone, Roger et al. 2007) and fewer patients may need reoperations (lev-el IV evidence)

� Better cosmetic results (especially in women who wish to reducebreast weight or ptosis) (level IV evidence)

� OPS extends the indications for BCS and patients with larger tu-mors are scheduled to BCS (level IV evidence)

� Contralateral procedures done for symmetrization may detectpreviously unknown cancer (Petit, Rietjens et al. 1997)

� Contralateral reduction mammaplasty may reduce the risk of breast cancer (Boice, Perrson et al. 2000)

� A reduced breast volume allows a more homogenous dose distribu-tion of postoperative radiation

6.2 Disadvantages of OPS – BCS:

� Longer duration of surgery � More visible scars (however, the position of the scars may be an

advantage – perimamillary or in the submammary fold) � Higher complication rate possible (more complex procedures or

contralateral surgery done), but no delay of adjuvant treatment � Less refunding from insurance companies (in Europe) for concom-

itant procedures performed either in the same breast (quadran-tectomy and reduction mammaplasty) or the contralateral breast (symmetrization procedures)

� Experience in oncological and plastic reconstructive breast sur-gery is necessary in the one-team approach; the two-team ap-proach requires timing and planning of two disciplines

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General Surgery

6.3 Evaluation of outcome of OPS –BCS compared to standard BCS

In a prospective randomized study, we compared standard BCS to OPS – BCS. Oncoplastic surgery allowed resection of significantlylarger breast volumes, yielded wider free surgical margins and alower (non-significant) number of patients requiring re-excision sur-gery or conversion to secondary mastectomy. These results were alsoseen by other authors (Kaur, Petit et al. 2005; Giacalone, Roger et al.2007).

Several studies demonstrated the oncological safety of OPS. Al-though they comprised selected patients, were done by experiencedoncoplastic surgeons and had a short follow-up, local and distantrecurrence rates were comparable to those seen with standard BCS(Table 1). Patient satisfaction and cosmetic results have been evalu-ated based on individual judgment (Clough, Lewis et al. 2003) but need objective assessment (Fitzal, Nehrer et al. 2007).

Table 1. Local recurrence and systemic disease after OPS - BCSMean FU (range) LR DS (in months)

Rietjens et al 2007 (n=148) 74 (10-108) 3 % 13 %

Clough et al 2003 (n=101) 46 (7-168) 6.9 % 12.9 %

Schrenk et al 2006 (n=125) 32 (11-106) 0.8 % 2.4 %

Caruso et al 2007 (n=63) 68 1.5 %

Losken et al 2007 (n=63) 40 2 % 0

Papp et al 1998 (n=40) 52 (18-72) 5 % 10 %

Galimberti et al 1993 (n=37) 32 (6-60) 0 0

Da Silva et al 2007 (n=30) 15.5 (4-28) 3 %

Almasad et al 2008 (n=25) 48 4 % 4 %

Smith et al 1998 (n=10) 37 0

FU = follow-up, LR = local recurrence, DS = distant disease, OPS-BCS = oncoplastic surgery – breast conservation surgery

37


7. Preoperative and intra-operativeplanning

The success of OPS depends on evaluation of the size of the defect and choice of the appropriate technique for defect remodeling.

7.1 Tumor size

Assessment of the size of the tumor and the defect:The first decision to make is whether a patient is scheduled for BCS or total mastectomy. This is determined by the defect size in relationto the breast size (Munhoz, Montag et al. 2008).

Some patient- and tumor parameters are associated with a higher risk for involved surgical margins and a larger resection volume is suggested:

� Young age (<35 years) � Large tumor (>30mm) � Palpable tumor � Invasive cancer and presence of intraductal carcinoma in situ � Multiple microcalcifications � Biological parameters, e.g. negative receptor status

Preoperative breast magnetic resonance imaging is mandatory to: � evaluate tumor size � identify possible satellite lesions � exclude multicentricity � exclude bilateral / contralateral breast lesions not found in the

mammogram or ultrasound. � plan the access to the tumor � provide three-dimensional image of the tumor

Neoadjuvant chemotherapy (NC) may help decrease tumor size. Pa-tients with a tumor size requiring a mastectomy prior to NC are poor candidates for breast conservation after chemotherapy, even in the case that the tumor shows excellent response to chemotherapy. Al-though technically feasible, these patients carry a significantly high-er risk for local recurrence and are better treated with mastectomy and immediate reconstruction.

Marking the extent of the cancer with multiple bracketing wires helps in complete surgical excision of non-palpable tumors, intra-ductal carcinoma in situ and multifocal disease, and after neoadju-vant chemotherapy

38

General Surgery

Pathological diagnosis of any suspicious breast lesion should be at-tempted prior to surgery using core needle biopsy. This allows proper surgical planning with excision of all malignant lesions (multicentric cancers are scheduled to mastectomy).

7.2 Tumor location

The location of the tumor in the breast determines the techniqueused for OPS – BCS (Table 2).

Table 2. Type of OPS – BCS for reconstruction of partial mastectomy defects with respect to the location of the tumor in the breastBreast quadrant Breast size

small medium large/ptotic

central BenelliS reductionmodified Batwing

GrisottiBenelliinferior pedicleS reductionmodified Batwing

inferior pedicleGrisottiinverted T resection

upper outer Round blockS reductionLD

Round blockS reductioninferior pedicleLD

inferior pediclesup. / inf. pedicleS reductionRound block

upper middle Round blockBatwingS reduction

Round blockS reductioninferior pedicleBatwing

inferior pediclesup. / inf. pedicleRound blockS reduction

upper inner Round blockS reduction

Round blockS reductioninferior pediclesup. / inf. pedicle

inferior pedicleS reductionsup. / inf. pedicleRound block

lower outer thoracoepig. flapLDmodified Grisotti

superior pediclesup. / inf. pediclemodified GrisottiLD

superior pediclesup. / inf. pedicleinferior pedicle

lower middle thoracoepig. flapsuperior pediclemodified Grisotti

superior pediclemodified Grisottithoracoepig. flap

superior pediclemodified Grisotti

lower inner thoracoepig. flapmodified Grisotti

superior pediclesup. / inf. pediclemodified Grosottithoracoepig. flap

superior pediclesup. / inf. pedicleinferior pedicle

sup./ inf. pedicle = quadrantectomy with superior pedicle mammaplasty and defect coverage with an inferior pedicleLD = latissimus dorsi muscleOPS-BCS = oncoplastic surgery – breast conserving surgery

39


7.3 Operative access

Access to the tumor and the axilla � Direct access to the tumor is preferable. Inci-

sions are planned so that the tumor lies within the skin incision lines.

� Sentinel lymph node biopsy is preferable for ax-illary staging in patients with a clinically nega-tive axilla. Patients with intraductal carcinoma in situ show a low risk of involved nodes and sentinel node biopsy is done through the inci-sions used for breast surgery. In patients withinvasive cancers, we prefer a separate axillary incision. Axillary surgery is done prior to OPS.

7.4 Re-excision

Re-excision following OPS-BCS: Breast conserva-tion or mastectomy?The number of involved positive margins predictsresidual tumor disease after BCS (Papa, Zippel et al. 1999). Whether one involved margin allows re-exci-sion, patients with smaller breasts or two or moremargins involved are scheduled for mastectomy.

7.5 Radiotherapy

Immediate reconstruction after mastectomy should be delayed when postoperative radiation is consid-ered. This is due to a higher risk for complications and an inferior cosmetic result (Kronowitz, Robb 2004).

7.6 Shifting of the original tumor bed after OPS – BCS

Following reduction mammaplasty techniques, tumor cells which are left behind in the breast tis-sue around the tumor may be transferred from theprimary tumor location to other quadrants in the breast and may lead to local recurrences in quite adistance from the original tumor. Knowledge of the

Fig. 5a and 5b:Oncoplastic reduction mammaplasty using an inferior pedicle. The tumor is located in the upper outer quadrant.The tumor (BLACK) is resected with an adequate margin of healthy tissue (GREEN). Tumor cells left behind in the area around the quadrantectomy defect (RED) may be shifted to the new location in the breast midline.

5a)

5b)

40

General Surgery

oncoplastic surgical procedure performed, together with the originaland the new location of the tumor site is important for the radiolo-gist for “recurrence” diagnosis (Fig. 5). Following OPS – BCS we mark thepectoral muscle as well as the subcutaneous tissue around the tumor cavity with clips before it is shifted to the final location. These clips alsoallow exact planning of radiation therapy.

7.7 Frozen section

Intraoperative evaluation of the resection margins.Intraoperative frozen section evaluation is preferable in patients withinvasive breast cancer. This allows immediate re-excision in case of close or involved margins. No frozen sections are done in patients withintraductal carcinoma in situ since no reliable information is provided about margin status. In these patients, however, intraoperative speci-men radiograms are mandatory.

7.8 The contralateral breast

Most patients undergo bilateral single-staged surgery to achievebreast symmetry in one operation. This requires more accurate preop-erative planning with the contralateral breast made slightly smaller and the nipple put higher than that on the breast cancer site. Time of surgery is reduced by using a two-team approach.

A delayed symmetrization procedure (6 to 12 months after primary surgery) has the advantage that the final histological examination is available (no more re-excisions) and the radiated breast has reached its final position. Especially in Europe, insurance companies do not re-imburse all procedures done simultaneously as they do in the case of delayed symmetrization surgery.

8. OPS and special training

Subspecialist training in breast surgery should incorporate oncologi-cal surgery as well as reconstructive and esthetic surgery. For several reasons, the present author prefers the individual surgeon who is ex-perienced in both disciplines (e.g. availability, preoperative planning). However, not all surgeons are trained in oncological and plastic breast surgery, close collaboration thus being necessary between oncologicaland reconstructive surgeons.

41


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ONCOPLASTIC SURGERY (OPS)

45

OPS and Breast Conserving Surgery (BSC)

BCS and Immediate Reconstruc-tion – Local Techniques = Local in Breast Tissue Flaps

Reconstruction of PartialMastectomy Defects: SuperiorPedicle Reduction Mammaplasty

Peter Schrenk

2.12.1.1

2.1.1.1

1. Concept

Superior-based pedicle mammaplasty is considered a standard tech-nique for cosmetic breast reduction / mastopexy (Robbins and Hof -ffman 1992). It serves to resect the inferior quadrant of the breast togeth-er with a wedge of tissue behind the areola and tissue in the superior

46

OPS and Breast Conserving Surgery

breast quadrant. Compared the inferior reduction mammaplasty, it provides a longer-lasting cosmeticresult with a more pronounced upper pole filling (Robbins and Hoffman 1992). In oncoplastic breast surgery, it allows excision of breast tumors located in the inferior and central pole of the breast, as well as the medial or lateral quadrants, when the traditional skin incision patterns are modified (Grisotti 1994, Clough at al 2003, McCulley and Macmillan 2005).

2. Indication

Reconstruction of postquadrantectomy defects in women with moderate-sized or hyperplastic/ptotic breasts and the tumor located in:

� the lower central breast quadrant � the lower outer / lower inner quadrant � the retroareolar or upper central quadrant,

provided that the tumor is not close to the skin � The prerequisite is a moderate-sized / large or

ptotic breast with an inframammary fold toareola distance of at least 6 cm.

3. Contraindication

� Tumors located in the upper central / upper outer / upper inner quadrant when the tumor is close to the skin

� Small breasts without ptosis and an areola to inframammary distance of less than 6 cm

� Tumors in the uppermost pole of the breast

4. Preoperative Drawings

Drawings are done preoperatively with the patient in an upright standing position (Fig. 1, 2a). The size of the tumor is outlined on the skin. A central midlineis drawn from the sternal notch to the umbilicus. Avertical line is drawn from the midclavicular pointto the nipple and this line is extended through thenipple to the inframammary fold and on the tho-

Fig. 1:Preoperative drawings for superior pedicle reductionmammaplasty. The tumor is located in the lower centralquadrant of the left breast. Note: The future nipple isdrawn slightly higher on the non-tumor side (right breast)which compensates for descending of the non-radiatedbreast with time.

1)

47

BCS and Immediate Reconstruction – Local Techniques

racic wall. Using the index finger the new positionof the nipple is marked at the level of the originalinframammary fold with this point projected anteri-orly on the midclavicular line.

As the future areola is 4 cm in diameter, 2 cm aredrawn cranially on the vertical breast axis from thefuture nipple site. From this point, 5 cm are meas-ured caudally on the vertical axis and from this point,two horizontal lines are drawn with each line 4 cm inlength. The cranial and the two horizontal points areconnected to a “mosque”-like figure with the circum-ference of 14 – 16 cm in length. The breast is pushed medially and laterally with an upward rotation and medial and lateral markings are drawn on the breastcontinuing the vertical axis line on the thoracic wall. Where the vertical lines meet the “mosque”-shaped figure, 6 cm are measured caudally. Horizontal linesare drawn from the end of both these lines and con-nected to the inframammary fold medially and lat-erally with the breast moved laterally or medially, resp., and folded down towards the inframammaryfold at the same time. The two lines may meet 1-2cm above the inframammary fold to avoid inverted-T scars (vertical scar technique).

Alternatively, an inverted V is drawn from the futurenipple site with the angle between both lines deter-mining the volume of resection and future breast size. Both lines of the V measure 8 cm in length andare connected to the inframammary fold medially and laterally. The superior pedicle is outlined on theskin, the areola is determined intraoperatively. Mar -kkings are drawn in the same way as in contralateralreduction mammaplasty for symmetrization.

4.1 Special considerations

The superior pedicle technique may also be usedwith a circumareolar or vertical incision to mini-mize scars (Fig. 2b). The drawings may be rotated laterally / medially when the tumor is in the lower outer or lower inner quadrant (Grisotti et al 1994).

Fig. 2:Drawings for oncoplastic superior pedicle reduction mam-maplasty. (a) Inverted-T scar technique (b) Vertical scar technique (c)

2a)

2b)

2c)

48


5. Surgery

The patient is laid in a supine position with botharms extended 70° and operated under generalanesthesia on a flexible adjustable operating ta-ble. The tumor may be resected prior to reductionmammaplasty. However, the present author pre-fers to couple both surgeries and first dissect the breast flaps for reduction mammaplasty and thento excise the tumor through these incisions.

The new areola is marked with a cookie cutter putting slight tension on the areola (Fig. 3a).

The skin is incised along the drawn markings andthe superior pedicle is deepithelialized (Fig. 3b).

Skin flaps of 1-2 cm in thickness are dissected mediallyand laterally. The dissection is carried out to the up-per half of the areola on both sides but with the sub-dermal plexus being preserved cranially (Fig. 3c, d).

3b)

3c)

3a)

49


The superior pedicle is dissected from the inferiorpedicle and further to the upper breast fold with atissue of 1 – 2 cm left behind the areola (Fig. 3e, f).The more tissue left behind the areola, the moredifficult it proves to insert the superior pedicle. This may compromise the blood supply to the nipple.

3d)

3e)

3f)

Fig. 3:Surgical procedure (a) Preoperative skin markings for supe-rior pedicle reduction mammaplasty. The tumor is outlined on the skin as well as the superior pedicle (dotted line), theareola and the incision lines used for reduction mammaplasty.(b) The skin is incised and the superior pedicle is deepithelial-ized. (c) The subdermal plexus is incised laterally and mediallybut preserved cranially. (d) Breast tissue flaps are dissected medially and laterally. (e) The dissection of the breast flapscontinues cranially and the inferior pedicle is dissected from the superior pedicle. (f) The inferior pedicle with the tumor is dissected from the major pectoral muscle. Dissection includes the major pectoral muscle fascia.

50


The inferior pedicle containing the tumor is re-moved together with the major pectoral major muscle fascia, the amount of tissue resected de-termining the final breast size (Fig. 3g, h). The spec-imen is oriented and frozen section examinations are done for evaluation of the margins. The tumorbed is marked with clips.

The skin is closed temporarily with skin staples(Fig. 3 i) and suction drains are placed for 1-2 days. The wound is closed using inverted d 3-0 absorb-able Vicryl sutures and intradermal 4-0 or 5-0 su-tures (Fig. 3 j). Tapes are placed. Sentinel node bi-opsy / axillary dissection is either done through the mammaplasty incisions or through a separateaxillary incision.

Fig. 3:(g) The inferior pedicle is removed. The tissue behind thesuperior pedicle is made as thin as possible. (h) Resectionspecimen measuring 14 x 10 x 8 cm. (i) The skin is temporarlyclosed using skin staples. ( j) Immediate postoperative result.

3g)

3h)

3i)

51


6. Postoperative care

A circumferential mild compression dressing is applied for one day followed by a brassière for 8weeks. No antibiotics are used routinely. All su-tures are removed 2 weeks after surgery.

4a) 5a)

4b) 5b)

Fig. 4:56-year-old woman with a 21 mm breast cancer in thelower quadrant of the left breast. She underwent partial mastectomy and superior-based pedicle reduction mam-maplasty. (a) pre- and (b) postoperative view 3 years aftersurgery and radiation.

Fig. 5:42-year-old woman with a 16 mm tumor in the inferiorpole of the left breast and a moderate-sized ptotic breast.She underwent partial mastectomy and superior-basedpedicle reduction mammaplasty. (a) Preoperative view.(b) Postoperative view 5 years after surgery and radiation.

3j)

52


7. Tips and tricks

� Superior pedicle oncoplastic reduction mammaplasty is preferred in patients with large or moderate-sized breasts who wish to re-duce breast weight for cosmetic reasons and a tumor located inthe lower quadrant of the breast.

� The distance from the present to the future nipple positionshould not extend 10 – 12 cm as this impedes areola insetting with decreased blood supply to the areola.

� The longer the superior pedicle, the thinner it should be made to provide adequate blood supply to the nipple.

� To provide a better shape or in case of larger / ptotic breasts, tis-sue may be preserved in the inferior quadrant (medially, laterallyor caudally) and may be used for breast remodelling.

� In order to avoid glandular deficit in the inferior pedicle (in pa-tients with a small tumor or moderate breast size), lateral andmedial dissection should be done straight down to the pectoralmuscle fascia or with minimal bevelling.

� The pronounced fullness of the upper pole tends to descenddown to the inferior pole within months.

ReferencesClough KB, Lewis JS, Couturaud B, Fitoussi A, Nos C, Falcout MC (2003) Oncoplastictechniques allow extensive resections forbreast-conserving therapy of breast carci-nomas. Ann Surg 237: 26-34

Grisotti A. Immediate reconstruction afterpartial mastectomy (1994) In: JurkiewiczMJ, Culbertson JM, Bostwick J (Eds): Opera-tive techniques in Plastic and Reconstruc

tive Surgery: Breast reconstruction. WBSaunders Company Vol 1 (1), pp1-12.

McCulley SJ, Macmillan RD (2005) Plan-ning and use of therapeutic mammoplasty– Nottingham approach. Br J Plast Surg 58: 889-901

Robbins LB, Hoffman DK (1992) The superior dermoglandular pedicle approach tobreast reduction. Ann Plast Surg 29:211-216.

53

1. Concept

The principles of inferior pedicle reduction mammaplasty are ahorseshoe-like resection of tissue in the upper, medial and lateralbreast quadrants and remodelling of the breast with an inferior-based glandular flap (Courtiss, Goldwyn 1977).

In oncoplastic surgery, inferior pedicle reduction mammaplasty isfrequently used for defect reconstruction following partial mastec-tomy on account of its relative safety and reproducibility (McCulley,Macmillan 2005; Munhoz, Montag et al. 2007). It provides for resec-tion and reconstruction of tumors located in any breast quadrant except the inferior central quadrant, on the condition that the skinincision patterns and the pedicle are rotated according to the loca-tion of the tumor in the breast (Grisotti 1994).

2. Indications

Reconstruction of postquadrantectomy defects in women with hy-perplastic/ptotic breasts and the tumor located in the:

� upper medial/ upper outer/ upper inner quadrant. � lower outer quadrant/ lower inner quadrant. � central quadrant (retroareolar tumor with resection

of the nipple areola complex) (Huemer, Schrenk et al. 2007).

The only prerequisite is a medium-sized, large or ptotic breast withan inframammary fold to areola distance of at least 6 cm.

Inferior Pedicle Mammaplastyfor Reconstruction of PartialMastectomy Defects

Peter Schrenk

2.1.1.2

54



� Tumors located at the 6 o’clock position. � Small breasts without ptosis. � Tumors in the uppermost pole of the breast:

In these patients, the nipple areola complexis positioned too high on the vertical breast axis (no man’s land) and results in an inferiorcosmetic result.

4. Preoperative drawings

Drawings are done preoperatively with the patient in an upright standing position (Fig. 1). A central midline is drawn from the sternal notch to the um-bilicus. The size of the tumor and the area of breast tissue planned to be resected with the tumor are marked on the skin (green circle).

A vertical line is drawn from the midclavicular pointto the nipple and this line is extended through thenipple to the inframammary fold and on the tho-racic wall. Using the index finger, the new position of the nipple is marked at the level of the original inframammary fold with this point projected ante-riorly on the midclavicular line.

The breast is pushed medially and laterally with an upward rotation and medial and lateral markings are drawn on the breast continuing the vertical axis line on the thoracic wall.

An inverted V is drawn with its peak at the fu-ture nipple position. The two lines of the V aredrawn by pinching the breast tissue between the thumb and middle finger and connectingthese points to the peak of the V. The angle be-tween these two lines determines the amountof breast tissue to be resected. (Some authors prefer to use a ruler to draw the two lines of theV with an angle of 70 to 120° between both linesdepending on the breast size and the amount of tissue planned to be removed). 1)

55

BCS and Immediate Reconstruction - Local Techniques

Each of these lines is 8cm in length. Horizontal lines are drawn from the end of both lines of the invertedV and connected to the inframammary fold medi-ally and laterally with the breast moved laterally or medially, resp., and simultaneously folded down towards the inframammary fold. In small breasts, these lines may meet 1 to 2 cm above the pre-ex-isting inframammary fold to avoid a horizontal inci-sion in that fold (vertical scar technique).

The inferior pedicle is outlined on the skin with abase width of 6 to 12cm. A small triangle of skin maybe left above the midline of the inframammary fold to release some tension in the inverted T scar.

4.1 Special considerations

In cases of retroareolar cancer, a skin island accord-ing to the size of the areola is outlined on the infe-rior pedicle and used for reconstruction of the areola(Fig. 2a). The drawings may be rotated laterally / me-dially if the tumor is in the lower outer or lower innerquadrant (Fig. 2b). If the tumor is high in the upperbreast pole, a vertical skin paddle to be resected withthe tumor is drawn cranially from the future nipple(Fig. 2c). Markings are drawn in the same way as incontralateral reduction mammaplasty for symmetri-zation but with the nipple placed 1 to 2cm higher onthe inframammary fold in order to compensate theresulting ptosis as no radiation is applied.

Fig. 1:Preoperative drawings for inferior pedicle reduction mamma-plasty. The tumor is located in the upper central quadrant of the right breast (black circle). Note: The future nipple is placedslightly higher in the non-tumor-affected breast.

Fig. 2:Special situations for oncoplastic reconstruction with inferior pedi-cle mammaplasty. (a Centrally located tumor. The areola is excised )and the defect reconstructed with a skin island on the inferior pedi-cle. (b) The tumor is in the lower inner quadrant. The skin incisionpaddle is rotated according to the location of the cancer. (c Tumor )located high in the upper breast pole. A skin paddle located crani-ally to the areola is excised, resulting in an additional vertical scar.

2b)

2c)

2a)

56


5. Surgery

The patient is laid in the supine position with botharms extended at 70° and operated under generalanesthesia on a flexible adjustable operating table.

The present author prefers to dissect the breastflaps for reduction mammaplasty first and then to excise the tumor through these incisions. The tumor is excised through a separate incision only when it is very close to or infiltrates the skin. In these patients, we prefer superior pedicle mammaplasty and re-construction of the defect with an inferior pedicledermoglandular flap (see Chapter 2.1.1.5).

The new areola is marked with a cookie cutter putting slight tension on the areola and is about40mm in diameter (Fig. 3a). The skin is incisedalong the drawn markings and the inferior pedicleis de-epithelialized (Fig. 3b). Skin flaps of 1 to 2 cm in thickness are dissected superiorly, medially and laterally down to the pectoralis fascia (Fig. 3c). Care should be taken not to overextend the dissection laterally or medially or to the pectoral muscle suchthat blood supply is not compromised.

3c)

3a)

3b)

3d)

57


The skin overlying the tumor is made thinnerthan done in cosmetic reduction mammaplastyto allow local resection with adequate margins toward the skin. The tumor and surrounding tis-sue is dissected from the inferior pedicle (Fig. 3d). We prefer to resect the tumor en bloc includingthe pectoralis fascia and both lateral and medial breast quadrants (Fig. 3e). The specimen is orient-ed and frozen section examinations are done for margin evaluation.

The tumor bed is marked with clips as is the breast tissue around the original tumor. The inferior pedi-cle is prepared with a basis of 6 to 12cm in width and a thickness of 2 to 6 cm. It is transferred supe-riorly into the defect but not sutured to the fascia or the breast parenchyma (Fig. 3f, g).

3e)

Fig. 3:Surgical procedure (a) Preoperative skin markings with the cancer in the upper central quadrant of the right breast. Thetumor/ resection volume is outlined on the skin together withthe inferior pedicle, the areola and the incision lines used for reduction mammaplasty. (b) The skin is incised and the inferior pedicle is de-epithelialized. The skin overlying the tumor is re-sected upon completion of surgery. (c) Skin flaps are dissected cranially, laterally and medially and down to the pectoral fascia.The location of the tumor is marked blue. (d) The lateral, medial and superior quadrants are dissected from the inferior pedicle. (e) The tumor is resected en bloc with the lower outer and lower inner quadrants and oriented for pathological examination. (f)Following tumor resection, the inferior pedicle is advanced into the defect. (g) The skin flaps are closed over the inferior pedicle. The blue circle delineates the skin over the original tumor.3g)

3f)

58


The skin is closed temporarily with skin staplesand symmetry is assessed in the sitting position(Fig. 3h). The final nipple position is drawn on the breast midline 6cm from the inframammary fold and the skin is excised in full thickness and sent to pathology (Fig. 3i). The inferior pedicle is elevat-ed through the incision with care in order not tofold or rotate the pedicle and compromise blood supply (Fig. 3j). Suction drains are placed for 1 to 2days. The wound is closed using inverted d 3-0 ab-sorbable Vicryl sutures and intradermal 4-0 or 5-0 sutures (Fig. 3k). Tapes are placed. Sentinel node biopsy / axillary dissection is either done through the mammaplasty incisions or through a separateaxillary incision.


A circumferential mild compression dressing is ap-plied for one day and then a brassière for 8 weeks.No antibiotics are used routinely. All sutures are re-moved 2 weeks after surgery.

3i)

3k)

3j)

(i) Excision of the skin in the area of the future nipple are-ola complex. ( j) The inferior pedicle with the nipple is el-evated through the incision. (k) Immediate postoperative result.

Fig. 3:(h) The patient is put in sitting position to assess symmetry.The new nipple areola complex is drawn 6 cm above the in-framammary fold. Note: The skin overlying the original tumor bed is in the new areola position and is excised in full thick-ness.

3h)

59


Fig. 5:38-year-old woman with a 19mm breast cancer in the upper quadrant of the right breast. The partial mastectomy defectwas reconstructed with an inferior based pedicle. (a) Pre- and (b) postoperative view 8 years after surgery and radiation.

5b)

5a)

4c)

4b)

4a)

Fig. 4:Retroareolar tumor treated by central quadrantectomy and inferi-or pedicle mammaplasty. (a) Preoperative drawings. A skin islandis drawn on the inferior pedicle in order to reconstruct the nip-ple areola complex. (b) Central quadrantectomy and skin islandon the de-epithelialized inferior pedicle. (c) Postoperative result.

60


7. Tips and tricks

� Inferior pedicle oncoplastic reduction mammaplasty is preferred in patients with hyperplastic breasts who wish to reduce breast weight for cosmetic reasons and a tumor located in the upperquadrant of the breast

� If the tumor is located high in the upper pole, inferior pedicle mammaplasty may result in poor cosmetic results.

� The longer the pedicle, the thinner it should be made, and thewider should be the base. Avoid making the pedicle too long – in these cases, resect the nipple areola complex and carry out free nipple-grafting.

� We place surgical clips in the tumor bed and the subcutaneous breast tissue beneath the skin flaps which are transferred from the original tumor bed to a new location in reduction mamma-plasty. These clips allow more precise planning for postoperative radiation therapy and assist in local recurrence diagnosis.

� The most common complication is delayed inverted-T-incision wound healing which may be avoided by leaving a small triangle of skin in the midline above the inframammary fold.

� Fatty tissue necrosis is most commonly seen at the top of the in-ferior pedicle. It is caused by decreased blood supply to the pedi-cle peak and leads to difficulties in distinguishing fatty tissue necrosis from cancer recurrence.

� Resection of the skin and breast tissue in the future nipple areola complex may be done initially. This facilitates pathological evalua-tion of margins. However, the new position of the areola may be re-positioned only with difficulty thereafter.

Courtiss, E.H., R.M. Goldwyn. (1977).“Reduction mammaplasty by the infe-rior pedicle technique: an alternative to free nipple and areola grafting for severemacromastia or extreme ptosis”. PlastReconstr Surg 59: 500-7.

Grisotti, A. (1994). “Immediate reconstruction after partial mastectomy”. In:Jurkiewicz MJ, Culbertson JM, Bostwick J (Eds): Operative techniques in Plasticand Reconstructive Surgery: Breast re-construction. WB Saunders Company Vol 1 (1), pp 1-12.

Huemer, G.M., P. Schrenk, et al. (2007). “Oncoplastic techniques allow breast-conserv-ing treatment in centrally located breast cancers”. Plast Reconstr Surg 120: 390-8.

McCulley, S.J., R.D. Macmillan. (2005). “Planning and use of therapeutic mammo-plasty – Nottingham approach”. Br J PlastSurg 58: 889-901.

Munhoz, A.E., E. Montag, et al. (2007). “Relia-bility of inferior dermoglandular pedicle reduction mammaplasty in reconstruction of partial mastectomy defects: surgical plan-ning and outcome”. The Breast 16: 577-89.

References

61

1. Concept

Removal of a breast tumor can be performed as a lumpectomy but incombination with standard breast reduction techniques depending on where the tumor is located. A medial pedicle (Hall-Findlay 1999)vertical breast reduction (Asplund, Davies 1996; Hall-Findlay 2002) can be used when the tumor is in the inferior or lateral quadrants. A variation using the lateral pedicle can be used if the tumor is in the upper medial quadrant. Some tumors in the upper outer quadrantcan be combined with the medial pedicle if the tumor is deep and athinned lateral skin flap is appropriate. In cases of central cancer theskin below the nipple areola complex may be used to create a new nipple, which is rotated into the defect.

The advantage of the medial pedicle is, that it has excellent bloodsupply, is quite mobile and is easy to inset with the nipple at a higher level without distortion or kinking. More over, sensation of the nipplemay be improved as medial nerve branches are very important.

Tissue is removed as a vertical wedge in the breast meridian inferi-orly and the resection is continued out laterally by beveling out asneeded under a lateral flap. Breast parenchyma is left attached to thesuperior skin flaps and all tissue below the Wise pattern is removed. As long as there is not too much skin remaining, it can be allowed to adapt to the new breast shape leaving only a vertical scar below the areola. There is also a complete circumareolar scar that results fromtransposing the nipple-areolar complex using a medial pedicle.

Medial or Lateral PedicleVertical Breast Reduction

(Hall-Findlay orSnowman Technique)

Elizabeth J. Hall-Findlay, Florian Fitzal

2.1.1.3

62


2. Indications

� all small and medium sized (up to about 800 gm) lumpectomies

� The concept of the medial pedicle can be ex-tended to larger breast reductions, but the skin resection pattern may need to be converted from a vertical to a combined vertical and hori-zontal pattern (anchor). This procedure is ap-plicable to all but superior tumors and modifi-cation to a lateral pedicle can be made whenneeded

� Tumors in all quadrants may be resected


� Very large breasts (unless skin resection isconverted to combined vertical and horizontal pattern

� Very small breasts with large tumors � Contraindication for breast conserving surgery.


It is important to first mark the upper breast bor-der (where the breast meets the chest wall) andthe inframammary fold.

The patient in Fig. 1, 2 is fairly “high-breasted” with a fairly large vertical breast footprint. Next thebreast meridian should be marked where it should be after the breast reduction is performed (notwhere it is preoperatively). Once the breast merid-ian is marked, the surgeon marks the ideal nipple position. It is often (but not always) at the level of the inframammary fold but the ideal nipple posi-tion is generally 8-10 cm below the upper breast border. In this case the new nipple is placed some-what higher than the inframammary fold level (marked with arrows on the chest wall betweenthe breasts). It helps if the surgeon can visualize the final shape. Next the areolar opening is drawn 2)

1)

63


2 cm above the new nipple position. The areolaropening should be about 16-18 cm in circumfer-ence. The skin resection pattern is then marked to stay 2-4 cm above the inframammary fold with notension resulting on the final skin closure. The pat-tern resembles a snowman (Fig. 3, 12, 15). The me-dial pedicle is then drawn with half of the base inthe areolar opening and half of the base in the ver-tical opening (Fig. 2). This design makes the pedicle very easy to inset. The base of the areolar opening is usually about 8 cm.

The above photo (Fig. 3) shows the comparison of the anchor Wise pattern (Wise 1956) design com-pared with the medial pedicle vertical design onthe same patient shown above. The areolar open-ing with the Wise pattern was 14 cm (4.5 cm diam-eter) and the vertical design is about 16 cm (5 cm diameter).

The medial pedicle is de-epithelialized (Fig. 4) and then created as a full thickness pedicle down tothe chest wall. Either cutting cautery or a scalpel can be used. The red cross-hatched areas showwhere the parenchyma is to be removed.

The skin and parenchyma are excised as shown(Fig. 5) with more parenchyma being removed by beveling out under the skin edges. The tissue is undermined down to the chest wall, leaving skin about 2-4 cm above the inframammary fold to pre-vent the scar from ending up below the fold.

4)

5)

3)

64


The pedicle is very mobile and will move into posi-tion easily. Extra breast tissue can be removed out laterally under the lateral skin flap. The pectoralismuscle is not exposed because it tends to cause more bleeding and leaving tissue over the pectora-lis fascia is more likely to preserve the deep branch of the lateral fourth intercostal nerve (Schlenz, Kuz-bari et al. 2000). However, in cases of malignancy itis necessary to include the pectoralis fascia in the resected specimen. Note that the inferior border of the medial pedicle will become the medial pillar. The arrow shows the inferior level of the lateral pillar. Tis-sue (but not skin) is removed in the cross-hatchedarea (Fig. 6).

The medial and lateral pillars are brought together above the cross-hatched areas. The parenchymaunder the cross-hatched skin is removed either bydirect excision or liposuction. This leaves behind theremaining breast tissue attached to the superior, su-peromedial, and superolateral skin. The inferior bor-der of the medial pedicle becomes the medial pillarand this rotation gives an elegant curve to the lowerpole of the breast. The pillar closure starts about half way up the skin opening, not in the cross-hatched areas. This leaves pillars which measure about 7 cmin height. Only about three sutures of 3/0 resorbable sutures (e.g. Monocryl) are used in the parenchyma and this closure should be achieved without tensionto approximate the pillars (Fig. 7).

Closure of the pillars starts about half way up theskin opening. The first sutures are placed at the levelof the arrows shown. The parenchyma left behindafter excision comes together as a Wise pattern(Wise 1956). with the remaining tissue giving a good breast shape and good projection. The skin then adapts to the new breast shape. The areas shownwith red cross-hatching in Fig. are areas where 8liposuction may be performed. The area at the bot-tom of the vertical incision needs to be thinned to allow the pucker to tuck in postoperatively (Fig. 9). The inferior skin should retain enough fat under the dermis to prevent scar retraction (Fig. 8, 9).

7)

6)

8)

65


The incisions are then covered with paper tape forabout three weeks and the patient is allowed toshower on the first postoperative day and pat thetape dry. Drains are rarely used and a surgical bras-siere is not used for compression but only to holdsome postoperative dressings in place and to give the patient a sense of support.

The patient in Fig. 11 is shown postoperatively atone month to reassure surgeons that the immedi-ate postoperative shape is more than acceptable.It is hard for a surgeon to leave the puckers behind(Fig. 9) but they do tuck in quite quickly. There is no need to suture the pucker down. This patient inFig.10, 11 had 550gm removed from the right breast and 420gm removed from the left breast. Another700 cc of liposuction was removed inferiorly, in the preaxillary area and along the lateral chest wall (Fig. 10, 11).

9)

11)

10)

66


5. Central Breast Cancer

For centrally located breast cancers (Fitzal, Mittl-boeck et al. 2008), the nipple areola complex has to be removed (Fig 12 and 13 red arrow). The medialor lateral (Fig 12, 13 and 14) pedicle reduction tech-nique is excellent to be used in combination withthe creation of a new nipple areola complex (Fig 12,13 and 14 black arrow) which arises from the skinbelow the cancer involved nipple areola complex (Fig. 12, 13, 14).

12)

14)

13)

67


The drawings are performed as described above.Note that the medial pedicle is lower compared with the technique used for other locations (Fig. 2)to supply the newly formed nipple areola complex below the patients own nipple, which is cancer in-volved (Fig. 15).

After incising the skin, the cancer with the nippleareola complex is resected as a lumpectomy. Intra-operative frozen section should reveal no cancercells at the margins, final histology should show atleast a 2mm resection free margin (Dunne, Burkeet al. 2009) (Horst, Smitt et al. 2005) (Fitzal, Riedl et al. 2008) (Fig. 16, 17) (adopted from (Fitzal, Nehrer et al. 2007), copyright EJSO, with permission fromthe journal).

17)

16)

15)

68


After the defect has been marked with titaniumclips for the radio-oncologist, the new nipple areo-la complex is created and the skin around the newcomplex is deepithelialized to assure blood andnerve supply to the new nipple areola complex(Fig. 18) (adopted from (Fitzal, Nehrer et al. 2007), copyright EJSO, with permission from the journal).

The nipple areola complex is rotated into the de-fect and the skin is closed with 4/0 for subcuta-neous and 5/0 for intracutaneous running suture(Fig. 19) (adopted from (Fitzal, Nehrer et al. 2007),copyright EJSO, with permission from the journal).

Pre- and postoperative pictures one month after surgery of a central breast cancer with the medialpedicle reduction oncoplastic technique combined with a central lumpectomy and a sentinel lymphnode biopsy, which is always performed before lumpectomy with the blue dye detection meth-od (Fig. 20, 21) (adopted from (Fitzal, Nehrer et al. 2007), copyright EJSO, with permission from the journal).

18)

19)

69


6. Tips and tricks

� The medial pedicle vertical breast reduction involves leaving parenchyma behind attached to the skin in a Wise pattern and removing alltissue below the Wise pattern with direct exci-sion which is then tailored out with liposuction. When the pattern is closed, good projection re-sults along with coning and narrowing of the breast base. Both the parenchyma and the skinshould be closed without tension for a long-lasting result.

� 3-0 or 4/0 absorbable sutures (Monocryl, Vic-ryl) are used to close the pillars and the deepdermis. The final skin closure is achieved using a subcuticular sutured with no skin gathering (4/0 or 5/0 Monocryl).

� In the past it was assumed that a short verti-cal scar was needed and the skin was puckeredup and pleated in order to shorten the vertical length (Lejour et al. 1990). Unfortunately this just resulted in wound healing problems andthe skin eventually stretched back out. It is im-portant for the surgeon to understand that along vertical length is actually needed to ac-commodate the increased projection that re-sults with this approach.

7. Complications

Nipple necrosis is an inevitable complication inabout once every 300-400 cases. This probably re-sults when only three of the four main blood sup-plies to the nipple are dominant and the problem is less likely to be one of surgeon error than vari-ation in anatomy. (The main blood supply comesfrom the internal mammary system with a superi-or pedicle being supplied by the second interspace,the medial pedicle by the third and an inferiorpedicle by the deep perforator of the fourth inter-space. A lateral pedicle is supplied by the superfi-cial branch of the lateral thoracic artery [Palmer, Taylor 1986]).

20)

21)

70


Seromas do occur but they disappear without treatment. Drains donot prevent either hematomas or seromas. Drains would need to beleft in place for several days to reduce the incidence of seroma and fortunately they disappear quite well without aspiration. The key toprevention of hematomas is to identify and secure the known arter-ies with cautery.

Wound healing problems are caused by tension and constriction of blood supply. The skin is not being used as a brassiere with this tech-nique and the skin closure should be loose. Gathering the vertical skin to shorten the length is not only unnecessary but it is contrain-dicated because it causes constriction of blood supply to the wound edges resulting in incision breakdown.

Puckers are a short term problem and are best managed by goodpreoperative patient information. They tend to disappear over weeks and months and about 5 % of patients will need a revision at one year. Most plastic surgery involves a similar revision rate and puckers are easily corrected under local anesthesia in the office.

Asplund O, Davies DM. Vertical scar breast reduction with medial flap or glandulartransposition of the nipple-areola. Br JPlast Surg 1996; 49:507-514

Hall-Findlay EJ, Vertical Breast Reductionwith a Medially Based Pedicle. Opera-tive Strategies, Aesthetic Surgery Journal,22:2:185-195, March/April 2002.

Hall-Findlay EJ, A Simplified Vertical Reduc-tion Mammaplasty: Shortening the LearningCurve, Plast. Reconstr. Surg. 104: 748, Sep 1999.

Schlenz I, Kuzbari R, Gruber H, Holle J, Thesensitivity of the nipple-areola complex:An anatomic study. Plast Reconstr Surg 105: 905-909, 2000.

Wise RJ. A preliminary report on a methodof planning the mammaplasty. Plast Re-constr Surg 1956;17:367

Lejour M, Abboud M, Declety A, Kertesz P.Reduction des cicatrices de plastie mam-maire: de l’ancre courte a la verticale. AnnChir Plast Esthet 1990;35:369

Palmer, JH, Taylor, GI. The vascular terri-tories of the anterior chest wall, Br J PlastSurg, 1986; 39:287-29

Dunne, C., J. P. Burke, et al. (2009). “Effect of Margin Status on Local Recurrence AfterBreast Conservation and Radiation Therapyfor Ductal Carcinoma In Situ.” J Clin Oncol.

Fitzal, F., M. Mittlboeck, et al. (2008).“Breast-conserving therapy for centrallylocated breast cancer.” Ann Surg 247(3): 470-6.

Fitzal, F., G. Nehrer, et al. (2007). “An oncoplastic procedure for central and medio-cranial breast cancer.” Eur J Surg Oncol 33(10): 1158-63.

Fitzal, F., O. Riedl, et al. (2008). “Recent de-velopments in breast-conserving surgeryfor breast cancer patients.” LangenbecksArch Surg.

Horst, K. C., M. C. Smitt, et al. (2005). “Predictors of local recurrence after breast-conserva-tion therapy.” Clin Breast Cancer 5(6): 425-38.

References

71

1. Concept

All patients with a tumor in the breast may be eligible for round block technique. This simple technique may be used to avoid scars on the breast (Giacalone, Dubon et al. 2007; Fitzal 2008). Perimamillary scars only arethen visible. This technique has no further comorbidities as comparedwith breast-conserving therapy and is easily acquired. The nipple-areolacomplex may or may not be moved higher with this technique, depend-ing on the distance of the outer incision from the new areola incision.Thus, this technique may be used in patients who do not want to change the position of the nipple or in those with mild ptosis (see below).

2. Indications

Patients with symmetric, smaller to medium-sized breasts and without major ptosis who may not require contralateral breast surgery for sym-metrization are best suited for this technique. There are only a few con-traindications that depend on breast size and tumor location (see below).

Round Block Technique(Doughnut Mastopexy)

Florian Fitzal

2.1.1.4

72



� Very large breasts AND peripheral tumorlocation.

� Centrally located breast tumors. � Tumor size > than 70% of one quadrant or

multicentric or large multifocal disease inwhich cases real quadrantectomy or evenbi-quadrantectomy may be indicated.

� Contraindication for breast-conserving surgery


Preoperative drawings, outer and inner incision lines marked with arrows, area inbetween to be de-epithelialized (dots), 1 to 2cm distance betweeninner and outer incision line depending on tumor size, location and nipple position. The more breastvolume to be excised, the more ptosis to be cor-rected, the larger the distance between inner andouter incision line. In small tumors and breasts with similar nipple positions, the distance be-tween the inner and outer incision line should beas close as possible. The diameter of the inner cir-cle (neo-areola) should be 40mm (Fig. 1 and Fig. 2).

1. Patient may be positioned upright, however,it may prove useful to mark the incisionson the operating table.

2. The new nipple areola complex may be between38 and 42mm in diameter depending on theother nipple-areola size. This line is drawnafter using a “nipple-cutter” with the assistantholding the breast firmly.

3. Thereafter, the assistant keeps the breast firmand the upper, lower and side borders are marked. This depends on the extent of ptosis, the tumor location and the size of the tumor. 2)

1)

73


a. In the absence of ptosis and in case of normal breast symmetry presurgery, the lateral incisions should be about 1 to 1.5cm awayfrom the inner new nipple-areola incision in order to keep thenipple-areola complex in the same place.

b. In the presence of mild ptosis, the upper border may be 2 to 3cm away from the inner nipple-areola incision, while thelower and side borders may be 1 to 1.5cm away from the innerincision line to lift the breast.

c. In cases of larger tumors and thus larger defects, it may benecessary to increase the distance between the two incision lines at the side of the tumor by up to 4cm. This may assistin reshaping the breast and filling the defect by simple inner rotation of the lateral breast parenchyma into the defect after mobilization. However, it is necessary in such cases to have a thin skin around the new nipple-areola complex so that theskin wrinkles from the sutures are flattened out after severalweeks.

74


5. Surgery

The patient is operated in the supine position with both arms elevated at 90°. Preoperative biopsy im-proves the operation planning, however, is not nec-essary for this type of surgery (unlike other larger reduction techniques). In cases of preoperatively histologically verified breast cancer, the present author prefers to start with sentinel node biopsyin order not to disturb the lymphatic drainage. Theeasiest way is to use permanent blue dye, however, this depends on the breast cancer center. I also prefer to de-epithelialize straight away and to dis-sect the breast parenchyma from the skin beforeremoving the lump with the tumor. This strategywarrants a large operating field and better control of the resection margins which are substantial in breast cancer surgery. We always use intraopera-tive frozen section analyses to reduce the neces-sity of a second operation (Riedl, Fitzal et al. 2008).The tumor bed is marked with 6 titan clips at allmargins for radiotherapy orientation to reduce ra-diation scattering.

De-epithelialization (�) between outer (lateral borders �) and inner (neo-areola�) incision line. The nipple areola complex is supplied by dermal vessels from all sides. DO NOT CUT THROUGH THEDERMIS! (Fig. 3)

Cut through the dermis (�) at the side of tumor location. Lift and undermine the skin in order to free the breast parenchyma from the skin above the tumor (+) and at least 5 cm laterally (�) andmedially (�) from the tumor and up to the upperend of the breast (�) to have a good exposure. Thenipple is still supplied by dermal vessels (Fig. 4).

After dissecting the breast parenchyma and the lump with the tumor from the skin, the lump islifted up with the pectoralis fascia and elevated outside the skin envelope to optimize palpable control during lumpectomy (Fig. 5).

4)

3)

5)

75


After resection of the tumor, the defect (�) canbe closed by approaching the lateral parenchyma(� ) either with sutures or just by mobilization and �simple positioning. Mobilize the lateral breast tis-sue by undermining ABOVE the pectoralis fasciaand between the skin and breast parenchyma.Mark the breast borders (6!) with titan clips (Fig. 6).Close the dermis with interrupted single stitches using absorbable 4/0 and the epidermis with run-ning absorbable 5/0 (Fig. 7). Result 4 weeks afterthe operation before radiotherapy (Fig. 8).

6. Tips and tricks

� The incision through the dermis may be as wide as 180° to 270° around the areola. The more, thebetter exposure for resecting the lump.

� I prefer a 40mm diameter for the neo-areola. � The more tissue is dissected from the skin, the

better the repositioning and defect filling fromthe lateral edges.

� I always mobilize the breast parenchyma fromthe pectoralis fascia such that the parenchymais easier to rotate into the defect.

� I do not always use fixation sutures, the skin is usu-ally good enough to hold the parenchyma in place.

� I prefer to have the skin as thin as possible so theshrinkage is better and skin folds retract more easily resulting in a flat breast skin after 2 weeks.

6)

8)

7)

Fitzal, F. (2008). “Analysing breast cosmesis.” Eur J Surg Oncol.

Giacalone, P. L.; O. Dubon et al.(2007). “Doughnut mastopexy lumpectomy versus standard lumpectomy in breast cancer

surgery: a prospective study.” Eur J Surg Oncol 33(3): 301-6.

Riedl, O.; F. Fitzal et al. (2008).“Intraoperative frozen section analysis for breast-conserving therapy in 1016 patients withbreast cancer.” Eur J Surg Oncol.

References

77

1. Concept

Superior- and inferior-based pedicle mammaplasties are commonlyused in oncoplastic breast cancer surgery (Schönegg, Keppke et al.1989; Clough, Lewis et al. 2003). They facilitate resection of tumorslocated in any breast quadrant when skin incision patterns are ro-tated according to the location of the tumor in the breast. Combin-ing the two techniques, wide tumor quadrantectomy is performed as part of a superior pedicle mammaplasty/reduction. The inferiordermoglandular pedicle (either de-epithelialized or with a skin is-land paddle) which usually is discarded in superior pedicle reduction mammaplasty is used for immediate reconstruction of the tissue defect.

Inferior pedicle autograft mastopexy for cosmetic reasons was ini-tially described by Ribeiro (Ribeiro 1975) and modified by other au-thors (Graf, Biggs 2002). It provides a more distinct and long-lasting upper filling with less bottoming out over time.

In oncologic breast surgery, Daher (Daher 1993), Clough (Clough, Krollet al. 1999) and our own group (Schrenk, Huemer et al. 2006) have described the flap for reconstruction after quadrantectomy defects.

Superior Pedicle Mammaplasty andReconstruction of QuadrantectomyDefects With Inferior Pedicle Flaps

Peter Schrenk

2.1.1.5

78


2. Indications

The inferior pedicle reconstruction technique may be used for recon-struction of postquadrantectomy defects in almost any quadrant in the ipsilateral breast, as well as in the medial quadrants of the con-tralateral breast and the thoracic wall.

1. According to the type of surgerya. Reconstruction of breast defects immediately after quadran-

tectomy in primary or recurrent breast cancer.b. Secondary reconstruction of breast defects following tumor

surgery, cosmetic reduction mammaplasty or on account of wound complications (in these patients, viable breast tissue is transferred into the defect).

2. According to the location of defecta. Tumors / defects in the upper quadrants: either lateral, medial

or central quadrant.b. Tumors / defects in the lower outer and inner quadrants.c. Tumors / defects in the medial (inner) quadrants of the con-

tralateral breast, or in the thoracic wall.


� Tumors / defects located right at the 6 o’clock position of the in-ferior pedicle.

� Small non-ptotic breasts. � When the inferior pedicle cannot be mobilized into the defect

without tension: This may be the case with quadrantectomy de-fects high in the upper quadrants or in the contralateral breast.


Drawings are done preoperatively with the patient in an upright standing position.

The size of the tumor and the amount of breast tissue to be re-sected are marked on the skin (Fig. 1a). Drawings are done as a stand-ard Wise or vertical pattern for reduction mammaplasty.

A central midline is drawn from the sternal notch to the umbili-cus. A vertical line is drawn from the middle point of the clavicle tothe nipple, and this line is extended through the nipple below theinframammary fold. Using the index finger, the new nipple height

79


is marked on the midclavicular line at the level of the original inframammary fold, this point being projected anteriorly on the vertical axis line.

As the diameter of the areola is assumed to be 4cm, the upper border of the new areola is marked2cm above the new nipple. A mosque dome with alength of about 14cm is drawn freehand throughthis upper limit of the new areola with a diameter varying according to breast size. The width of themosque dome is drawn according to breast size and is wider in larger breasts.

The breast is then pushed medially and laterally with an upward rotation, and medial and lateralmarkings are drawn in extension of the verti-cal axis line on the thoracic wall and connected with the mosque dome. In small breasts, thesemarkings meet 1 to 2cm above the pre-existing in-framammary fold and avoid a horizontal incision in that fold (vertical scar technique). In large / me-dium-sized or ptotic breasts, horizontal lines are drawn 6cm below on the vertical lines and join theinframammary fold laterally or medially (invertedT-technique).

The inferior pedicle which is normally discarded insuperior-based pedicle reduction mammaplasty is outlined on the skin and extents up to 1 to 2cmbelow the inferior edge of the areola, with a base width of 6 to 10cm depending on breast size. Incases of malignant skin involvement, a skin pad-dle is outlined on the skin of the inferior pedicle inaccordance with the size of the resected skin. Thispart is not de-epithelialized and is used for recon-struction of the skin defect. The areola is markedwith a diameter of 4cm using a cookie cutter; this may also be done intraoperatively.

Markings are drawn in the same way as in con-tralateral reduction mammaplasty for symmetri-zation, but with the nipple placed 1 to 2cm higheron the inframammary fold in order to compensatethe resulting ptosis as no radiation is applied.

1a)

Fig. 1a: Surgical technique: Preoperative skin markings in a patient with a breast cancer in the upper outer quadrant close to the skin. The tumor / resection volume with the skin to be excised and the inferior pedicle with a skin island used for defect reconstruction are outlined on the skin.

80


5. Surgery

The patient is operated under general anaesthe-sia, in the supine position on a flexible adjustable operating table with the arms extended at 70°. The present author prefers to initially dissect the breast flaps for reduction mammaplasty and thenexcise the tumor through these incisions. The tu-mor is resected through a separate incision with skin resection only when it is very close to or infil-trates the skin.

A superior or superomedial pedicle is used for theblood supply of the nipple-areola complex. The skinis incised along the drawn markings and the supe-rior and inferior pedicles are de-epithelialized. Skin flaps of approximately 1 to 2cm in thickness are dis-sected laterally and medially to create the lateraland medial pillars (Fig. 1b). Care should be taken notto extend the dissection too far laterally or medially in order not to compromise blood supply or inner-vation. If the tumor is resected with overlying skin,a skin island according to the size of the skin to be resected is left on the inferior pedicle. The inferiorpedicle is prepared and separated from the de-ep-ithelialized superior pedicle 1 to 2cm inferiorly tothe areola and bevelled beneath the areola down tothe pectoral fascia. A vertical subglandular tunnel is thus created beneath the superior pedicle as far asthe horizontal upper breast line (Fig. 1b). The basis of the flap is 6 to 10cm in width and the thickness may vary from 2 to 6cm.

Wide local excision of the cancer is carried out (Fig. 1c), and this includes the pectoralis fascia and the skin whenever the latter is clinically infiltrated or the tumor is close to the skin. The more tissue is availablefrom the inferior pedicle, the more healthy tissuemay be resected around the tumor. The specimen isoriented and frozen sections are done to assess tu-mor margins (except in ductal carcinoma in situ). Re-excisions are performed intraoperatively in the pres-ence of close or involved margins. The tumor bed ismarked with surgical clips in three dimensions.

1b)

1c)

1cc)

81


The quadrantectomy defect is then reconstructed using the inferior pedicle which is mobilized andtransposed into the defect (Fig. 1cc, 1d). The flap is secured with 2 to 3 absorbable sutures to the pec-toralis muscle fascia in order to prevent dislocationor “bottoming out” of the breast.

Breast tissue may be resected from the medial, lat-eral or central part of the inferior pedicle to obtaina pedicle volume which substitutes for the tissue loss. The skin is temporarily closed with skin sta-ples. In the case of contralateral mammaplasty,symmetry is assessed in the sitting position (Fig. 1e). Suction drains are placed for 1 to 2 days. Thewound is closed using inverted 3-0 absorbable Vic-ryl sutures and intradermal 4-0 or 5-0 sutures (Fig. 1f). Tapes are placed.

Sentinel node biopsy/axillary dissection is eitherdone through the mammaplasty incisions or through a separate axillary incision.

1d)

Fig. 1:(b) The superior and inferior pedicles are de-epithelialized, leaving a skin island on the inferior pedicle corresponding to the skin resected with the tumor. (c) The tumor is resected lat-erally and through the incisions used to mobilize the pediclesfor reduction mammaplasty. (cc) Drawing: The inferior pedi-cle is de-epithelialized and rotated into the quadrantectomydefect. (d) The inferior pedicle is mobilized from the superiorpedicle and from the fascia and rotated into the defect. (e) Fix-ation of the inferior pedicle with its skin island fitting into the skin defect. (f) Immediate postoperative result.

1e)

1f)

82




2a)

2b)

3a)

3b)

3c)

3d)

Fig. 2:37-year-old woman with a breast cancer close to the skin inthe upper inner quadrant of the right breast, (a) pre- and (b)postoperative view 6 years after surgery and radiation.

Fig. 3:42-year-old woman with small breasts and a cancer inthe outer quadrant of the left breast. She previouslyhad breast conservation surgery with involved margins.(a) Preoperative view. (b) Mobilization of the deepithelializedinferior pedicle. (c) The inferior pedicle is brought into thequadrantectomy defect and fixed to the muscle fascia. (d)Postoperative view 4 years after surgery and radiation.

83


4a)

4b)

4c)

Fig. 4:58-year-old woman with T4b breast cancer in the upper quadrant of the left breast. (a) Preoperative view. (b) Fol-lowing neoadjuvant chemotherapy, the cancer is resected with wide margins and parts of the pectoralis major muscle and the defect are covered with the inferior pedicle.(c) Postoperative view 6 years after surgery and radiation.

5b)

5a)

5c)

Fig. 5:82-year-old woman with local recurrence and infiltration of the rib 32 years following Halstedt mastectomy and radia-tion. (a) Preoperative view. (b) Resection of the tumor with riband coverage of the thoracic wall defect with a large infe-rior pedicle from the contralateral reduction mammaplasty.(c) Postoperative view.

84


7. Tips and tricks

� We prefer to perform this technique in patients with large or me-dium-sized breasts and lesions located in the upper inner, medial or outer breast quadrant.

� The technique may also be used in patients with small breasts.The only prerequisite is a certain degree of ptosis and a nipple areola complex to inframammary fold distance of at least 6cm inorder to transpose the flap in the breast (Fig. 3).

� Depending on breast ptosis and size, as well as adequate mobiliza-tion of the flap, the inferior pedicle may be used to cover defects of almost any part in the ipsilateral breast (Fig. 4), as well as in medial quadrants in the contralateral breast (Fig. 5).

� The pedicle is fixed to the muscle fascia. Pedicles that are not fixedtend to bottom out with time.

� Excessive mobilization, undermining or exerting too much ten-sion on the inferior pedicle when suturing it to the muscle fasciashould be avoided, for this may compromise the blood supply of the pedicle.

� The longer the pedicle, the thinner it should be made, and thewider should be the base.

� In cases of very long or excessively mobilized inferior pedicles, de-epithelialization is done at the end of surgery in order to assess theblood supply.

� The pedicle is trimmed according to defect size when the frozen sections are available and when the size of the defect can be eval-uated. This avoids pedicles that are too small as compared to thedefect size should intraoperative re-excisions be necessary.

� We place surgical clips in the tumor bed and the subcutaneousbreast tissue beneath the skin flaps which are transferred fromthe original tumor bed to a new location in reduction mamma-plasty. These clips allow a more exact planning of postoperativeradiation therapy and serve in diagnosing local recurrences.

� The most common complications are delayed inverted T-incisionwound healing, altered nipple and skin sensation, and fatty tissuenecrosis.

� Fatty tissue necrosis usually occurs at the tip of the inferior pedi-cle and may mimic local recurrence. Whenever possible, removesome tissue from the tip of the inferior pedicle to improve the blood supply.

� It is advisable that both tumor surgery and defect reconstructionare performed by the same surgeon.

85


Clough, K.B., S.S. Kroll, et al. (1999). “Anapproach to the repair of partial mastectomy defects”. Plast Reconstr Surg 104:409-20.

Clough, K.B., J.S. Lewis, et al. (2003). “On-coplastic techniques allow extensive re-sections for breast-conserving therapy of breast carcinomas”. Ann Surg 237: 26-34.

Daher, J.C. (1993). “Breast island flaps”. AnnPlast Surg 30: 217-23.

Graf, R., T.M. Biggs. (2002). “In search of bettershape in mastopexy and reduction mammo-plasty”. Plast Reconstr Surg 110: 309-17.

Ribeiro, L. (1975). “A new technique for re-duction mammaplasty”. Plast ReconstrSurgery 55: 330-4.

Schönegg, W.D., E.M. Keppke, et al. (1989).“Brusterhaltende Krebschirurgie unterplastisch-rekonstruktiven Gesichtspunk-ten“. Acta Chir Austriaca 21: 273-7.

Schrenk, P., G.M. Huemer, et al. (2006).“Tumor quadrantectomy combined withreduction mammaplasty for the treatmentof breast cancer”. Eur Surg 38: 424-32.

References

87

1. Concept

The use of a simple batwing mini flap technique is possible in anypatient, however typical it is for central breast cancer (Fitzal, Mittlb-oeck et al. 2008) in the elderly with whom longer durations of surgi-cal treatment should be avoided, and in supramamillary breast can-cer patients, especially if the skin is involved (Anderson, Masetti et al. 2005). The technique is easy, simple to learn and shows no increasedmorbidity. With this technique, the surgeon fills the defect with thesurrounding breast tissue right below the defect. Moreover, it is pos-sible to resect a small part of the skin (max. 4cm in diameter) whichcan be replaced by the skin just below. This may be the nipple or the skin below the nipple in an attempt to reconstruct a resected nipple-areola complex.

2. Indications

� All breast sizes are eligible. � Smaller breast cancers up to 3cm. � Central breast cancer. � Paget’s disease. � Breast cancer in a directly supramamillary

position involving the skin.

Batwing Technique

Florian Fitzal

2.1.1.6

88



� Large skin involvement exceeding 3cm in diameter. � Inflammatory breast cancer. � T3 or large extensive intraductal carcinoma. � Multicentric disease. � Contraindication for breast-conserving surgery.


Drawings may be done on the operation table or before surgery. Fig. 1a shows a patient with acentral breast cancer involving the nipple, Fig. 1b shows a woman with supramamillary disease andskin contact just above the nipple-areola complex. The patient can be positioned upright. However, itmay be equally beneficial to mark the incisions onthe operating table.

1. The height of the skin resection is measured.2. This height should be the same on both trian-

gles beside the inferior flap which is to be ro-tated into the defect (the inferior flap consists of either the area below the nipple-areola com-plex or the nipple-areola complex itself).

3. The bases of the triangle should be verticalso that the medial corners are directly next toeach other.

4. The other sides of the triangle beside the flapshould be equal, the lateral corner (the edge of the triangle) should be 2 to 4cm off the bases.

5. Surgery

The patient is operated in the supine position with both arms elevated at 90°. A preoperative biopsy improves planning of surgery, although it is notimperative for this type of operation (unlike withother more extensive reduction techniques). In this case, the present author does not always prefer tostart with sentinel node biopsy, as this techniquedoes not impede lymphatic drainage. We continu-

1b)

1a)

2)

89


ously use intraoperative frozen section analyses to reduce the necessity of a second intervention (Riedl, Fitzal et al. 2008). The tumor bed is markedwith 6 titan clips at all margins for orientation of radiotherapy and to reduce radiation scattering.

The operation starts with incisions above and be-side the tumor (white dotted line). The trianglesare then de-epithelialized (x) which is not neces-sary but increases the perfusion of the flap (y) which is to be rotated into the defect after tumor(tu) resection (Fig. 2).

The tumor is undermined (arrow) from above andthen excised with macroscopically clear margins (dotted line). Picture A shows the resection of acentral cancer, picture B is of the patient with a su-pramamillary lesion (cf. drawings Fig. 1) (Fig. 3).

Resection of a tumor with macroscopically clearmargins (at least 2cm) leaves a large defect. Simple closure of this defect results in a central hole with-out breast projection and loss of the nipple-areolacomplex (Fig. 4).

The upper side of the triangle is to be incised(white arrow) as shown in the above picture, and the resulting de-epithelialized triangle should beput underneath the skin laterally from the defect(dashed gray arrow) (Fig. 5).

The defect can now be closed with subcutaneousand subsequently with intracutaneous sutures (Fig. 6).

4b)

4a)

3b)

3a)

90


Postoperative picture taken one month after bat-wing technique without radiotherapy of the cen-tral breast cancer seen in Fig. 1a. The nipple-areola complex can be reconstructed and the left breast may be reduced at a later time point (Fig. 7).

Result one year after batwing surgery and radio-therapy of the supramamillary breast cancer seenin Fig. 1b (Fig. 8).

5b)

5a) 7)

6)

8)

ReferencesAnderson, B. O.; R. Masetti, et al. (2005).“Oncoplastic approaches to partial mastectomy: an overview of volume-displacementtechniques.” Lancet Oncol 6(3): 145-57.

Fitzal, F.; M. Mittlboeck, et al. (2008). “Breast-conserving therapy for centrallylocated breast cancer.” Ann Surg 247(3): 470-6.

Riedl, O.; F. Fitzal, et al. (2009). “Intraop-erative frozen section analysis for breast-conserving therapy in 1016 patients withbreast cancer.” Eur J Surg Oncol 35: 264-70.

91

1. Concept

Resection of tumors in the upper pole with standard quadrantecto-my frequently results in an inferior cosmetic result. This can largely be ascribed to the inadequate amount of tissue available in these quadrants. Oncoplastic surgery using inferior pedicle mammaplasty allows resection of cancers in the upper pole with an acceptable cos-metic result in most patients. With this technique, the areola is mo-bilized and shifted upwards on the vertical breast axis. For cosmeticreasons, however, the nipple areola complex cannot be placed toohigh.

S-shaped oblique reduction mammaplasty (Audretsch 2006) serves to remove an S-shaped quadrant of breast tissue. It allows resection of tumors located in all upper breast quadrants as well as retroare-olar cancers (Schrenk, Huemer et al. 2006) (Fig. 1).

2. Indications

� Patients with medium-sized or small breasts and � Tumors located in the upper outer, upper central or upper inner

breast quadrant. � Centrally located tumors.

As the tumor is excised with overlying skin, tumors close to the skinor infiltrating the skin are no contraindication to this technique.

S-Shaped Oblique ReductionMammaplasty for Reconstructionof Partial Mastectomy Defects

Peter Schrenk

2.1.1.7

92



� Tumors in the lower breast quadrants. � Large ptotic breasts: In these patients, the pro-

cedure may lead to an inferior cosmetic result, as it reduces breast size in the upper quadrantsbut leaves the excess of breast tissue in the in-ferior quadrants untouched.


Drawings are done preoperatively with the patient in an upright standing position.

The tumor is outlined on the skin. Two S-curved lines are drawn freehand from the axilla to the lower inner quadrant and down to the inframam-mary fold, the widest distance between the two lines being in the vicinity of the tumor (Fig. 2, 3a).

In small or medium-sized breasts, an area to be de-epithelialized is marked in the inner quadrant(except when the tumor is located in the inner quadrant).

Markings can be drawn in the same way as in contralateral reduction mammaplasty for sym-metrization, but any other technique for reductionmammaplasty may be more appropriate.

3a)

1)

2)

Fig. 1:S-shaped oblique reduction mammaplasty. The tumor to be excised may be located anywhere in the S-shaped quadrant.An area to be de-epithelialized is marked in the lower innerbreast quadrant (dotted area) and may provide additional tis-sue for defect reconstruction.

Fig. 2:Preoperative drawings of S-shaped reduction mammaplasty.

93


5. Surgery

The patient is operated under general anesthesia in a supine position on a flexible adjustable op-erating table, with the arms extended at 70°. The sentinel node is removed through the lateral in-cision. The skin is incised along the drawn mark-ings. A small area is de-epithelialized in the inner quadrant (Fig. 3a, b) and is later advanced under-neath the superior breast tissue to provide a moredistinct upper and inner pole filling. Superior andan inferior breast flaps are dissected down to the pectoral muscle fascia with minimal bevelling(Fig. 3c, d).3b)

3c)

Fig. 3: Surgical technique of S-shaped oblique reduction mammaplasty. (a) Preoperative view and drawings. (b) The skin is in-cised along the S-shaped pedicle. Breast tissue in the lower in-ner quadrant is de-epithelialized. (c) Dissection of the superiorflap. (d) Dissection and mobilization of the inferior flap.3d)

94


The S-shaped quadrant with the tumor is excisedand the specimen sent to frozen section examina-tion for tumor margin assessment (Fig. 3e). The tumor bed is marked with surgical clips. The in-ferior breast flap with the areola is mobilized androtated into the defect. The de-epithelialized areain the inner quadrant is mobilized and transferred underneath the superior breast flap (Fig. 3f). A suc-tion drain is placed for 1 to 2 days. The wound is closed using inverted 3-0 absorbable Vicryl suturesand intradermal 4-0 or 5-0 sutures (Fig. 3g).

3e)

3f)

3g)

Fig. 3:(e) The tumor is excised together with the pectoralis fascia. Asmall area of tissue is left in the medial quadrant. (f) The de-epithelialized area in the inner quadrant is transferred under the superior breast flap. (g) Immediate postoperative result.

Fig. 4:56-year-old woman operated with an S-shaped oblique reduc-tion. (a) preoperative view, (b) postoperative result 3 years aftersurgery and radiation.

95




7. Tips and tricks

� In patients with large ptotic breasts, S-shapedreduction may provide an inferior cosmetic re-sult, as it only reduces breast size in the upperquadrant but leaves an excess of breast tissue in the inferior quadrants.

� If the tumor is not located in the inner quad-rants, breast tissue is preserved in that quad-rant, providing additional tissue for defect re-construction.

� Both lines for the S-shaped reduction should be drawn down to the inframammary fold. Thisprovides a better breast shape.

� Excessive bevelling of the flaps results in an in-adequate amount of breast tissue for defect re-construction. Therefore, dissection of the flapsshould be straight down to the pectoral musclefascia.

4a)

4b)

Audretsch, W.P. (2006). “Re-construction of the partial mastectomy defect: classification and method”. In, Spear SL (ed). Surgery of the breast. Principles and art. 2nd Edition. Lippincott Williams & Wilkins: Philadelphia, pp 179-216

Schrenk, P., Huemer, G.M., etal. (2006). “Tumor quadrantec-tomy combined with reductionmammaplasty for the treat-ment of breast cancer”. Eur Surg 38: 424-32.

References

97

1. Concept

Patients with central breast tumors account for 5 to 20% of allbreast cancer cases and until recently were inevitably treated withmastectomy.

Radical surgery has been the treatment of choice for this typeof tumor, both because of the risk of tumor multicentricity and be-cause conservative treatment generally gives rise to a poor cosmet-ic outcome. Experience has shown that the majority of deformitiesfollowing conservative treatment are the result of scar contractureand local glandular defects. Indeed, central quadrantectomies gen-erally include excision of the nipple-areola complex (NAC), leading to significant residual distortion of breast contour (Simmons, Bren-nan et al. 2002; Vlajcic, Zic et al. 2005).

In recent years - thanks to the use of neoadjuvant chemotherapy, a bet-ter understanding of the natural history of the disease, and new surgi-cal techniques adopted from plastic surgery - centrally localized tumors with increasing frequency have been treated conservatively (Grisotti, Calabrese 2006; Wagner, Schrenk et al. 2007; Fitzal, Nehrer et al. 2007). In these cases, there are basically three options (to correct defects arisingfrom tumor resection): 1) replacement of lost volume with myocutane-ous flaps (in the majority of cases, the latissimus dorsi pedicled flap); 2) reduction mammoplasty with a pattern including the area containing the tumor; 3) correction of the defect with glandular / dermoglandular rotation flaps from areas adjacent to the quadrantectomy. In this chap-ter, our attention will be focused on this last reconstructive modality.

Immediate Reconstructionof Central QuadrantectomyDefects With a Rotation Flap –The Grisotti Technique

Andrea Grisotti, Donato Casella, Claudio Calabrese

2.1.1.7

98


2. Indications

� Retroareolar localization of the tumor. � Small tumor dimensions and / or a favorable

ratio between tumor size and breast size (such that contralateral mammoplasty to restoresymmetry is less likely to be required).

� Patients with ptotic breasts.


� Tumor dimensions larger than thenipple-areola complex.

� Small or non-ptotic breasts. � Neoplastic type with a high probability of

leaving involved margins following excision(such as when there are areas of microcalcifi-cation or non-homogeneous tumor regressionfollowing primary chemotherapy).

� Contraindications for breast-conserving surgery


The most important moment in determining thesuccess of a reconstructive procedure is the preop-erative interview. The patient must be made to un-derstand that even the most sophisticated surgical technique will never give a result comparable tothat of cosmetic surgery and most importantly, thatsurgical considerations represent only one aspect of the complex course of breast cancer treatment.

The first step in the patient’s preparation for sur-gery consists of marking a mastoplasty pattern before the patient is brought into the operatingroom. With the patient in the sitting or standing position, the extent of breast tissue to be resectedfor tumor removal is marked on the skin.

A circle outlining the areola is drawn. A smaller cir-cle is then drawn marking the new nipple-areola complex to be created adjacent to the native are-

1a)

2)

1b)

99


ola. Next, the submammary fold is marked. Finally, tangents to the NAC extending to the submam-mary fold (medial and lateral borders of the flap) are drawn (Fig. 1a, 1b).

5. Surgery

Surgery is performed under general anesthesia.The patient is in the supine position upon an ad-justable operating table. For quadrantectomy, sen-tinel lymph node biopsy and/or axillary dissection, the patient’s arms are abducted at 90°.

The procedure generally begins with a sentinel node biopsy, followed by quadrantectomy, at the end of which four titanium clips are placed along the margins of the tumor bed to facilitate subse-quent adjuvant radiotherapy. The reconstructive flap, in this case, can be executed while awaitingthe result of frozen section analysis. If an axillarydissection is then decided upon, it is carried out at the end of the procedure using a curved access tothe anterior axillary pillar. Following resection of the NAC (Fig. 2), the quadrantectomy defect is re-constructed using the rotation of inferior glandularflaps with mobilization of the skin circle which is to take the place of the excised areola (Fig. 3, 4a, 4b).

3)

4a)

4b)

Fig. 1:(a, b) Preoperative skin markings for removal of the tumor (cir-cumareolar incision) and dermoglandular flap, with the newareola lying adjacent to the native structure. The new areola will have slightly smaller dimensions than the original one.

Fig. 2:Excision of the NAC included in the pattern of central quad-rantectomy. The excision is usually extended down to the pec-toralis fascia.

Fig. 3:De-epithelialization of the flap. A skin island is preserved for reconstruction of the areola.

Fig. 4:(a, b) The medial and inferior margins of the flap are incised down to the fascia and the flap is advanced and rotated to fill the defect.

100


At the end of the reconstructive procedure, the re-sult is evaluated by lifting the operating table toan inclination of 60 to 80° (Fig. 5).

6. Tips and tricks

� To avoid kinking of the new areola due to down-ward traction, the dermis can be released by asuperficial incision along the lateral margin of the flap and as far down as necessary.

� To facilitate rotation of the flap as well as toachieve a better breast shape, the flap and, if necessary, the entire gland are widely mobi-lized from the pectoralis fascia.

� This maneuver of recruiting tissue helps achieve an ideal redistribution of volume.

� To guarantee proper projection of the new are-ola, one or two Vicryl stitches can be placeddeep in the breast tissue between the flap andthe pedicle. The sutures should bite deeper on the flap side, in order to exert sufficient pull,thus avoiding a depression.

Fitzal, F., G. Nehrer, et al. (2007).“An oncoplastic procedure for central and medio-cranial breast cancer”. Eur J Surg Oncol 33: 1158-63.

Grisotti, A., C. Calabrese. (2006). “Conservative treat-ment of breast cancer: Recon-structive problems”. In, Spear SL (Ed). Surgery of the breast: Principles and Art Lippincott Williams & Wilkins, Philadel-phia, pp 147-178.

Simmons, R., M. Brennan, et al. (2002). Analysis of nipple/areolar involvement with mas

tectomy: can the areola be preserved?” Ann Surg Oncol 9: 165-8.

Vlajcic, Z., R. Zic R, et al. (2005). “Nipple-areola complex pres-ervation: predictive factors of neoplastic nipple-areola com-plex invasion”. Ann Plast Surg55: 240-4.

Wagner, E., P. Schrenk, et al. (2007). “Central quadrantec-tomy with resection of the nip-ple-areola complex compared with mastectomy in patients with retroareolar breast can-cer”. Breast J 13: 557-63.

5)

6)

Fig. 5:The reshaped breast at the end of the procedure.

Fig. 6:Postoperative result 8 years following surgery and radiation.

References

101

1. Concept

The use of large lumpectomies has the potential to impair breast symmetry (Clough, Nos et al. 2008) and affect psychosocial func-tioning and quality of life (Waljee, Hu et al. 2008). Methods suchas volume replacement and volume displacement techniques (Association of Breast Surgery at BASO et al. 2007; Masetti, Di Leo-ne et al. 2006; Anderson, Masetti et al. 2005; Rezai, Darsow et al.2008) applied to avoid asymmetries and localized volume defectsimply additional incisions and scars. Superior- and inferior-basedpedicle mammoplasties (Ribeiro 1975; Clough, Thomas et al. 2004;Huemer, Schrenk et al. 2007; McCulley, Macmillan 2005) and full-thickness dermoglandular rotational flaps (Takeda, Ishida et al. 2005; Almasad, Salah 2008) lead to favorable cosmetic results butalso to additional scars and sometimes nipple and areola hypo-sensitivity. The use of the latissimus dorsi flap or other “mini mus-cle flaps” for immediate reconstruction of breast defects (Rains-bury 2002; Dixon, Venizelos et al. 2002; Noguchi, Taniya et al. 1990;Gendy, Able et al. 2003) bears the risk of losing this method asa salvage procedure in cases of local recurrence, or in the event that a re-resection after primary breast cancer surgery becomesnecessary. We therefore made an attempt to identify a method of transferring tissue from within the breast through the samesmall incision used for lumpectomy. This technique is now being applied in up to 70% of all breast-conserving cancer interventionsat our department.

Intramammarian Flap Technique

Christoph Rageth

2.1.1.9

102


2. Indication

The method presented here requires no ad-ditional incisions and can be used to displaceglandular tissue from the part of the ipsilat-eral breast which need not be resected duringlumpectomy. Thus, it may be suitable for allbreast sizes and all tumor locations.


1. Contraindications for breast-conserving surgery.2. Cases in which more than 50% of breast tissue

has to be resected.3. Previous breast surgery in the upper outer

quadrant due to a possible blood supply im-pairment.


Preoperative drawings are not necessary for thistype of immediate volume displacement.

5. Surgery

We start the dissection with an incision directly above the tumor in all cases except in patients with mediocranial tumors (Fig. 1a, 2a, 3a). For tu-mors in the upper inner quadrant that are notclose to the skin, a radial or semicircular incisionlateral to the tumor may be used to avoid scars in the décolleté. The size of the skin incision de-pends on whether skin has to be removed. Skinis usually excised in the presence of adjacent tumors or in cases with lesions larger than 2 to 3 cm in diameter. When more skin has to beremoved, a radial rather than a semicircular in-cision may be appropriate in an effort to avoid nipple deviation. If no skin and only small pieces of breast tissue are to be removed, a semicircu-lar skin incision is to be considered.

1a)

1c)

1b)

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Sentinel node biopsy is done before lumpecto-my and is mostly performed through the sameincision, while axillary dissection usually needs a separate or longer incision.

First, a lumpectomy is performed, and then thepreparation of the intramammarian flap is car-ried out (Fig. 1b, c, 2b, 3a). The need for a flap not only depends on the tumor/breast size relation. Firm breast tissue may necessitate the use of an immediate volume displacement as describedhere, due to difficulties in forming the breast tissue in a simple fashion. Provisional closure of the lumpectomy defect may help in indicatingthe necessity of using this technique.

The pedicle should be based either laterally ormedially. Mostly (in 70 to 80% of cases), a medi-ally pedicled flap is feasible and more appropriate. The defect is filled with the flap taken from thehealthy part of the breast (Fig. 1d). Without further incisions, the gland in this part of the breast is ini-tially detached from the pectoral muscle and then divided horizontally by a sharp incision as shownin Fig. 1b, 1c and 2b. The incision is placed exactly in the middle between the skin and the pectoralmuscle. Most of the flaps have a length of about 9cm and the base measures at least 4 cm (mostly 6to 8 cm). Blood supply comes from the intercostal arteries.

In order to maintain symmetry, if necessary, con-tralateral adaptation may be achieved either byresecting a central piece of the gland or by per-forming reduction mammoplasty.

Suction drains are placed for 1 to 2 days and thewound is closed as usual with a two-layer tech-nique for subcutaneous tissue and the skin it-self. Taping of the breast is very important – we use an adhesive flexible tape (Microfoam™, 3M). The taping applies pressure to the operating field, principally to give a favorable shape to the breast and to avoid excessive bleeding of the1e)

1d)

104


large wound planes. Circumferential compres-sion dressings are not appropriate as they may displace and lead to a mis-shaping of the breast.

6. Data

In a prospective study of 134 breast-conservingsurgeries in 2007 (9 with benign alterationsand 125 with invasive or in situ cancer), the in-tramammarian flap technique was used in 87cases (65%). The median weight of the removed specimens was 53 g in the patients without need for a flap and 62 g in the group requiring a flap reconstruction, while the median estimated breast sizes were 400 g (without flap) and 350 g (with flap), respectively. Fifteen flaps were based laterally and 72 medially. The median diameter of the flap base was 7 cm (3.5 to 22 cm) and the median length 9 cm (5 to 17 cm).

There were three postoperative infections. Twocases of excessive postoperative bleeding result-ed in an operative evacuation of the hematoma.The cosmetic results were considered favora-ble or acceptable in 131 cases. In the remaining three patients, the results were cosmetically un-satisfactory. One of these three presented with wound infection which healed after operative revision. In another case, we recognized only during surgery that mastectomy would becomenecessary due to tumor size. We therefore re-frained from carrying out an intramammarian flap reconstruction which would have other-wise been necessary. In the third case, too much breast tissue (498 g in a large breast of about1.5 kg size) had to be removed due to a bifocal tumor with additional ductal carcinoma in situ (DCIS). However, evaluation of the cosmetic re-sults is difficult (Asgeirsson, Rasheed et al. 2005)as we used only subjective scores.

2a)

2c)

2b)

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7. Tips and tricks

Avoid using multiple flaps from the same side by performing more than one horizontal inci-sion, as this will impair blood supply. Rather, prepare a wider and longer flap if the defect is large. Rarely are two flaps necessary (one from the lateral and one from the medial side). The length of the flap should be fitted such that theflap is tension-free. One single stitch is usuallysufficient to fix the flap within the cavity. Onlysubcutaneous stitches, skin adaptation andshaping of the breast with the external tapeare required subsequently. In the case of tumor-infiltrated resection margins, the unclear mar-gin of the tumor bed must undergo secondary resection. If feasible, further breast-conservingsurgery is performed. Since the former wound cavity is easier to evaluate before resection of the margins, early reintervention facilitates eas-ier detachment and restoration of the flap to itsoriginal location. We do not use clips to mark the resection margins after lumpectomy.

3a)

4a) 4b)

3b)

106


Almasad, J.K., B. Salah. (2008). “Breast re-construction by local flaps after conservingsurgery for breast cancer: an added assetto oncoplastic techniques”. Breast J 14(4):340-4.

Anderson, B.O., R. Masetti R, et al. (2005).“Oncoplastic approaches to partial mastec-tomy: an overview of volume-displacement techniques”. Lancet Oncol 6(3): 145-57.

Asgeirsson, K.S., T. Rasheed, et al. (2005).“Oncological and cosmetic outcomes of oncoplastic breast conserving surgery”. EurJ Surg Oncol 31(8): 817-23.

Association of Breast Surgery at BASO,BAPRAS and the Training Interface Group in Breast Surgery. (2007). “Oncoplasticbreast surgery - A guide to good practice”.Eur J Surg Oncol 33, Suppl 1: S1-23.

Clough, K.B., C. Nos, et al. (2008). “Partial reconstruction after conservative treatment for breast cancer: classification of sequelae and treatment options”. Ann ChirPlast Esthet 53(2): 88-101.

Clough, K.B., S.S. Thomas, et al. (2004). “Reconstruction after conservative treatment

for breast cancer: cosmetic sequelae clas-sification revisited”. Plast Reconstr Surg114(7): 1743-53.

Dixon, J.M., B. Venizelos, et al. (2002). “Latissimus dorsi mini-flap: a technique forextending breast conservation”. Breast11:58-65.

Gendy, R., J. Able, et al. (2003). “Impact of skin-sparing mastectomy with immediatereconstruction and breast-sparing reconstruction with miniflaps on the outcomesof oncoplastic breast surgery”. Br J Surg 90:433-9.

Huemer, G.M., P. Schrenk, et al. (2007). “Oncoplastic techniques allow breast-conserv-ing treatment in centrally located breast cancers”. Plast Reconstr Surg 120(2): 390-8.

Masetti, R., A. Di Leone, et al. (2006). “Oncoplastic techniques in the conservativesurgical treatment of breast cancer: anoverview”. Breast J 12(5 Suppl 2): S174-80.

McCulley, S.J., R.D. Macmillan. (2005).“Therapeutic mammoplasty – analysis of 50 consecutive cases”. Br J Plast Surg 58: 902-7.

Noguchi, M., T. Taniya, et al. (1990). “Im-mediate transposition of a latissimus dorsi muscle for correcting a post quadrantecto-my breast deformity in Japanese patients”.Int Surg 75:166-170.

Rainsbury, R.M. (2002). “Breast-sparingreconstruction with latissimus dorsi mini-flaps”. Eur J Surg Oncol 28:891-5.

Rezai, M., M. Darsow, et al. (2008). “Autolo-gous and alloplastic breast reconstruction--overview of techniques, indications and results”. Gynakol Geburtshilfliche Rundsch48(2): 68-75.

Ribeiro, L. (1975). “A new technique for re-duction mammaplasty”. Plast ReconstrSurg 55(3): 330-4.

Takeda, M., T. Ishida, et al. (2005). “Breastconserving surgery with primary volumereplacement using a lateral tissue flap”. Breast Cancer 12: 16-20.

Waljee, J.F., E.S. Hu, et al. “Effect of esthetic outcome after breast-conserving surgery on psychosocial functioning and quality of life”. J Clin Oncol 26(20): 3331-7.

References

107

1. Concept

The B-technique as described by Regnault (Regnault 1974) may be usedto excise tumors in all breast quadrants, when small modifications of the technique are applied.

Especially in patients with a large tumor in the upper quadrants in a large breast it would be helpful to extend the incision lines to S - or W -shaped patterns (Schöndorf 2001). Therefore we proposed to subsumeall these modifications under the term of ‘B-S-W-Plasty’ which repre-sents in German also an acronym for ’Brust-spezifische Wiederherstel-lung’ = breast-specific reconstruction (Schöndorf and Dimpfl 2004).

In principle, these techniques supplement a peripheral removal of breast volume with a crescent-shaped skin surface (of any localisation)with a ring-like deepithelialization of the skin around the nipple (Fig. 1 a).Pressing on the ‘bowstring’ of the half moon produces a pull on the outer incision line around the nipple, which then – similar to a tobacco-pouch – becomes smaller and adapts to the inner incision line as thenew circumference of the nipple. Prerequisite for success is that thelength difference of the half moon’s curves is identical to the length di -ffference of the outer and inner nipple circumcision (Fig.1 b).

2. Indications

We propose the B-plasty for patients with medium or large sized breasts without major ptosis (Schöndorf and Dimpfl 2004). Preferably they have no greater tissue reserves at the lateral thoracic wall, which can better be treated by transpositional flaps (Schöndorf 1997). The ideal indicationfor BSW-Plasty is if a minor reduction of the breast is desired.

Reconstruction of PartialMastectomy Defects:The B – Plasty

Norbert K. Schöndorf

2.1.1.10

108



� Centrally located tumors � Slim patients with major ptosis / tubular ptosis


Preoperative drawings are done the day before the operation and in an upright sitting (or standing)position (Fig. 2 a, b). The tumor and tissue to be re-sected are outlined on the skin together with an area around the areola to be de-epithelialized. In case of large or ptotic breasts the drawings shouldbe re-examined in the lying position. The larger the breast basis and the thicker the surrounding fattissue (especially on the lateral thoracic wall), the more it is possible to pull tissue (and wound length)from the outer breast area, and the less is the needfor the periareolar skin reduction, which would re-sult in a flatter breast (Fig. 3 b, c). Then the previously described ‘half-moon’ is drawn around the tumor resection field. Using longer half-moon curves al-lows smooth adjustment of the wound closure on the spherical surface of the breast. Some markingsof the corresponding points after lengths measur-ing may be helpful to better adapt the skin margins(Fig. 1 b, Fig. 2 a, b).

5. Surgery

Sentinel node biopsy is done through the lateral in-cision. The skin is incised along the drawn markingsand the periareolar skin is deepithelialized (Fig. 2c). The incisions are continued down to the pectoralis major muscle and a wedge of tissue is excised un-derneath the nipple areola complex (Fig. 2d). This is done for oncological reasons and to facilitate the ro-tation of the breast tissue through the central breast axis when closure is attempted. Tumor quadrantec-tomy is done including the pectoralis fascia and theglandular flaps are mobilized (Fig. 2e).

1a)

2b)

2a)

1b)

109


If the remaining tissue for reconstruction is very poor we mobilise skin and fat tissue from inframammary epigastric area to increase the resulting breast vol-ume. Two or three stitches may be helpful to recon-struct a new inframammary fold. The breast recon-struction is begun with some deep sutures (Fig. 2f)to adapt the both basal tissue margins.

The glandular flaps are sutured in two layers (parenchyma basis and corium) using Vicryl® 2 or 3x0 and the wound is closed with Prolene® 3 or 4x0 intracutaneously or by use of a glue stick (Der-mabond®) (Fig. 2g). We routinely use a drainage for two days. The wound is taped for 1-2 weeks.

If necessary an adaptation reduction of the contralateral breast can be performed, either as amirror image procedure or any classical reduction technique. This is performed at a second operation12 to 18 month after initial surgery for any minor correction needed on the tumor side may be per-formed during that surgery when the main altera-tions following operation and radiation therapy achieve a stable stage (Fig. 2h).

2e)

2f)

2d)

2c)

Fig. 1: B-plasty, preoperative drawings. (a) Principle of the B-Plasty, pr-eoperative drawings: the peripheral removal of breast volumewith a crescent-shaped skin surface (of any localisation) is sup-plemented with a ring-like deepithelialization of the skin aroundthe nipple. (b) Measuring the length of the incision lines with ad-ditional skin markings: the length of the adapted skin margins must be identical: abc = a’b’c’, and cdefg = g’d’e’f’g’!

Fig. 2: B-Plasty, planning and surgery (a Measurement of the correspond) -ing incision lines, skin markings (b)Definitive drawing as docu-mented by preoperative photograph (scheme in the top). (c The )skin is incised along the drawn markings and an area of periareolar skin is de-epithelialized. (d The incisions are continued to the fascia )of the pectoralis major muscle and a wedge of tissue is dissectedunderneath the areola (black cross) (e The tumor is excised en bloc:)green hatching: basal mobilisation area on the pectoral fascia (un-derneath the inferior and superior flap), red line: additional incision line towards mamilla allowing better rotation of the remainingbreast tissue. Blue curved arrows: direction of needed tissue rota-tion. Yellow line: expected scar line. (f Breast reconstruction: blue )arrows: optional inclusion of inframammary skin and fat tissue (as done in this case. See also scheme above), yellow loops: points of basal sutures to joint the both basal tissue margins.

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6. Tips and tricks

� Periareolar skin reduction makes the breast ‘flat’ or results in higher elevation of the nip-ple and a more obvious asymmetry (Fig. 3b, c). On the other hand reduction of the basis of the breast (or of the basal circumference) makesthe breast ‘slim’ and ptotic (Fig. 3d, e).

� Despite the width of the periareolar skin reduc-tion the incision lines must keep a rotational symmetry to preserve the central position of the nipple and to avoid a squint of the areola(Fig. 6 a).

� When drawing the curved lines on the spheri-cal breast surface, strictly avoid opposite curveswith opposite curvature, in particular rhom-boid-like figures. Instead use the geometry of the described half-moons that follow the volu-metric form of the breast (Fig. 6b).

� Freehand designed curved lines over moving hemisphere need training!

� Curved-lined skin incisions must be directedstrongly vertically to the surface to avoid ‘claps’ which inhibit a smooth scar healing.

� If the central part of the upper incision line cor-responds with a greater part of the areola cir-cumference of the lower incision line (Fig. 4a ��– ��) a little opposite curve modification(Fig. 4a � –�, blue line) may be helpful to bet-ter adapt the both resulting skin margins and to avoid a tipping of the mamilla.

� In case of very well defined tumor borders witha thick layer of healthy tissue towards the skinwe prefer modifications with subcutaneous tu-mor resection, preserving a thick padded skinand immediate reconstruction with deepitheli-alized flaps. This allows the removal of greater tumors while saving tissue and reducing thevolume defect of the breast, and can by later-alisation avoid disturbing scars in the female ‘décolleté’.

2h)

2g)

Fig. 2: (g) Immediate postoperative result (h) Late postoperative re-sult following radiation therapy

Fig. 3: B-Plasty: Preoperative Drawing – Impact of the incisionlines on breast shape (a) Preoperative view with tumorand volume planned to be removed (b) Operation planningwith length compensation of the lower incision line (‘bow-string’) only by a part of the periareolar circumference (c)results in a flatter breast (d) Length compensation fromthe outer breast area at the thoracic wall which reducesthe basal breast circumference (e) results in a slimmerbreast and possibly in more ptosis

111


3a)

3b)

3c)

3d)

3e)

112


5b)

4c) 5c)

4a) 5a)

Fig. 4: (a) 44 year old women with multifocal tumor in upper outerquadrant of the left breast. a: Preoperative drawings. Note the little opposite curve modification (� – �, blue line) to betteradapt the upper incision line at the central periareolar part of the lower incision line (��– ��) and to avoid a tipping of themamilla. (b) Lateral view 6 months after surgery and radiation (c) Anterior view 6 months after surgery and radiation. Adapta-tion reduction is suggested.

Fig. 5: (a) 42 year old, slim women with tumor in lower outer quadrant of the left breast (T2N1M0). a: Preoperativedrawings: lifting-reduction in B-technique after tumor-reduction by neoadjuvant chemotherapy to 1 cm (pnT1b).(b) 2 weeks after surgery (c) 3 months after radiation.

113


References

6b)6a)

Fig. 6: Not advisable Drawings for B – Plasty. (a) excentric periare-olar circumcision may effect a not predictable dislocation of the mamilla. (b) opposite curves with opposite curvature or rhomboid-like fi gures produce a hight vertical tension

Regnault P. Reduction mammaplasty by the ‘B’ technique (1974) Plast Reconstr Surg 53:19-25

Schöndorf NK (2001) The technique of B-, S- or W- reduction mammaplasty in the conservative therapy of breast carcinomas: experience with a new surgical techniqueThe Breast 10: 501-508

Schöndorf NK, Dimpfl C (2004) Brust-spe-zifi sche Wiederherstellung nach Quad-rantektomie in BSW-Technik. Gyn 9: 90-99

Schöndorf NK (1997) The double transpo-sition fl ap in the breast-saving therapy of breast carcinoma as a versatile possibilityin segment – or quadrantectomy in theelderly woman. Gynäkol Geburtshilfl ischeRundsch 37: 136-142.

115

BCS and ImmediateReconstruction - Flaps

Partial Mastectomy / BCS andReconstruction With Latissimus

Richard M. Rainsbury

2.1.2

2.1.2.1

1. Concept

Breast-conserving surgery (BCS) has become ‘standard of care’ when breast cancer can be completely excised without significant loss of breast volume. The risk of major local deformity with dis-tressing cosmetic results increases in step with the proportion of breast tissue excised. The larger the defect, the greater chance of an unacceptable cosmetic result. This is particularly true for resec-tions in the upper inner, central and lower pole of the breast (Co-chrane et al 2003).

Immediate reconstruction of these defects with a subcutaneouslatissimus dorsi (LD) miniflap prevents deformity and has extended the availability of BCS to a group of women traditionally treatedby mastectomy. The technique questions the logic of removing the whole breast in a patient when at least 50% of the breast is entirelynormal, with normal sensation, movement and consistency. It com-pares favourably with skin-sparing mastectomy and immediate reconstruction, with fewer complications, less sensory loss, fewerrevisional procedures and better physical and cosmetic outcomes (Gendy et al 2002).

116


The operation can be performed either in one stage(Raja et al 1997) or in two stages (Dixon et al 2002)leading to low local recurrence rates (Rusby et al2008). This approach requires good communication and coordination with the department of histopa-thology, coupled with comprehensive sampling of thewall of the resection cavity. Alternatively, the resection is performed as a first step, deferring reconstruction until clear resection margins are confirmed by analysis of paraffin sections (Dixon et al 2002). This approach may be preferable when frozen section examinationcan be particularly difficult to interpret, such as in those patients with non-high grade DCIS, or followingneoadjuvant chemotherapy (Riedl et al 2008).

2. Indications

Ideal candidates for the LD miniflap procedure arepatients with a small to medium sized breast (200-600 gm of breast tissue) who require resection of more than 20% of the breast volume to achieveclear tumour margins. The indications for this ap-proach have increased with experience, and mini-flaps should be considered for patients who:

� don’t want a mastectomy, even though 20-70%of the breast tissue needs to be resected to achieve clear margins

� don’t have enough subcutaneous fat overlying LD to enable full autologous LD reconstruction after total mastectomy

� don’t have enough lower abdominal fat to en-able TRAM-flap reconstruction after total mas-tectomy, or don’t want an abdominal procedure

� want to avoid the reduction in breast sizewhich occurs following volume displacement (therapeutic mammoplasty) procedures

� don’t want contralateral symmetrizing surgery � want to avoid the use of implants or expanders � will require post-mastectomy radiotherapy

(thus no advantage for mastectomy) � are requesting correction of major cosmetic defor-

mity following BCS with significant volume loss.Fig. 1:Pre-operative mark-up

1b)

1a)

117



LD miniflaps may take up to 3 hours to perform. They require care-ful margin analysis, and the harvesting of a significant volume of LD muscle and subcutaneous fat through a relatively small incision.They also require clear resection margins, a patent blood supply and an intact muscle, so this technique is contraindicated in the follow-ing situations:

� when there is significant co-morbidity (heavy smoking andBMI >35; cardiac or pulmonary risk; vascular risk)

� when clear margins cannot be confirmed � if both the thoracodorsal and the serratus anterior branches

of the subscapular pedicle have been divided � in patients with a high risk of a local relapse (premenopausal,

more than 4 nodes, G3 and L1 and her2 positive etc). � if the LD muscle has been divided during a previous thoracotomy � in patients with established lymphoedema following previous

axillary surgery


The operation which is shown to illustrate the LD miniflap tech-nique was performed on a small-breasted patient who was anideal candidate for the technique. She had an extensive area of malignant microcalcification associated with DCIS in the outerquadrant of her left breast. This contained two small invasive car-cinomas, some 15 mm apart.

Figure 1a shows a lateral view of the line of incision (a), zone of re-section (b), access tunnel (c), upper border of breast (d) and anterior border of LD (e) (Fig. 1a).

Figure 1b is a posterior view showing the midline (a), scapula (b), up-per border of LD (c), posterior limit of dissection (d), inferior limit of dissection (e). The position of a skin island (f), and the additional dis-section required to harvest a full LD flap (g) are marked. These will only be used in patients requiring resection of the nipple/areola complex (NAC), or in those proceeding to a full mastectomy (Fig. 1b).

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1. When the tumor is palpable, the outer border is clearly marked onthe breast skin.

2. A second circular line marking a 2 cm resection margin is drawn around the outside of this border.

3. In this case shown, the tumors were impalpable, and the resec-tion zone was determined by a combination of mammographyand ultrasound measurements. Wire-guided localization was not required. Note that the resection has been planned to in-clude the major lactiferous ducts, which will be examined byfrozen section to determine if the NAC can be preserved.

4. The resection zone (Fig. 1a) (b) is in continuity with the ‘accesstunnel’(c). The access tunnel is an area of normal breast paren-chyma which is resected to accommodate the LD tendon follow-ing transposition of the flap into the resection defect. A bulky ten-don can cause an ugly bulge in this part of the breast if this access tunnel isn’t developed. The tunnel also facilitates the resection of tumours in the upper central and upper inner quadrants of the breast, by improving surgical access to these locations.

5. The position of the S-shaped incision (Fig. 1a) (a) is best decided bylateral displacement of the breast with the patient sitting at 45º. This usually accentuates a fold along the lateral border. The inci-sion runs down behind the anterior axillary fold in the apex of the axilla to the lateral limit of the inframammary fold. This results in a scar which is almost hidden when the arm is fully abducted.

6. Marking up the miniflap will help to maximise the muscle har-vest and the amount available for volume replacement. The dot-ted line (Fig. 1b) (d) represents the limit of dissection between LDand skin which can realistically be achieved when working in a posterior direction around the rigid convex surface of the chest wall. Compare this preoperative mark up with the shape of the seroma outlining the limits of this dissection in Figure 11c.

7. Patients are fully informed about the impact of margin analysis on the extent of surgery. They may consent to proceed to NAC ex-cision or to full mastectomy if intra-operative margin assessment confirms incomplete tumour excision by partial mastectomy. Al-ternatively, they can request that no further surgery is carried out,and await formal margin analysis by paraffin section (Rusby et al 2008).

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4. Surgery

One of the most important steps in the procedureis to ensure that the patient is correctly positioned and fixed on the operating table. A paravertebralblock with local anaesthesia and urinary catheteri-sation will support monitoring and early recovery.The patient is secured in the lateral decubitus po-sition with ipsilateral shoulder fixed at 90º of ab-duction, using a suitable arm rest. A support placedbehind the scapulae helps to prevent lateral move-ment when the table is tilted to improve access tothe deeper cavities which are developed when har-vesting the flap. The surgeon normally stands be-hind the patient, facing the assistant, who stands in front. Careful draping enables the surgeon to move freely from side to side, and also to gain access to the operation site from the head end of the table.

The subcutaneous tissues overlying the operat-ing site are infiltrated with 300-500 ml of a dilutesolution of adrenaline:saline (1:250,000). Make alazy-S incision (a). Deepen this incision to identifythe lateral border of pectoralis major (b), and begin to develop a retromammary space deep to the pec-toralis fascia (c). Retracting the breast anteriorly(d), develop the retromammary space medially (e)to the limits already determined by the preopera-tive drawings (Fig. 2).

Grasp the breast parenchyma and retract it firmly in a posterior direction (a) while developing a sub-cutaneous space up to the marked resection bor-ders using a broad-bladed scalpel (b). This frees thereference quadrant superficially (c) from the sub-cutaneous fat and deeply (d) from pectoralis major (Fig. 3).

Fig. 2:Development of the retromammary space

Fig. 3:Mobilising the overlying skin envelope

2a)

2b)

3a)

3b)

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The specimen is grasped between fingers andthumb (a) and separated circumferentially from the surrounding parenchyma (b). Bed biopsies aresent from all four quadrants of the cavity wall andfrom the subareolar tissue. The whole cavity wall is then inked in situ with Methylene Blue to iden-tify the inner and outer surface of a ‘cavity shaving’ or ‘re-excision specimen’ (c). This is 5-10 mm thick,and is normally harvested as two strips of breasttissue – one from the superior and one from the inferior aspect of the cavity wall. If frozen section analysis reports a positive bed biopsy, the cavity wall adjacent to the biopsy is inked again and re-excised before sending a further bed biopsy forfrozen section examination (Fig. 4).

While waiting for bed biopsy results, dissect theaxilla to identify the axillary vein (a), the thora-codorsal nerve (b), the subscapular (c), circumflex scapula (d) and serratus anterior vessels (e), andthe thoracodorsal pedicle (f). Tumour parametersand local protocols will determine the extent of axillary surgery and node harvest carried out, butdissection must be sufficient to identify and pre-serve these key structures (Fig. 5).

Fig. 4:Partial mastectomy and re-excision

Fig. 5:Identification of the neurovascular pedicle

4a)

4b)

5)

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Turning to the lateral aspect of the incision, iden-tify the anterior border of LD (a) and retract it firm-ly in a medial direction. With good retraction andlighting, it is possible to develop superficial and deep pockets around LD which extend posteriorly beyond the scapula (Figs 1b, 11c). Alternating the dissection between these pockets helps with thedeeper aspect of the mobilisation, which is ham-pered by the convexity of the rib cage (Fig. 6).

Develop a superficial subcutaneous pocket by dis-secting in a posterior direction along the deep sur-face of the superficial fascia, which is retracted lat-erally as a sheet of white tissue (b). This will leavea layer of deeper fat on the surface of the miniflap(c). Now retract LD latero-posterior (d) and dissectbetween the LD miniflap and the serratus anterior muscle (e) developing a similar sized pocket anteri-or as posterior to the mini LD flap. If you dissect onthe surface of serratus anterior, a further layer of fat can be harvested attached to the deep surface of the miniflap (f). Divide the inferior border of theflap (g), then start to divide the posterior borderby working in a cranial direction from the inferioredge of the muscle along the posterior margin of the subcutaneous cavity which you have already developed (h).

Fig. 6:Mobilisation and harvest of the miniflap: phase 1

6a)

6b)

6c)

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The miniflap is now delivered into the wound bydividing the remaining fibres of LD (a). This reveals serratus anterior (b) and terres major (c) lying un-derneath. Separation of terres major is completed by dividing a well-defined fascial layer (d) runningbetween LD (e) and terres major (f). Hazard! The thoracodorsal pedicle lies very close to the deep surface of this fascia, and should be retracted away from it using a sling to avoid damage duringdivision of the fascia (g) (Fig. 7).

Expose the LD tendon lying deep in the upper as-pect of the incision (a). Again, protect the thoraco-dorsal pedicle by retracting it medially (b) beforedividing the tendon with bipolar diathermy scis-sors (c). The miniflap is now completely mobilised. The flap is retracted anteriorely, lies in the upperleft corner of figure 8b and is perfused through the subscapular (d) and thoracodorsal vessels (e). A variable number of serratus anterior branches (1-3) run across the space between LD and serratusanterior. Division of one or two of these branches (f) and (g) helps to increase the mobility in the flap.On the one hand, this allows a greater proportionof the muscle to be used for reconstruction of the resection defect, which is now less tethered by itsblood supply. On the other hand, if the subscapularpedicle is subsequently damaged, a valuable sec-ondary pedicle is lost (Fig. 8).

7a)

8b)

7b)

8a)

Fig. 7:Mobilisation and harvest of the miniflap: phase 2

Fig. 8:Division of the LD tendon and preparation of the pedicle

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Check for bleeding in the resection cavity (a) andsuture the divided LD miniflap tendon to the lat-eral border of pectoralis major (b). Take care not to narrow the thoracodorsal pedicle, or to place itunder tension (c). Then fold the end of the mini-flap over on itself to increase the volume of the tipwhere it is most needed in the deepest part of theresection defect. Finally, model the shape of the flap by fixing it to the cavity walls with a few care-fully placed interrupted sutures (d) (Fig. 9).

9a)

9b)

9c)Fig. 9:Reconstruction of the resection defect

124


Close the incision over a suction drain and confirm the miniflap is in the correct position by checkingfrom the side (a) and from the front of the patient(b). Correct the position at this stage, rather than later on (Fig. 10).

Two weeks after surgery and before radiotherapy. The seroma (a) outlines the amount of LD whichwas harvested to form the miniflap (Fig. 11).

10a) 11b)

10b) 11c)

11a)

Fig. 11:Appearance at 10 days

Fig. 10:Appearance immediately following closure

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5. Tips and tricks

� Mark the tumour and resection border carefully, because it’s easy to get disorientated when resecting a tumour through a retro-mammary approach.

� Make sure you have a high intensity headlight, good retraction and good cutting and coagulation equipment. This will ensurethat you get good views of the narrow cavities you will be work-ing in by improving visualisation and reducing haemorrhage.

� Hazard! Make sure the patient’s arm is fixed to prevent abductionof the shoulder beyond 90º. This will avoid a traction injury to the brachial plexus, which can take months to recover.

� Practice towelling and securing the arm in a way which helps you to get access to the donor site from the head of the table as wellas from both sides.

� Avoid excessive dissection of the retromammary space, whichcan lead to ischaemic atrophy and oedema of the breast.

� Hazard! Remember that axillary anatomy looks quite different when the patient is in the lateral position. The axillary vein is col-lapsed and appears to run more superficially. The axilla itself is also collapsed, and the structures appear to lie one on top of each other and need to be separated carefully by retraction.

� Try hard to increase the volume of the miniflap. You can do this if you harvest a good layer of fat on both surfaces, and if you carry your dissection as far as possible in the posterior and inferior di-rections. Help yourself and your assistant by using long narrow retractors and by alternating between the development of thesuperficial and the deep pockets, and the division of the inferiorborder and the posterior border of the miniflap. Bipolar diathermyscissors are particularly useful when dividing the miniflap from the remaining muscular and tendinous parts of LD.

� Always secure the tendon before insetting the flap to avoid inad-vertent damage to the pedicle, as well as subsequent flap retrac-tion, which can lead to hollowing of the resection defect over time.

� Understand and master conventional LD reconstruction before planning a miniflap procedure. The operation is technically moreexacting than raising a conventional flap, and you may need toconvert the operation and harvest a conventional LD flap if re-quired for full reconstruction after total mastectomy.

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Cochrane RA, Valasiadou P, Wilson ARM, Al-Ghazal SK, Macmillan RD (2003). Cosmesisand satisfaction after breast-conservingsurgery correlates to the percentage of breast volume excised. Br J Surg 90: 1505-9

Raja MAK, Straker VF, Rainsbury RM (1997).Extending the role of breast-conserving surgery by immediate volume replace-ment. Br J Surg 84: 101-5

Riedl O, Fitzal F, Mader N, Mittlböck M,Dubsky P, Gnant M, Jakesz R. Intraoperativefrozen section analysis for breast-conserv-ing therapy in 1016 patients with breastcancer. EJSO 2008 epub ahead of print

Rusby JE, Paramanathan N, Laws SAM,Rainsbury RM (2008). Immediate latis-simus dorsi miniflap volume replacementfor partial mastectomy: use of intra-oper

ative frozen sections to confirm negativemargins. Am J Surg 196: 512-8

Gendy RK, Able JA, Rainsbury RM (2003).Impact of skin-sparing mastectomy withimmediate reconstruction and breast-sparing reconstruction with miniflaps onthe outcomes of oncoplastic breast sur-gery. Br R J Surg 90: 433-9

References

127

1. Concept

The transverse thoracoepigastric flap is a long- and well known al-ternative to reconstruct the breast after ablative tumor surgery. Tra-ditionally, this flap was surgically delayed in order to augment itsvascularity and enhance safety (Brown, Vasconez et al. 1975, Cronin,Upton et al. 1977, Bohmert 1980). The concept of this flap is that it utilizes local tissue in a rotation or advancement fashion. Due to theincreased demand for reconstructive techniques for partial breastreconstruction, this flap has experienced a renaissance.

The principal blood supply to this flap consists in musculocutane-ous perforating vessels from the superior epigastric artery and veinextending from the underlying rectus abdominis muscle into thesuperficial fascia. This flap commonly has a rather broad base and isrotated upwards into the defect of the breast. However, flap mobility is limited with this approach. An alternative would be to prepare theflap as a pedicled perforator flap, which greatly enhances mobility, insetting and donor site closure (Uemura 2007, Schoeller, Huemer etal. 2007).

Partial Mastectomy: BreastReconstruction With thePedicled Thoracoepigastric Flap

Georg M. Huemer

2.1.2.2

128


2. Indications

The flap may be used either as a dermoglandular flap or completelyde-epithelialized to reconstruct defects in the lower quadrants of the breast, preferably the lower medial quadrant. By extending the flap more laterally, the medial upper quadrant may be reached.

The pedicled thoracoepigastric flap should be considered for pa-tients who

� are no candidates for a breast reduction procedure: small or me-dium-sized breast or patients who do not want a reduction inbreast size.

� do not want defect reconstruction with a latissimus dorsi flap. � do not want a procedure involving tissue transfer from the lower

abdomen. � do not want a microsurgical procedure utilizing tissue from a

remote site such as the inner thigh - transverse myocutaneousgracilis (TMG) flap - or buttock - superior gluteal artery perforator (SGAP) flap.

� have sufficient tissue and laxity in the lateral upper abdomen. � have a significant cosmetic deformity after breast-conserving

therapy (secondary defect reconstruction).


There are two major contraindications to the pedicled thoracoepi-gastric flap:

� Previous surgery in the ipsilateral upper abdomen with a resul-ting scar in the proposed flap (possible disruption of blood supply).

� Paucity of tissue in the upper abdomen which would preclude di-rect closure of the donor site.

129



1. Prior to outlining the flap dimensions, a Dop-pler evaluation of the detectable perforators atthe presumed flap base should be carried out.Usually, two to four audible perforators can befound laterally to the midline (Fig. 1).

2. Having marked the perforators, the flap can beoutlined in the upper abdomen. The midline denotes the most medial border of the flapbase. In many cases, the flap base is more lat-eral, depending on the location of the defect. It should be kept in mind that closure of the do-nor site will create a new inframammary fold.Thus, the lower incision should not extend too far medially and caudally in order to facilitate tension-free closure.

3. The width of the flap is mainly determined bythe ability to close the donor defect primarily, a split-thickness skin graft otherwise being re-quired. Usually, a width of 7 to 8 cm can easilybe closed primarily.

4. The length of the flap mainly depends on the location of the defect (Fig. 2).

Fig. 2:The tumor is removed through an incision in the inframam-mary fold. The incision can reach as far as the lateral border of the thoracoepigastric flap. Sentinel node biopsy can be done through this incision.

Fig. 1:Perforators to the thoracoepigastric flap should be marked pr-eoperatively with the aid of a Doppler probe. The patient is ex-amined in the supine position. The above picture shows threemarked perforators in the typical position in the area below theexisting inframammary fold just laterally to the midline. Thetumor is located in the lower central quadrant.

1)

2)

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5. Surgery

1. The patient is positioned in the supine positionon a flexible adjustable operating table withboth arms abducted at approximately 90°.

2. Before raising the flap, any oncologic resection should be completed, so that the exact amount of tissue that is needed can be determined (Fig. 3).If patient selection is appropriate (see Indica-tions section), tissue defect of up to one quar-ter of the breast can be replaced with the pedi-cled thoracoepigastric flap.

3. The outlined borders of the flap are incised andincisions are carried down to the deep fascia.In order to minimize donor site morbidity, thedeep fascia is not included in the flap (Fig. 4).

4. Harvesting of the flap continues from lateral to medial just on top of the deep fascia. All smallperforating vessels supplying the lateral portion of the flap should be cauterized meticulously.

Fig. 3:After oncologically sound tumor resection, the defect is re-evaluated in terms of defect size and flap dimensions are changed accordingly.

Fig. 4:After outlining the definite flap borders, the flap is incised down to the deep fascia. In order to prevent weakening of theabdominal wall, the deep fascia is not violated. Depending onthe patient’s individual characteristics, a significant amount of flap volume can be harvested.

Fig. 5:The flap is raised in a suprafascial plane. A large perforatorfrom the superior epigastric vessels is encountered and iso-lated. For increased mobility and freedom of flap inset, thefascia is incised around the perforator and traced back in a ret-rograde fashion.

Fig. 6:The flap is completely mobilized and de-epithelialized. This,however, is dependent on the needs of the defect. In cases in which a skin defect should be addressed, the flap is only par-tially de-epithelialized. 6)

4)

5)

3)

131


5. Once the base of the flap or the area of themarked perforators is approached, care should be taken to spare the perforators supplyingthe flap (Fig. 5). Theoretically, one large perfora-tor with a visible pulse will be sufficient. More than one perforator can be spared, however, if rotation of the flap does not kink the detectedperforating vessels. To gain length, the deep fas-cia around the perforators is incised and the ves-sel can be traced through the rectus abdominis muscle. If not needed, this intramuscular prepa-ration should be omitted since it requires micro-surgical technique and small muscular branchescan be injured easily which results in brisk bleed-ing. Obtaining hemostasis with electrocautery would then jeopardize the entire flap circulation.

6. After completion of flap raising, the flap can betailored according to the needs of the defect. The whole flap can be de-epithelialized (Fig. 6)and buried or a skin defect can be reconstruct-ed with a partially de-epithelialized thoracoepi-gastric flap.

7. The flap is now rotated upwards into the de-fect and fixed with a few absorbable stitches.As a final step, the donor site is closed over adrain. If closure is under undue tension, a limit-ed undermining of the lower wound edge as inreverse abdominoplasty can facilitate tension-free closure. The superficial fascia of the caudal wound edge should be fixed with long-lastingabsorbable sutures to the periosteum of theribs underlying the old submammary fold. Thiswill recreate a natural-looking breast mound(Fig. 7a, b).

Fig. 7a, b:Immediate postoperative result after the flap has been rotatedinto the defect an d the flap donor site has been closed directlyover a drain.

Fig. 8a, b:36-year-old patient with a tumor in the lower outer quadrant. Pre- and postoperative view 1 year after surgery and radiation.

7a)

7b)

8a)

8b)

132


6. Tips and tricks

� If a long flap for reconstruction is planned, a delay procedure 10 to14 days prior to flap harvesting is recommended.

� For enhanced mobility of the flap, the flap can be raised com-pletely as islanded pedicled perforator flap. However, this requiresa skilled microsurgeon, as damage to the pedicle would impair the entire flap.

� The base of the flap should not extend further medially than themedial border of the ipsilateral breast. Closure of the donor sitewould otherwise result in a scar that does not lie within the sub-mammary fold.

� For prevention of flap displacement, the flap can be fixed withstrong absorbable sutures (such as 2-0 Vicryl or Polysorb) either to the breast tissue or the pectoralis muscle fascia.

Bohmert, H. (1980). “Experience in breast re-construction with thoraco-epigastric and ad-vancement flaps”. Acta Chir Belg 79: 105-10.

Brown, R.G., L.O. Vasconez, et al. (1975). “Transverse abdominal flaps and the deepepigastric arcade”. Plast Reconstr Surg 55: 416-21.

Cronin, T.D., J. Upton, et al. (1977). “Recon-struction of the breast after mastectomy”.Plast Reconstr Surg 59: 1-14.

Schoeller, T., G.M. Huemer, et al. (2007). “Correction of contour deformities of the hip region with a pedicled DIEP flap”. PlastReconstr Surg 119: 212-5.

Uemura, T. (2007). “Superior epigastric ar-tery perforator flap: preliminary report”.Plast Reconstr Surg 120: 1e-5e.

References

133

1. Concept

Skin sparing mastectomy (SSM) removes the breast, nipple-areolacomplex, previous biopsy incisions, and skin overlying superficialtumors. Nipple sparing mastectomy (NSM) preserves the nipple-areolar complex (NAC) as well. Preservation of the inframammaryfold, native skin, and potentially the NAC greatly enhances the aes-thetic result of immediate breast reconstruction. Theses techniquesfacilitate breast shaping and the abundant native skin reduces the amount of tissue transfer required. In cases of autologous recon-struction, there is an added advantage in a reduction in surgery on the contralateral breast to achieve symmetry. The periareolar or in-framammary fold incisions are relatively inconspicuous and are eas-ily hidden in clothes.

Non-randomized studies comparing the local recurrence of breast cancer associated with SSM and conventional total mastec-tomy have found no significant differences (Carlson et al. 1997). Pro-phylactic NSM is effective in women at high risk of developing breastcancer. Limited data has shown that the selective use of NSM in thetreatment of early breast cancer has a low incidence of recurrence inthe NAC (Chung et al. 2008).

Resection Techniques

Nipple and Skin SparingMastectomy

Grant W. Carlson

2.2.12.2.1.1

OPS and Mastectomy2.2

134

OPS and Mastectomy

2. Indication

2.1 Nipple sparing mastectomy

Nipple sparing and skin sparing mastectomy areused in patients having prophylactic mastectomy and those with early breast cancer in conjunctionwith immediate breast reconstruction. Specific in-dications for NSM include:

� Small tumors located at least 1cm outside of areolar margins

� Absence of nipple retraction or bloody nipple discharge

� Absence of retroareolar microcalcifications onmammography

� Small to moderate sized breast with minimalptosis (grade I)

3. Contraindication

NSM does not allow modification of the native skin envelope as does a SSM. Movement of the NAC, unless used as a free graft, requires its trans-position on a dermoglandular pedicle. This wouldrequire preservation of additional breast tissue which significantly impacts the completeness of the mastectomy. Contraindications for NSM / SSMinclude:

� Locally advanced breast cancer with nipple in-volvement or peripheral skin involvement

� Recent smoking history and history of breast ir-radiation are relative contraindications

� Large ptotic breast (grade II / III) are not candi-dates for NSM

Fig. 1:Types of skin sparing mastectomy 1b)

1a)

135



4.1 Incisions

The inframammary fold is delineated preopera-tively with a marking pen with the patient in the upright position. The nipple-areolar complex, skin overlying superficial cancers and previous biopsy incisions are removed. The type of skin sparing mastectomy has been classified by the type of in-cision used and the amount of skin removed (Fig. 1)(Carlson et al., 2007).

� A Type I SSM is commonly used in prophylacticcases and for non-palpable cancers diagnosed by needle biopsy. In patients with small diam-eter areola, a lateral extension of the incisionwas sometimes necessary to improve exposure to the axillary tail. A modified of a type I SSMuses a purse string partial closure of the peri-areolar incision to provide a round block mas-topexy effect in breasts with moderate ptosis.Complete purse string closure of the periare-olar defect often leads to unsightly puckered scars which are difficult to incorporate in nipplereconstruction.

� A Type II SSM is used when a superficial tumor or previous biopsy is in proximity to the areola.

� Type III SSM is used when the superficial tumoror previous incision was remote from the are-ola. Care must be taken to ensure the viabilityof the intervening skin.

� A Type IV SSM was used in large, ptotic breasts when a reduction was planned on the oppositebreast. A common problem with this Wise pat-tern incision is the occurrence of native skinflap necrosis of the most distal portions of the flap, particularly at the “T” junction. Another op-tion to avoid skin flap necrosis in ptotic breasts is a vertically oriented skin takeout. After re-section, the skin excess can be taken up witha purse string or “round block technique”. If ex-cessive inferior skin persists, a limited horizon-tal takeout can be performed.

1c)

1d)

136

OPS and Mastectomy

� In NSM there are several incision options de-pending on the size of the breast and nipple-ar-eolar complex as well as the type of reconstruc-tion performed (Fig. 2).

Inframammary fold incision is useful insmaller breasts when implant/expanderreconstruction is plannedA lateral radial incision with a possible 180° periareolar extension is the most versatile. Itcan be used with any breast size and providesadequate exposure to the internal mammaryvessels if free flap reconstruction is planned.

� A separate axillary incision is often required foraxillary lymph node sampling. This is made in an axillary skin fold behind the lateral the bor-der of the pectoralis major muscle, one finger breath below the axillary hair line.

5. Surgery

Defining the location and extent of the breast can-cer is essential prior to performing a skin sparingmastectomy. Careful review of mammograms and pathology of excisional biopsies is necessary toprevent close or involved margins.

5.1 Positioning

� The patient is placed supine; the arms are ab-ducted 90˚ and supported on arm boards and secured with gauze. This is in preparation for immediate breast reconstruction.

� Draping is performed so an assistant can be ce-phalad to the operative arm. Both breasts areprepped in the operative field with exposure fromabove the sternal notch to below the costal mar-gin. The arms are exposed to the mid humerus.

2)

3)

Fig. 2:Incisions for nipple sparing mastectomy

Fig. 3:Skin flap elevation for a skin sparing mastectomy. The dis-section moves in a circular manner to increase exposure.

137


5.2 Nipple and Skin Sparing Mastectomy

� The skin flaps are elevated superficial to the en-veloping fascia of the breast. The skin flap thick-ness depends on the location on the breast and body habitus of the patient. Breast tissue ex-tends closer to the skin in the lower quadrants and the subcutaneous tissue is thicker in theupper, outer quadrant of the breast. In a thinpatient, skin flap thickness may be only 2 to 3mm. and transmit light. In the obese patient,the flaps may be 5 to 10 mm. in thickness.

� Electrical cautery on low blended coagulation current is used for skin flap elevation. The ma-jority of the blood vessels lie deep to the fascia but perforating vessels to the skin are encoun-tered and controlled with coagulation cur-rent. Skin retraction is performed with doublepronged skin hooks. Because the skin openingis small, the flaps are elevated centripetal to as-sist in exposure (Fig. 3).

� In large, ptotic breasts where a type IV incisionis used, a Wise pattern can be drawn and theskin surrounding the NAC de-epithelialized (Fig. 4). A rim of de-epithelialized skin along thevertical limbs improves the vascularity. The de-epithelialized inferior skin flap is elevated downto the inframammary fold. This flap can beused to cover a tissue expander, with the supe-rior flaps approximated down to the IMF (Fig. 5).

4b)

4a)

Fig. 4:(a+b) The patient is a 54 year old female who presented with unilateral breast cancer. She desired smaller breasts and au-tologous reconstruction. (c+d) Postoperative appearance after bilateral type IV SSMs and TRAM flap reconstruction.

4c)

4d)

138

OPS and Mastectomy

�

5e)

5d)

5b)

5a)

5f)

5g)5c)

139


� In NSM, elevation of the NAC is done with the scalpel, leaving a5mm thick flap of areolar tissue. The lactiferous ducts are dissect-ed out of the nipple using scissors and are sent for frozen sectionpathological analysis. A 2-3 mm rim of nipple tissue is preservedto prevent ischemic complications. Preservation of the entire skin envelope and inframammary fold makes expander / implant re-construction a good option after NSM (Fig. 6).

� Superiorly, the breast falls away from the skin as the clavicle is approached. The fascia is followed down to the pectoralis major muscle. Medially, the fascia is not as defined and the dissection ends at the border of the sternum. Perforating vessels of the in-ternal mammary artery are frequently encountered along the sternal border. Attempts are made to preserve these perforators to improve the blood supply of the skin flap. These vessels canalso be used as recipient vessels in free flap breast reconstruc-tion. Inferiorly, the dissection follows the superficial layer of thefascia to its junction with the deep layer. The skin is adherent tothe anterior abdominal wall at this juncture. This is appreciated by observing the previous skin marking of the fold. This fascialjunction occurs at the inferior edge of the pectoralis major mus-cle. Laterally, the dissection continues over the pectoralis muscletoward the humerus enabling removal of the axillary tail.

� A lighted retractor and an extended electrocautery tip are use-ful in cases with difficult exposure as seen with a NSM via an in-framammary fold incision.

� The breast is removed by elevating the fascia of the pectoralismajor muscle with the specimen. This is best accomplished by dissecting parallel to the muscle fibers.

� A purse-string suture can be used in type I in conjunction with TRAM flap reconstruction to reduce the size of the areola and pro-vide a mastopexy (Fig. 7).

Fig. 5:(a) The patient is a 64 year with unilateral breast cancer and mild breast ptosis. (b) Intraoperative photograph showing Wise pattern incisions and de-epithelializationof the skin. The area outlined in yellow will be resected as part of the type IV SSM. This excision leaves a rim of dermis along the vertical limbs of the skin excision. (c) Theinferior skin flap is eleveated down to the inframammary fold. (d) The mastectomyspecimen with a suture marking the axillary tail. (e) The de-epithelialized inferior skinflap is draped over a tissue expander and sutured to the released inferior border of the pectoralis major muscle. (f) Appearance just prior to closure of the Wise patternincisions. (g) Postoperative appearance after implant exchange.

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6. Tips and tricks

A NSM or SSM is technically more demanding and time consumingthan a traditional total mastectomy. Careful handling of the skin flaps is required to prevent ischemic complications. Deep retractorsare used judiciously to prevent damage to the base of the skin flapsand low electric cautery is used for flap elevation.

� The procedure should be used cautiously in patients with a his-tory of chest irradiation or tobacco smoking because of the in-creased risk of skin or nipple ischemia.

� Skin flap viability is assessed clinically and ischemia skin / NACare resected, especially in cases of immediate implant reconstruc-tion where native skin necrosis could result in implant exposure.If there is a question of skin perfusion, fluoroscein can be em-ployed (Losken et al., 2008).

� Patient selection is critical in NSM, both from the oncological and reconstructive standpoint. Despite frozen section analysis, can-cer can be detected on permanent pathological sectioning. This would require removal of the NAC at a second operation. Malpo-sition of the NAC can occur, especially after expander / implant reconstruction.

Carlson, GW, Bostwick, J, 3rd, Styblo, TM,et al., Skin-sparing mastectomy. Oncologicand reconstructive considerations. AnnSurg, 1997. 225(5): p. 570-5; discussion 575-8.

Chung, AP and Sacchini, V, Nipple-sparingmastectomy: Where are we now? Surg On-col, 2008. 17: p. 261-266.

Carlson, GW, Tailored Surgery for EarlyBreast Cancer: Surgical Techniques. Breast

Cancer Management and Molecular Medi-cine: Towards Tailored Approaches, ed. M. Piccart, et al. 2007: Springer Publishers.

Losken, A, Styblo, TM, Schaefer, TG, et al.,The use of fluorescein dye as a predictorof mastectomy skin flap viability follow-ing autologous tissue reconstruction. AnnPlast Surg, 2008. 61(1): p. 24-9.

References

141

1. Concept

Several techniques are available today for immediate breast recon-struction and the choice depends on patient desire, the local condi-tion of the thoracic tissues and, of course, surgeon experience and skills (Petit, Rietjens et al. 2001). If a definitive implant is used or a flap performed, it generally requires only one surgical procedure un-der general anesthesia, while using a tissue expander requires twosurgical procedures.At our Institute, breast implant reconstruction has in the past dec-ades become more and more popular as compared to flap recon-struction. Certainly, the evolution of breast silicone implants (Hang-Fu, Snyderman 1991; Al Ghazal, Blamey 2000; Collis, Coleman et al.2000) with a large variety of anatomical, cohesive gels and the evolu-tion of surgery toward more conservative techniques (Petit, Veronesiet al. 2005; Petit, Gentilini et al. 2008) have influenced this trend. Anadequate selection of patients is mandatory in order to achieve low complication rates and satisfactory results (Clough, O’Donoghue et al. 2001). Reconstruction with definitive implants is only indicated in cases of good vascular supply of the mastectomy flaps and adequate availability of soft tissues at the site of mastectomy.

Implant Reconstruction

Immediate Breast ReconstructionWith Implants

Francesca De Lorenzi, Mario Rietjens, Andrea Manconi

2.2.22.2.2.1

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2. Indications

� Nipple-sparing and skin-sparing mastectomies. The availability of well vascularized local tissues is necessary for immediate recon-struction with definitive implants.

� Small to medium-sized breasts with a low grade of ptosis. In turn,no implant can replace large and ptotic breasts, and a discrepancyis present between the skin envelope resulting from mastectomy and the muscular pocket to cover the prosthesis.


� Mastectomies involving removal of a huge skin paddle and/or partial or total removal of the pectoralis major muscle. In suchcases, the muscular and/or cutaneous coverage of the implant isinsufficient.

� Large and ptotic breasts. � Patients with small breasts desiring breast volume improvement.

These women are candidates for immediate reconstruction with an expander and subsequent definite implant position and con-tralateral augmentation.

� Irradiated tissues. In these patients, local tissues are fibrotic and commonly not well vascularized. A higher percentage of mastec-tomy flap necrosis and delayed healing is observed. Moreover,capsular contracture rates are higher if compared to non-irradi-ated tissues (Contant, Van Geel et al. 2000), therefore impairingthe esthetic outcome.

� Contraindication for immediate reconstruction. Candidates for mastectomy and following conventional irradiation (i.e. locally advanced tumor, massive axillary involvement) are more suit-able for delayed autologous reconstruction (Gilliland, Larson et al.1993; Hussien, Salah et al. 2004).


� Patients are examined in the upright standing position. The skinincision depends on tumor location and size, as well as the neces-sity of skin removal within the mastectomy specimen. Sentinel lymph node biopsy and complete axillary dissection are generally performed from the same incision (Toth, Lappert 1991).

143


� The midline (from the sternal notch to the um-bilicus) and inframammary folds are marked bilaterally. This helps during surgery to choose the right position of the implant.

� The width, height and projection of the con-tralateral healthy breast are measured. A pinchtest (Tebbetts 2001; Tebbetts 2002) is neces-sary to evaluate the soft tissue thickness atthe mastectomy site. All these measurements guide the choice for the implant preoperative-ly, reducing the number of sizers used duringsurgery and therefore the duration of surgery (Spear, Splitter 2001).

� A large variety of anatomical implants is avail-able to replace the mammary gland after mas-tectomy. Round-shaped prostheses are used ina minority of patients, since the drop shape ismore popular. There is a strict correspondencebetween breasts with a large basis and im-plants with a large width or ptotic breasts and strongly low-height prostheses. For each natu-ral breast, the more similar implant should beused.

� Of course, any contralateral procedure that maymodify breast width, height and projection (i.e. simultaneous contralateral augmentation or reduction, mastopexy) should be considered to choose the adequate implant.

Fig. 1:Ideal case

Fig. 2:Different implants according to width, height and projection. In the first case (left), an anatomical full-height prosthesis matches with the contralateral healthy breast. In the second case (right), a low-height and large-base prosthesis matches with the natural one.

2a)

2b)

1)

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5. Surgery

The patient is operated in the supine position with both arms elevated to 90° to allow axillary exami-nation.If soft tissues of the inferior external breast quad-rant show satisfactory thickness and post-mastec-tomy blood supply, and the skin incision lies over the pectoralis major, a partial muscular pocket is generally preferred undermining the pectoralismajor. Full projection in the inferior pole of the re-constructed breast is achieved with this technique. On the other hand, in cases of thin mastectomyflaps or skin incisions located in the inferior andlateral quadrants of the breast, a complete muscu-lar pocket is necessary, undermining the pectoralismajor and the serratus anterior muscles.

A suction drain is placed for 2 to 3 days. The wound in closed using inverted 3-0 absorbable sutures and intradermal 4-0 sutures.

4)

5)

3)

Fig. 3:The vascular supply of the mastectomy flaps is evaluated firstand informs the technique of reconstruction. In the presence of non-vascularized soft tissues, we recommend their removal and reconstruction with an expander if they are not sufficientfor coverage of the chosen implant.

Fig. 4:The lateral border of the pectoralis major muscle is elevatedand the muscle is harvested from the costal plane.

Fig. 5:We usually use a light retractor and electrocautery to facilitate the dissection of the muscle from the costal plane and to re-duce bleeding.

145


7)

8)

6)

Fig. 6:Medial and inferior insertions of the pectoralis major muscle are detached until fat tissue is visible.Inferiorly, the dissection reaches about 1 cm above the in-framammary fold. At this level, the muscle is not yet present and the integrity of the superficial fascia is mandatory to ob-tain a complete pocket.

Fig. 7:Evaluation of the muscular pocket and symmetry with the contralateral healthy breast.

Fig. 8:A sizer is used to confirm the implant chosen on the basis of the preoperative measurements. The skin is temporarily closedwith staples. Owing to a flexible adjustable operating table, the patient is moved to a sitting position to better evaluate symmetry with the contralateral breast.

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Simple dressings are used and are removed the day after surgery. Prophylactic antibiotics are deliveredaccording to short-term protocol (Cephazolin- firstgeneration cephalosporin) and antithrombotic prophylaxis for 7 days.

7. Tips and tricks

� Close collaboration between the breast sur-geon and the plastic surgeon is necessary toevaluate the candidates for immediate recon-struction with implants. The skin incision andthe amount of skin removed at the time of mastectomy have an impact on the possibility of definitive implant use.

� Blood supply of the flaps after mastectomymust be carefully evaluated and any suspicious,poorly vascularized area needs to be removed. Delayed healing and/or implant exposure may take place should the skin envelope be closed with tension over the definite prosthesis.

� Although the choice of the implant is visu-ally determined with the patient in the sit-ting position, preoperative measurements and the weight of the mastectomy specimen mayguide the decision.

� If skin necrosis occurs at the mastectomy site within the first days postoperatively, we rec-ommend wound revision to avoid implant in-fection and exposure. According to the extentof necrosis, the definite implant can be main-tained in place or replaced with an expander.

10)

9)

Fig. 9:Preoperative view. Augmented breasts (subglandular im-plants) with moderate capsular contracture. The tumoris located in the external quadrants of the right breast.Right-sided nipple-sparing mastectomy is planned withimplant change on the opposite breast.

Fig. 10:Postoperative view at 6 months` follow-up.

147


ReferencesAl Ghazal, S.K., R.W. Blamey. (2000).“Subcutaneous mastectomy with im-plant reconstruction: cosmetic outcomeand patient satisfaction”. Eur J Surg On-col 26: 137-41.

Clough, K.B., J.M. O’Donoghue, et al. (2001). “Prospective evaluation of late cosmeticresults following breast reconstruction:I. Implant reconstruction”. Plast ReconstrSurg 107(7): 1702-9.

Collis, N., D. Coleman, et al. (2000). “Ten-year review of a prospective randomizedcontrolled trial of textured versus smooth sub glandular silicone gel breast implants”. Plast Reconstr Surg 106(4): 786-91.

Contant, C.M., A.N. Van Geel, et al. (2000). “Morbidity of immediate breast recon-struction (IBR) after mastectomy by a sub-pectorally placed silicone prosthesis: theadverse effect of radiotherapy”. Eur J SurgOncol 26(4): 344-50.

Gilliland, M.D., D.L. Larson, et al. (1983). “Appropriate timing for breast reconstruc-tion”. Plast Reconstr Surg 72(3): 335-9.

Hang-Fu, L., R.K. Snyderman. (1991). “State-of-the-art breast reconstruction”. Cancer68(5): 1148-56.

Hussien, M., B. Salah, et al. (2004). “The ef-fffect of radiotherapy on the use of immedi-ate breast reconstruction”. Eur J Surg Oncol30: 490-4.

Petit, J.Y., M. Rietjens, et al. (2001). “Breast reconstructive techniques in cancer pa-tients: which ones, when to apply, whichimmediate and long term risks?” Crit Rew Oncol Hematology 38: 231-9.

Petit, J.Y., U. Veronesi, et al. (2005). “Whenmastectomy becomes inevitable: the nip-ple-sparing approach”. Breast 14(6): 527-31.

Petit, J.Y., O. Gentilini, et al. (2008). “Onco-logical results of immediate breast recon-

struction: long term follow-up of a largeseries at a single institution”. Breast CancerRes Treat 112(3): 545-9.

Spear, S.L., C.J. Splitter. (2001). “Breast re-construction with implants and expand-ers”. Plast Reconstr Surg 107(1): 177-87.

Tebbetts, J.B. (2002). “A system for breastimplant selection based on patient tis-sue characteristics and implant-soft tis-sue dynamics”. Plast Reconstr Surg 109(4):1396-1409.

Tebbetts, J.B. (2001). “Dual plane breastaugmentation: optimizing implant-softtissue relationships in a wide range of breast types”. Plast Reconstr Surg 107(5):1255-72.

Toth, B.A., P. Lappert. (1991). “Modified skinincisions for mastectomy: the need forplastic surgical input in preoperative plan-ning”. Plast Reconstr Surg 87(6): 1048-53.

149

1. Concept

Tissue expanders are regarded as a simple method for immediate breast reconstruction following mastectomy (Maxwell, Falcone 1992;Cordeiro, McCarthy 2006). However, in order to achieve a satisfying cosmetic result and avoid complications associated with the proce-dure, several technical aspects and a careful selection of patients is required (Woods, Managan 1992; Friedrich, Kolberg et al. 2005; Spear,Newman et al. 2008).

After performing mastectomy, a tissue expander is inserted under a muscular pocket and then inflated to expand the dermomuscularlayer. Once the expansion is completed, the device is changed to apermanent implant.

Currently, textured-surface anatomical breast-shaped expanders are in use, or alternately permanent expander implants (adjustable saline-filled inner volume, silicone gel outer volume) which avoid the need of an exchange of the expander to a permanent implant (Spear,Majidian 1998; Jones 2005; Becker 2006). The objectives of recon-struction with expanders are to restore the breast shape and volume to optimally resemble the contralateral breast and to reconstruct theinframammary fold with adequate ptosis.

Immediate Reconstruction AfterMastectomy: ReconstructionWith Tissue Expanders

Michael Friedrich, Darius Salehin, Stefan Krämer

2.2.2.2

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2. Indications

Immediate reconstruction with expanders is recommended in patients

� with small or moderate-sized breast withminimal or no ptosis.

� who want minimal scarring and no additional donor-site morbidity.

� with no prior radiation/no postoperative radiation planned.

� are not worried about a silicone implant. � are unwilling or unfit to undergo

autologous tissue reconstruction. � undergoing bilateral reconstruction

(and who meet the criteria mentioned above).

Contralateral mastopexy / reduction is required in most patients for symmetry.


� Poor quality of the soft tissue coverage(skin and muscle) does not allow expansion.

� Large / ptotic breasts. � Prior radiation or radiation planned after surgery. � Obese patients/patients with large

chest wall diameters. � Low patient compliance for the expansion process. � Patients with unrealistic cosmetic expectations. � Young patients (relative contraindication

for more re-operations may be required during life-span).

4. Preoperative drawing

The type mastectomy and the amount of skin tobe excised should be determined prior to surgery.Skin-sparing techniques are preferred, for they leave a skin envelope which assists in reconstruc-tion. Skin very close to or infiltrated by the tumoris excised, narrow skin bridges should be avoidedto ensure adequate blood supply of the skin flaps.

1)

2a)

2b)

151


The central midline, the vertical breast axis andboth inframammary folds are outlined with an additional line on the mastectomy side 1cm lower than the existing fold. The shape and contour of the new breast is outlined in accordance with the contralateral breast (Fig. 1). Base width and height of the contralateral breast are measured and trans-ferred to the tumor side (the markings may also be drawn using manufacturer’s templates).

5. Surgery

After completion of (skin-sparing) mastectomy, the viability of the skin flaps and the integrity of the pectoralis major muscle are assessed (Fig. 2a). Nonviable skin is excised and lesions in the muscle are fixed before inserting expander.

5.1 Insertion of the expander

The lateral border of the pectoralis major muscleis incised (Fig. 2b) and a submuscular pocket is cre-ated with the pectoralis major muscle released medially from the third intercostal space down and inferiorly (Fig. 2c). The inferior part of the dis-section is either subcutaneous or includes the anterior rectus sheath which is then elevated incontinuity with the pectoralis major muscle. Whenplanning total muscular coverage, the serratus anterior muscle is elevated from the chest wall toprovide lateral coverage (Fig. 2d, e).

Fig. 1:Preoperative drawing.

Fig. 2:(a) Following mastectomy, the viability of the skin flaps and the integrity of the pectoralis major muscle are evaluated. (b) The pectoralis major muscle is incised laterally. (c) A sub-pectoral pocket is prepared. The muscle is dissected medi-ally and in the inframammary fold. (d) The serratus muscle is dissected from the thoracic wall. (e) The serratus muscle is mobilized such that it can be sutured to the pectoralismajor muscle to create a total submuscular pocket.

2c)

2d)

2e)

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OPS and Mastectomy

The size and type of expander used depend on thewidth and height of the contralateral breast, and the volume may be estimated by the weight of themastectomy specimen. The size of the expander issmaller when planning contralateral breast reduc-tion and larger in case of a large or ptotic breast. The expander is completely evacuated of air usinga butterfly needle (Fig. 2f). It is then partially inflat-ed with sterile saline (may contain methylene blueto assure puncturing the expansion chamber dur-ing the expansion process) to warrant that there is no leakage. About 50cc of saline are left within the expander and this assists in implant insertion. Theprosthesis is brought into the submuscular pocket and oriented by help of markers on the implant surface (Fig. 2g).

Drains are placed in the submuscular pocket andsubcutaneously. The submuscular pocket is closed, suturing the serratus and pectoralis muscle with in-terrupted Vicryl 3-0 sutures which are pre-insertedbefore placement of the prosthesis to minimize riskof perforation of the implant by the needle (Fig. 2h).

Interrupted sutures Vicryl 4-0 can be used in orderto adapt the subcutaneous tissues and monocryl 4-0 for non-interrupted intracutaneous sutures. A bandage may be used for 3 weeks to keep the ex-pander in place. 2g)

2h)

2f)

Fig. 2:(f) The expander is completely evacuated of air using a but-terfly needle. (g) The expander is in the submuscular position.(h) The submuscular pocket is closed.

153


5.2 Expander inflation

The expander may be inflated immediately with saline (100 to 300cc) depending on the quality of the soft tissue coverage. Expansion begins 2 to 3weeks following surgery but depends on the skin flap viability and wound healing. The expander is gradually expanded using magnetic port locators with 50 to 100cc of saline every 2 to 3 weeks un-til the desired volume is reached (Fig. 3a, b, c). The expander is usually slightly overexpanded to gain more tissue for creating a more natural ptosis.

3b)

3c)

3a)

Fig. 3:(a) With the help of a magnetic port locator, the integratedvalve is located for safe filling of the expander. (b) The expand-er is filled with saline. (c) The expander at the end of the expan-sion period (slightly overexpanded).

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OPS and Mastectomy

5.3 Expander-to-implant exchange

Expansion is maintained over 2 to 6 months. If apermanent expander implant has been used, thevolume is adjusted according to the contralateral breast by aspirating saline. The fill tube is removed later under local anesthesia.

Using a temporary expander, the patient is placed in the sitting position and saline is aspirated fromthe expander until symmetry with the contralat-eral breast is reached (Fig. 4a). The expander is re-moved through the previous incision (Fig. 4b) and a capsulotomy (either circumferential or only in the inferior pole, with or without radial incisions) is done to release tension and enlarge the pocket(Fig. 4c). The volume of the permanent implant is chosen according to the expander volume af-ffter symmetry has been reached or may be testedwith sizers. Whether to choose an anatomic or a round-shaped implant depends on the shape and the upper pole fullness of the contralateral breast (Fig. 4d).

A drain is placed into the pocket and the incisions are closed. Final symmetry is evaluated in the sit-ting position (Fig. 4e). A bandage may be used for 3 weeks to avoid cranial displacement of theimplant. The reconstruction of the nipple-areola complex is performed 3 to 6 months later.

4b)

4c)

4a)

4d)

Fig. 4:(a) The patient is in the sitting position and saline is aspirat-ed from the expander until symmetry with the contralateralbreast is reached. (b) The expander is removed through theprevious incision. (c) A capsulotomy is done to release tensionand enlarge the pocket. (d) An anatomically shaped implanthas been selected as permanent implant and it is rinsed inbetadine solution.

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4e)

4f)

(e) Final result following insertion of the permanent implant.(f) Late postoperative view. Reconstruction of the nipple-areolacomplex is done 3 – 6 months after exchange of the implant.

Fig. 5:Skin flap necrosis during expansion. Following secondarywound healing, the patient opted for a reconstruction with alatissimus dorsi flap.

6. Tips and tricks

� Early complications associated with tissue expan-sion include skin necrosis with wound dehiscence and implant extrusion (Fig. 5). If the viability of the skin flaps is in doubt, the expansion proc-ess should be delayed and any nonviable tissue should be excised early to allow secondary woundhealing. The expansion is started no earlier than when wound healing is completed and viability of mastectomy flaps is secured.

� Complete muscular coverage of the expander re-duces the risk for expander extrusion in case of wound infection or wound dehiscence.

� In the presence of a ptotic contralateral breast,overexpansion is needed to obtain acceptable ptosis. If necessary, the mobilization of thelower part can be extended downwards to therectus sheath to gain an excess amount of skin which is used to create a submammary fold.When the expansion is finished, the excess amount of skin is fixed to the muscle fascia. An-other possibility is to overexpand and exchangethe expander to a slightly smaller implant.

� Skin-reducing mastectomy or mastectomy by a vertical elliptical incision is done in large or ptotic breasts to reduce the amount of skin.

� Leave the suction drains until drainage is less than 20cc for 2 consecutive days. This avoidsseromas which are related to a higher risk forcapsular fibrosis.

� Most women require contralateral mastopexy /reduction for symmetrization.

� Concomitant chemotherapy may negativelyinfluence the expansions process.

5)

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Becker, H. (2006). “One-stage immediatebreast reconstruction with adjustable im-plants”. In: Spear S.L. (ed) Surgery of thebreast: Principles and art. 1st Edition. Phila-delphia: Lippincot-Raven, 438-450.

Cordeiro, P.G., C.M. McCarthy. (2006).“A single surgeon’s 12 year experience withtissue expander / implant breast recon-struction: Part I. A prospective analysis of early complications”. Plast Reconstr Surg118: 825-31.

Friedrich, M., H.C. Kolberg HC, et al. (2005).“Primäre und sekundäre alloplastische Brustrekonstruktionen“. Gynäkologe 38(3): 209-15.

Jones, G. (2005). “Decision-making: sizingand system selection”. In: Jackson I.T. (ed)Innovations in Plastic Surgery: Tissue ex-pansion in breast surgery Quality Medi-cal Publishing, Inc. St. Louis, pp 27-38.

Maxwell, G.P., P.A. Falcone. (1992).“Eighty-four consecutive breast recon-structions using a textured silicone tis-sue expander”. Plast Reconstr Surg 89:1022-34.

Woods, J.E., M.A. Managan. (1992). “Breastreconstruction with tissue expanders: ob-taining an optimal result”. Ann Plast Surg28: 390-96.

Spear, S.L., A. Majidian. (1998). “Immediate breast reconstruction in two stages usingtextured, integrated-valve tissue expand-ers and breast implants: a retrospective re-view of 171 consecutive breast reconstructions from 1989 to 1996”. Plast Reconstr Surg 101: 53-63.

Spear, S.L., M.K. Newman, et al. (2008). “Aretrospective analysis of outcomes using three common methods for immediatebreast reconstruction”. Plast Reconstr Surg122: 340-7.

References

157

1. Concept

The use of the pedicled latissimus dorsi musculocutaneous islandflap (LDMF) was first introduced for breast reconstruction in 1977(Schneider, Hill et al. 1977) and has proved to be a reliable method of reconstruction.

The LDMF is known as a safe flap used in a pedicled form, reducedoperating time thus being a benefit for the patient. The muscle flapmay be applied immediately or at a later point in time.The skin island should be larger in delayed application. In immediateuse, in case of skin-sparing mastectomy, the skin island can be morestrongly de-epithelialized and immediate nipple reconstruction canbe done.

The following section is an accurate description of surgery with skin-sparing mastectomy and immediately subsequent reconstruction with an autologous latissimus dorsi musculocutaneous flap.

Autologous Reconstruction

Breast ReconstructionWith the Latissimus DorsiMuscle Flap

Daniela Hoch, Heike Benditte-Klepetko,Rolf Bartsch, Nina Gösseringer, Maria Deutinger

2.2.32.2.3.1

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OPS and Mastectomy

2. Indications

� This flap may be used after skin-sparing mastectomy or modified radical mastectomy. The flap may also be used for partial mas-tectomy defects the details of which we will not describe in this chapter.

� In the presence of risk factors and comorbidities such as nicotine abuse, diabetes mellitus and obesity, which are conditions inade-quate for microvascular reconstruction, the use of pedicled LDMFis a good choice.

� Radiation therapy or chemotherapy is no contraindication for autologous tissue transfer (Soong, Yau et al. 2004). The literaturedemonstrates that postmastectomy radiation therapy following autologous tissue-flap reconstruction is well tolerated and notassociated with increased incidence of complications (Carlson, Styblo et al. 2003). The local failure-free rate and disease-specific survival rate is up to 90% in patients treated. No adverse effect oncosmesis has been observed by adding bolus radiation on alter-nate days postoperatively (Jhaveri, Rush et al. 2008).

� Radiation therapy is indicated in high-risk mastectomized pa-tients (G3, lymph node-positive >3, very young age, genetic mu-tation, HER2neu-positive), we thus rather use autologous tissue instead of implants in these patients (Spiegel, Butler et al. 2003).


� Limiting factors include the patient’s disaffirmation of an addi-tional scar with the possibility of donor site morbidity and outline deformity on the back.

� Locally advanced and irresectable or systemic advanced diseaserepresents a clear contraindication.

� Large breasts do not represent a contraindication for a recon-struction with pedicled LDMF, as it is nowadays possible to de-sign the LDMF with a sufficient amount of subcutaneous fat tis-sue to achieve a good cosmetic result. Moreover, hypertrophy and ptotic breasts on the healthy side may be concomitantly reducedby mammaplasty or mastopexy to achieve a satisfying cosmeticresult.

159



The patient should be in an upright/standing posi-tion for preoperative markings.

4.1 Frontal position

Marking of the full enlargement of the breast onall sides. Marking the submammary fold, the mid-line and the incision in terms of an esthetic ap-proach – reduction mammaplasty. Around the are-ola, if necessary, in combination with a vertical cut toward the submammary fold (see section 2.1.1.3) (Fig. 1).

A single periareolar incision is sufficient in cases of less voluminous breasts. The periareolar scar maybe extended to a vertical scar (Fig. 2).

Skin reduction may be necessary in ptotic breasts in order to achieve this result, the drawing shouldbe placed as in reduction mammaplasty.

4.2 Dorsal markings

The arm is abducted in a 90° position and the el-bow joint is flexed to 90° to point out the ante-rior line of the LDMF. The skin island should have a maximum width of 7cm horizontally and a maxi-mum length of 30cm. The most distal part of theisland flap should fill the defect at the medial partof the ipsilateral breast after lifting the flap (Fig. 3).

A vertical line should be positioned from the frontwall of the LDMF and another line at a 30° angle isthe best position to design the skin island flap.

1)

2)

3)

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OPS and Mastectomy

5. Surgery

5.1 Patient in the lateral-side position

At the beginning of surgery, the patient is placedin the lateral position with the side to be operateduppermost. The ipsilateral shoulder is then fixatedon a rigid frame at a 90° angle.

Two teams of surgeons approach in parallel andperform the dissection. One team starts with theremoval of breast tissue working from the frontal approach and accomplishing mastectomy (onco-logic surgeon). The second team begins with the dissection and the elevation of the LDMF from adorsal approach (reconstructive surgeon).

Preparation of the LDMF starts with skin incisionand dissection between the skin and the subcu-taneous fatty tissue (Fig. 4a). It is important toleave as much fatty tissue on the muscle flap as possible (Fig. 4b) to obtain adequate volume. However, care is to been taken not to render the skin ischemic.

The next step is to dissect the muscle’s attach-ments at the iliac crest and from the posteriorlayer of the thoracolumbar fascia, by which it isattached to the spine. The dissection is done withclamps and a ligation (we believe that this pre-vents seroma formation). The flap elevation from the basal attachment starts from the distal part and continues proximally towards the vessel pe-duncle (Fig. 5).

This step illustrates the preparation of the thora-codorsal vessles (�) and their branches to the ser-ratus anterior muscle illustrated in Fig. 6a (�). Care is to be taken especially in delayed reconstructionbecause of the possibility of scar formation after axillary dissection (Fig. 5).

4b)

5)

4a)

6a)

161


After clearly identifying the thoracodorsal bundle (Fig. 6b), the serratus arcade is dissected to achievea maximum of mobilization (Fig. 6c). Thereafter, the muscle is dissected from its inserting part onthe humerus at the level just below the teres mi-nor muscle (Fig. 6d). Keep tracking the vessels. The flap is then pedicled only by its vessels.

The thoracodorsal nerve is dissected (Fig. 7). The proximal part is coagulated to prevent the pos-sibility of postoperative muscle contraction inthe reconstructed breast. Pay attention to leaveat least 2 to 3cm of space between the two nerve endings.

After creating a tunnel from the back to the frontthoracic side, the flap is placed through that tun-nel and the donor site is closed with absorbable su-tures (e.g. 4/0 Monocryl). Suction drains are placedsubcutaneously. Adapting sutures are placed, so-called pexin sutures, in order to further decrease the risk of postoperative seroma formation on thedonor site (Fig. 8).

6b)

6c)

6d)

7) 8)

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5.2 Patient in the supine position

During or after flap preparation, another team starts with the surgery of the breast. This teameither performs mastectomy after breast conser-vation or excises the scar and builds a pocket forthe flap after mastectomy in a delayed approach.In immediate reconstruction, the team performs subcutaneous mastectomy. Depending on the cancer size and its localization within the breast,the procedure may be planned as a skin-sparingor an areola/nipple-sparing technique (cf. chapter2.2.1.1) (Fig. 9).

The flap is rotated into the defect after preparing asubcutaneous pocket (Fig. 10).

The skin is resected leaving a small piece (skin-sparing mastectomy) for nipple reconstruction, which is done using local skin flaps (cf. chapter2.3.2) (Fig. 11).

The flap is positioned and the neo-areola is sutured to the breast skin for wound closure (Fig. 12, 13).

11)

9)

12)

10)

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Pre- and postoperative pictures of a patient with a bifocal laterocranially located lobular adeno-carcinoma of the right breast, G3. After right-sideskin-sparing mastectomy and latissimus dorsi reconstruction, the left breast was given contral-ateral reduction mastopexy. The nipple was recon-structed with a skin island from the flap (Fig. 14, 15).

Pre- and postoperative pictures of a patient with a retromamillary ductal adenocarcinoma of the left breast with extensive intraductal carcinoma for-mations. Following skin-sparing mastectomy onthe left side, the defect was filled with a latissimusdorsi flap. The nipple was reconstructed with a skin island from the flap (Fig. 16, 17).

Picture of the flap elevation scar 1 year after sur-gery (Fig. 18).

13)

14)

15) 17)

18)16)

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6. Tips and tricks

� Preoperative drawing should be done with the patient in the standing position.

� In terms of cosmetic outcome, it is best to take a skin island from a less ventral position, as fat tissue may otherwise be insufficient forthe décolleté.

� A vertical line should be positioned from the front wall of the LDMF, and another line at 30° is the best position to design the skin island flap (Fig. 3).

� In skin-sparing mastectomy, the skin graft from the flap shouldbe designed smaller which also results in a smaller scar on the donor site.

� If the breast is ptotic and a reduction effect is desired, the drawing should be placed as in reduction mammaplasty and positioned tothe cranial part.

� On the caudal side, it is best to preserve enough fat for sufficient vol-ume, and cranially less fat to reduce tissue overexpression in the axil-lary region.

� Do not forget to dissect the thoracodorsal nerve; if necessary, re-lease retaining fascial parts and ligate the serratus arcade below.

� Pexy sutures placed on the lateral side prevent the flap from fall-ing laterally.

� Physical and/or occupational therapists train patients to reduce tension at the donor site in the presence of scar adhesions.

ReferencesCarlson, G.W., T.M. Styblo, et al. (2003).“The use of skin sparing mastectomy inthe treatment of breast cancer: the Emoryexperience”. Surg Oncol 12(4): 265-9.

Jhaveri, J.D., S.C. Rush, et al. (2008). “Clini-cal outcomes of post mastectomy radiation therapy after immediate breast reconstruc-tion”. Int J Radiat Oncol Biol Phys 72(3): 859-65.

Schneider, W.J., H.J. Hill, et al. (1977). “Latis-simus dorsi myocutaneous flap for breast reconstruction”. Br J Plast Surg 30: 277-81.

Soong, I.S., T.K. Yau, et al. (2004). “Post-mastectomy radiotherapy after immedi-ate autologous breast reconstruction in primary treatment of breast cancer. ClinOncol (R Coll Radiol) 16(4): 238-9.

Spiegel, A.J., C.E. Butler. (2003). “Recurrencefollowing treatment of ductal carcinomain situ with skin-sparing mastectomy andimmediate breast reconstruction”. PlastReconstr Surg 111(2): 706-11.

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1. Concept

Autologous breast reconstruction with free flaps is preferable overpedicled transverse rectus abdominis myocutaneous (TRAM) flap (Garvey, Buchel et al. 2006; Chevray 2004). While the bipedicled TRAMflap is rarely used on account of increased donor site morbidity, the unipedicled TRAM flap (Hartrampf, Bennett 1994) is still performedby many surgeons (Clough, O’Donoghue et al. 2001; Jones 2007). This is ascribable to the reliability of the flap, the shorter duration of sur-gery, and the fact that a fully trained microsurgical team is not avail-able at all institutions.

The abdominis rectus muscle is elevated with tissue from the lower abdomen usually discarded in cosmetic abdominoplasty. The flap isnourished on lateral and medial perforators from the superior epi-gastric vessels (Hartrampf, Michelow 1991). The most striking disad-vantage of the pedicled TRAM flap may be morbidity to the donorsite (Petit, Rietjens et al. 1997; Edsander-Nord, Jurell et al. 1998; Asch-erman, Seruya et al. 2008).

Immediate Breast Reconstruction:The Pedicled TRAM Flap

Peter Schrenk, Georg M. Huemer

2.2.3.2

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2. Indications

� Patients seeking immediate reconstruction af-ffter mastectomy and with

� moderate-sized or large breasts � adequate tissue available in the lower abdomen. � Patients with large tissue defects after breast-

conserving surgery, and mastectomy and flap planned for defect reconstruction.

� Failure of autologous (e.g. latissimus dorsi mus-cle flap) or implant-based breast reconstruction.


� Very obese patients. � Patients with (very) small breasts. � Bilateral breast reconstruction

due to donor site morbidity). � Previous surgery to the abdomen, e.g. abdomino-

plasty, liposuction, open cholecystectomy – in thesepatients, the design of the flap may be modified

� (Heavy) smokers. � Patients unfit or unwilling to undergo

major surgery. � Patients receiving radiation therapy following

surgery (Spear, Ducic et al. 2005).


Drawings are done preoperatively with the pa-tient in the standing position. The incisions for(skin-sparing) mastectomy and the contour of the breast to be reconstructed are outlined on the breast. A central midline is drawn from the sternalnotch through the umbilicus to the suprapubic re-gion. The breast midline and inframammary fold are marked on both breasts.

The flap is designed in the lower abdomen in an elliptic form (Fig. 1). The upper line includes the umbilicus with the periumbilical perforators. Thevertical axis of the flap should accord with the dis-

2a)

1)

2b)

167


tance from the inframammary fold to the upperbreast line of the breast to be reconstructed, butshould allow closure of the donor site without un-due tension. The course of both rectus abdominis muscles is outlined together with the medial and lateral row of perforators (found with the help of an ultrasound Doppler). The tunnel over xiphoidfor transfer of the flap from the abdomen to the mastectomy site is marked on the skin.

5. Surgery

The patient is operated in the supine position, un-der general anesthesia on a flexible adjustable op-erating table, and with both arms extended to 70°. For immediate breast reconstruction, the present authors prefer a two-team approach with one team performing the mastectomy procedure and the other team managing reconstruction.

2c)

2d)

Fig. 1:Preoperative drawings and flap design for a left-sided unilater-al TRAM flap. The elliptical incision should incorporate the per-iumbilical perforators. The flap, the rectus abdominis muscle,the perforators and the costal margins are drawn on the skin.

Fig. 2:Elevation of the TRAM flap. (a) Upper and lower abdominalincisions. The flap is divided into 4 zones representing areasof different vascularization. The zone directly over the muscle(zone I) is regarded as the safest area for reconstruction. (b) Undermining of the abdominal flap cranially to the xiphoid and costal margins using a wedge-like dissection. A tunnel connects the abdomen and mastectomy sites. The course of the rectus abdominis muscle is outlined on the fascia. (c) The flap is dissected off the abdominal fascia from lateral to me-dial to the lateral row of perforators. The planned incision in the rectus fascia is outlined. (d) The anterior rectus sheath is in-cised laterally of the perforators and the fascia is dissected off the muscle. In the area of the tendinous sections, more fascia is left on the muscle to avoid injury of the epigastric vessels. (e)The opposite flap is elevated from the fascia from lateral to 5 to10mm over the midline. Circumcision of the umbilicus. (f) The abdominis rectus muscle is separated from the fascia medially. 2f)

2e)

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5.1 Elevation of the flap

The designed flap is incised (Fig. 2a) and the dis-section is carried straight down to the rectus ab-dominis muscle fascia caudally but is bevelled cra-nially to gain more tissue for reconstruction. The upper abdominal flap is elevated off the musclefascia as far as to the costal margins and the epi-gastrium. A tunnel is dissected over the xiphoid, which connects the abdominal incision and the mastectomy site (Fig. 2b).

The contralateral (or ipsilateral) rectus muscle flapis dissected from lateral to the midline until the lat-eral row of the perforators is reached (Fig. 2c). The rectus fascia is incised laterally of the perforatorsusing electrocautery or a scalpel. The lateral border of the rectus muscle is identified and the incision is continued caudally and cranially, dissecting theanterior rectus fascia from the rectus abdominis muscle. Preserving as much fascia as possible facil-itates closure of the donor site (Fig. 2d). In the area of the tendinous intersections, the anterior sheath of the fascia is adherent to the muscle and a stripof fascia is left on the muscle. We prefer to dissectthe muscle completely. Leaving parts of the muscle does not contribute to abdominal consistency butbears the risk of injury to the epigastric vessels. The dissection is continued on the opposite side and the flap is elevated over the midline (Fig. 2e). Care should be taken not to injure the medial row of perforators found 5-10mm over the midline. The umbilicus is elevated with 2 hooks, circumcised and dissected from the flap (Fig. 2e).

The rectus muscle is separated from the fascia me-dially (Fig. 2f, g). The inferior epigastric vessels are prepared (Fig. 2h) and divided. They are left as long as possible, as they may be used for microanasto-moses to “supercharge“ the flap (microanastomo-ses between the epigastric inferior vessels and thethoracodorsal vessels to increase blood supply to the flap).

2g)

2h)

2i)

2j)

169


The rectus muscle is divided in the suprapubic re-gion (Fig. 2i) and sutured to the fascia using 3-0vicryl (Fig. 2j) in order to prevent tension-induced damage of the perforators when the flap is trans-ferred to the mastectomy site. The flap is elevatedoff the dorsal rectus sheath (Fig. 2k) and the in-tercostal vessels are divided (ensuring atrophy of the rectus muscle in the tunnel). Once the supe-rior epigastric vessels have been identified medi-ally to the xiphoid at the costal margin (Fig. 2l), the muscle attachments above the costal margin areincised to allow tension-free rotation of the flapthrough the tunnel and into the mastectomy site.The tunnel should be wide enough to allow pas-sage of the flap without confinement. The flap istransferred from the abdomen to the mastectomy site through the tunnel using a 90 to 180° rotation(Fig. 2m, n).

2m)

2k)

2n)

2l)

Fig. 2:(g) The muscle is dissected off the fascia and the flap is at-tached to the muscle only by the perforator vessels. (h) Prepa-ration of the deep inferior epigastric vessels. (i) The rectus abdominis muscle is divided inferiorly with electrocautery. ( j)Fixation of the muscle to the fascia. (k) The flap is elevated from the dorsal rectus sheath dividing the intercostal vessels. (l) Superior epigastric vessels. (m) Transfer of the flap from the abdomen to the mastectomy site through the tunnel over the sternum. (n) Following transfer of the flap and (in this patient) 180° counter-clockwise rotation.

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5.2 Closure of the abdominal incision

The patient is brought into the sitting position with flexed knees. The anterior rectus fascia is closed using several interrupted non-absorbable running sutures (0 Prolene) (Fig. 3a, b).

No plication of the contralateral fascia is done. Ad-ditionally, we use a non-absorbable on-lay mesh to reinforce the abdominal wall and fix it with ab-sorbable 3-0 sutures (Fig. 3c).

The pedicle is checked in the tunnel for kinking orbleeding (Fig. 3d).

The umbilicus is elevated through an incision at the new umbilicus site and sutured to its new po-sition. Two drains are inserted and the donor siteis closed using an absorbable 3-0 running suture (V-LOCTM 180, Covidien Company). Either staples, tapes or a glue are used for skin closure (Fig. 3e).

3b)

3c)

3a)

3d)

Fig. 3:(a) The abdominal defect after transfer of the pedicle. (b) Thefascia is reconstructed with multiple non-absorbable runningsutures. (c) We use an onlay mesh in most patients. Drains areplaced. (d) Before closure of the abdominal wall, the pedicle ischecked for kinking or bleeding. (e) Closure of the donor site,reconstruction of the nipple.

171


3e)

4a)

5.3 Insetting and trimming of the flap

With the patient in the sitting position, the flap is stapled to the mastectomy skin. The viability of the flap is assessed and poorly vascularized tissue is discarded. Following skin-sparing mastectomy, the flap is de-epithelialized with the exception of a skin paddle according to the size of breast skinexcised during mastectomy. The flap is inserted into the skin envelope, trimmed according to therequired volume, and shaped beginning from lat-eral to medial (Fig. 4a).

Two drains are inserted and the flap is sutured to the mastectomy skin using 3-0 absorbable suturesand non-absorbable 4-0 running sutures for the skin (Fig. 4b).

4b)

Fig. 4:(a) The flap is inserted laterally. Zone II reveals a decrease in vas-cularization and is trimmed. (b) Immediate postoperative view.

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The viability of the flap is monitored on a regu-larly basis. The patient is kept in a slightly sitting position with the knees flexed for several days but is allowed to exercise from the day after surgery. Drains are moved when the drainage fluid is lessthan 20cc. No antibiotics are given routinely.

7. Tips and tricks

� The tunnel for flap transfer should be wideenough to allow safe passage of the flap with-out congestion.

� The pedicle in the tunnel should be checkedbefore abdominal closure to avoid kinking or twisting, confinement or bleeding.

� Dissection of the upper abdominal flap shouldnot exceed the inframammary fold. Extending the dissection too far cranially impairs the fold and results in a downward traction of the foldon the thoracic wall.

� Zones I, II and III of the flap may be used forreconstruction. However, in our and other au-thors’ experience, decreased vascularization and fatty tissue necrosis is more often seen inzone II than zone III (Kim, Lee et al. 2007).

� The unipedicled flap provides enough tissue for breast reconstruction. Whenever more tissue is needed, bilateral free flaps should be used in-stead of a bipedicled TRAM.

� In the presence of a large or ptotic breast, skin reduction mastectomy techniques should be used.

� Some authors perform contralateral plication of the anterior rectus sheath to re-position theumbilicus to the midline.

� Bulging in the epigastrium is due to the rectus muscle and diminishes with time once the in-tercostals vessels have been divided.

� The inferior epigastric vessels should be dis-sected as long as possible before dividing them.They may be used for “supercharging” the flap.

5a)

5b)Fig. 5:38-year-old patient with multicentric invasive breast can-cer and high-grade intraductal carcinoma in situ of the leftbreast. She underwent skin-sparing mastectomy with im-mediate unipedicled TRAM flap reconstruction. Preoperative(a) and postoperative (b) view 5 years after surgery.

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ReferencesAscherman, J.A., M. Seruya, et al. (2008). “Abdominal wall morbidity following uni-lateral and bilateral breast reconstructionwith pedicled TRAM flaps: an outcomeanalysis of 117 consecutive patients”. PlastReconstr Surg 121: 1-8.

Chevray, P.M. (2004). “Breast reconstruc-tion with superficial inferior epigastric ar-tery flaps: a prospective comparison withTRAM and DIEP flaps”. Plast Reconstr Surg114: 1077-83.

Edsander-Nord, A., G. Jurell, et al. (1998).“Donor-site morbidity after pedicled orfree TRAM flap surgery: a prospective and objective study”. Plast Reconst Surg102: 1508-16.

Garvey, P.B., E.W. Buchel, et al. (2006). “DIEPand pedicled TRAM flaps: a comparison of outcomes”. Plast Reconstr Surg 117: 1711-9.

Hartrampf, C.R., G.K. Bennett. (1994). “Tech-niques: Single-pedicle TRAM”. In: JurkiewiczM.J., Culbertson J.H. (Eds.): Operative tech-niques in plastic and reconstructive sur-gery: Breast reconstruction. WB SaundersCompany, Vol 1(1):46-51.

Hartrampf, C.R., B.J. Michelow. (1991).“Anatomy of the anterior abdominal wall”.In: Hartrampf C.R. (Ed): Hartrampf`s breastreconstruction with living tissue. RavenPress, New York, pp 3-19.

Jones, G. (2007). “The pedicled TRAM flap inbreast reconstruction”. Clin Plast Surg 34: 83-104.

Kim, E.K., T.J. Lee, et al. (2007). “Comparisonof fat necrosis between zone II and zoneIII in pedicled transverse rectus abdominismusculocutaneous flaps: a prospective study of 400 consecutive cases”. Ann Plast Surg 59: 256-9.

Petit, J.Y., M. Rietjens, et al. (1997). “Ab-dominal sequelae after pedicled TRAM flap breast reconstruction”. Plast Reconstr Surg 99: 723-9.

Spear, S.L., I. Ducic, et al. (2005). “The effectof radiation on pedicled TRAM flap breast reconstruction: outcomes and implications”. Plast Reconstr Surg 115: 84-95.

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1. Concept

Reconstructive breast surgery should be seen as an integral part of the treatment options offered by breast centers to optimize patient’ssubsequent quality of life. One type of breast reconstruction involvesthe use of saline or silicon gel implants. The advantages of this tech-nique are the absence of donor site morbidity and the simplicity of reconstruction, but disadvantages occur in an unnatural feeling of the breast and the possibility of implant exchanges due to capsu-lar contracture. Some patients may perceive the implant under themuscle as a foreign body. The complication rate for developing cap-sular contracture is higher as compared to esthetic augmentation,especially after chest wall irradiation (Behranwala, Dua et al. 2006).

The use of autologous tissue improves the natural look of the re-constructed breast and in most cases provides a long-term naturalperceptual result comparable to that achieved with “dynamic breastreconstruction”. The ideal tissue for breast reconstruction today is fat with or without skin. A good source for autologous breast recon-struction is the soft tissue from the patient’s lower abdomen. This fatty tissue is typically soft and easy to shape. For most patients, anadded bonus of an abdominal donor site is the improved abdominalcontour following flap harvest as in abdominoplasty.

Reconstruction After Mastectomy:DIEP and Muscle-/ Fascia-SparingTRAM Flap

Beatrix Munder, Christoph Andree

2.2.3.3

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Breast reconstruction using autologous tissue from the lower abdo-men was first described by Holmström in terms of a free flap (Holm-ström 1979) and popularized by Hartrampf et al. in 1982 with the pedicle transverse rectus abdominis myocutaneous (TRAM) flap(Hartrampf, Scheflan et al. 1982). The risk of bulges, hernias and weak-ness in abdominal wall in the postoperative period necessitated im-provements in the surgical technique in an attempt to reduce donor site morbidity. To minimize donor site morbidity, the free TRAM flaphas over the years further evolved into the techniques of muscle-sparing TRAM flap and deep inferior epigastric perforator (DIEP) flap (Allen, Treece 1994; Hartrampf, Scheflan et al. 1982; Blondeel, Vander-straeten et al. 1997; Blondeel 1999; Kroll, Schustermann et al. 1995).

Such perforator flaps as the DIEP flap represent the latest evolution of soft-tissue flaps. Using perforator flaps can minimize donor-site mor-bidity and optimize flap durability of transferred tissue (Granzow, Lev-ine et al. 2005; Feller, Galla 1998). The deep inferior perforator flap wasdeveloped by Koshima and Soeda in 1989 (Koshima, Soeda 1989). The first descriptions of autologous breast reconstruction were published in1994 by Allen and Treece (Allen, Treece 1994) and by Blondeel and Boeckx(Blondeel, Boeckx 1994). The tissue of the DIEP is nourished by perforatorvessels and can be managed without sacrificing the rectus muscle orfascia. It hast the same dimensions of tissue as the free TRAM flap andis associated with less postoperative pain and shortened recovery timeas compared to the TRAM flap procedures. Abdominal wall strength in patients who receive a breast reconstruction with a DIEP flap is main-tained (Granzow, Levine et al. 2005; Blondeel, Boeckx 1994; Blondeel 1999; Futter, Webster et al. 2000; Busic, Das-Gupta 2006; Grotting 1991;Feller 1994; Grotting 1994). It should be considered that specific, individ-ual surgical techniques differ greatly in the current literature.

2. Indications

The patient’s general health condition and oncologic situationshould be examined and considered for the planned procedure. Herpsychological situation and motivation for the planned breast recon-struction are evaluated carefully at the consultation.

Candidates for secondary breast reconstruction with the DIEP flap are women having undergone mastectomy, patients with skin-sparing mastectomy are candidates for primary reconstruction. TheDIEP flap can be used for a single or bilateral breast reconstruction if enough tissue is available.

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The present authors make no difference in choos-ing patients for a DIEP flap when they had previouschemotherapy or radiation therapy of the chest wall. Reconstruction with the DIEP flap is also pos-sible for patients with congenital deficiency, suchas Poland Syndrome, or in cases of single hypopla-sia of the breast. It could also be used in a lumpec-tomy defect for autologous breast augmentation (Allen, Heitland 2003).


Absolute contraindications � History of previous abdominoplasty. � Patients with major systemic diseases (cardio-

vascular, autoimmune diseases or chronic lungdiseases).

� Patients who had a previous ligation of thedeep inferior epigastric vessels.

� Relative contraindications (act with caution) � History of previous liposuction at the lower ab-

domen. � Patients with large transverse or oblique ab-

dominal incisions. � Heavy smokers (by at least 12 weeks presurgery,

heavy smokers should reduce smoking to an amount of less than 5 cigarettes per day).


Drawings are done preoperatively in the stand-ing and supine positions. In the standing position, the patient’s midline and the submammary fold of both breasts are marked. In patients undergo-ing immediate breast reconstruction, the surgicaloncologist outlines the suggested skin markings which may include markings around the nipple-areola complex.

The vertical and horizontal dimension of the DIEP flap is outlined in the supine position. Flaps aremarked approximately 10 to 15 cm caudally from

1)

Fig. 1:Preoperative skin markings. The patient’s midline, the base of the breast and the submammary fold are outlined in thestanding position. The perforators are located in the su-pine position with color flow duplex sonography. The best perforator is marked as X1.

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the navel down to the pubic, depending on the patient’s height andweight. The superior skin incision of the flap is made directly abovethe umbilicus to include the larger perforators which are oftenfound in the paraumbilical region. The flap extends approximately 15to 20 cm laterally from the midline, again depending on height and weight.

The perforators are located by color flow duplex sonography in the su-pine position in the exactly the same manner as planned for surgery. The dominant perforator is marked as X1 and the second as X2; up to10 perforators are marked in general (Fig. 1).

5. Surgery

5.1 Preoperative management

The patient is admitted to the hospital one day before surgery. For bilateral reconstruction, the authors encourage to donate two units of autologous blood preoperatively.

5.2 Surgical procedures

Surgical procedures are performed under general anesthesia bytwo teams simultaneously. The patient is placed in the supine po-sition. Both arms are placed securely next to the body. A two-teamapproach is applied. While one team harvests the flap, the otherteam prepares the recipient vessels. Single-shot antibiotics are givenbefore surgery. The patients’ temperature is kept stable at 37.7°C us-ing a warm-touch blanket which is ventilated with warm air. An airpressure system for both legs is used to enhance the venous returnsystem.

5.3 Dissection of the mammary internal vessels

The authors use the internal mammary vessels (IMV), artery and vein, in all patients, while the thoracodorsal vessels can be the sec-ond choice for blood supply of the free flap.

In secondary breast reconstruction, the approach for the IMV de-pends on the height of the existing mastectomy scar which is ex-

179


cised for histological examination, occasionally at the level of the third or fourth rib (Fig. 2a-c). A subcutaneous pocket is prepared in a cranial di-rection. In immediate breast reconstruction, theapproach for the IMV is usually at the level of the third rib. Only in thin patients do we use the fourthrib to avoid the postoperative formation of an im-pression in the region of the dissected rib. A smallportion of the pectoralis major muscle over the rib is dissected, removed and sent for histological examination. Two to three centimeters of the par-asternal rib are removed with a Luer. The IMV are prepared under the microscope. Vessel diameterscommonly range from 1.5 to 3 mm in size. A secondvein is often found.

2a)

2b)

2c)

Fig. 2:The internal mammary vessels are prepared at the level of thethird or fourth rib. (a) Periosteum (a) of the fourth rib after a partial resection of the pectoralis major muscle (b) which is re-moved by a raspatory. (b) Dorsal sheet of the periosteum after resection of the rib with a Luer forceps. (c) Periosteum and theintercostal muscle are removed cranially and caudally to theadjoining third and fifth rib; view on the recipient vessels with the internal mammary vein medially and the internal mam-mary artery laterally (* = caudally).

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5.4 Flap harvesting

After the skin and fat incision to the fasciae of the oblique externus and rectus muscles, the abdomi-nal skin-fat island is carefully elevated from lateral to medial until the lateral row of perforators be-come visible. The umbilicus is dissected. The flap is raised carefully as continued to the midline. Everysufficient perforator coming up from the DIEP is dissected. The same procedure is done on the con-tralateral side. The authors give no side preference with respect to the vascular pedicle, but rather pre-fer the side on which the best perforators are lo-cated. The dominant perforator is chosen by intra-operative Doppler probe investigation and clinical appearance (Fig. 3). All other perforators on bothsides are temporarily closed by bulldog clips to ver-ify a good venous and arterial blood supply which is seen after three to five minutes (Fig. 4a). One to three other perforators may also be includedshould problems occur, mostly due to venous con-gestion on the contralateral side in perfusion zoneIV and sometimes in zone III (Fig. 4b) (Holm, Mayr et al. 2006) one to three other perforators may bealso included. Preference should be given to perfo-rators in the same row to minimize the defect of the rectus muscle. Otherwise, if perforators from

4b)

3)

5)

4a)

Fig. 3:Intraoperative clinical and Doppler probe investigation of thelateral perforators on the right side. The abdominal fascia isseen at the bottom (*), the fatty tissue below (°). Good venousand arterial sound should be given.

Fig. 4:Dissection of all potential perforators. (a) After choosing one or two perforators, all other dissected perforators are temporar-ily closed with bulldog clips. Venous and arterial blood supplyshould still be good given by the chosen perforators. (b) Ve-nous congestion in zones III and IV (after Holmes et al.) with only one chosen perforator after 5 minutes.

Fig. 5:A free ms-2 TRAM flap is harvested if perforators of one roware not sufficient for good blood supply and more than threeperforators are to be integrated in the flap.

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the lateral and medial row are necessary for a good blood supply of the flap, it should be harvested asa free ms-2 TRAM flap (Fig. 5). After choosing the sufficient perforator, the pedicle is monitored withDoppler probe to the origin and the anterior rectussheath is opened around the perforator and overthe pedicle up to the rectus muscle. The perfora-tor is carefully dissected through the muscle downto the deep inferior epigastric artery and vein. Thedissection of the pedicle continues retrograde from cranial to caudal to the external iliac vesselsin an attempt to obtain a pedicle with a sufficientlength of approximately 10 cm. In the course of perforator dissection, the rectus muscle is spreadin the direction of its fibers (Fig. 6a-c). Care should be taken with respect to the segmental motoricintercostal nerves innervating the muscle. The in-tercostal nerves should be preserved whenever possible (Fig. 7). All other perforators are clipped and cut after verification of a good existing bloodsupply of the flap. The anterior part of the pedicleis marked with a surgical marker for pedicle orien-tation when bringing the flap to the chest (Fig. 8). The artery and vein of the pedicle are ligated andthe pedicle is pulled out under the preserved inter-costal nerves. The flap is transferred to the mas-tectomy defect after the deep inferior epigastric vessels are rinsed with 5 ml heparin solution (2500 IU heparin/ 500ml Ringer). The flap is temporarily sutured to the anterior chest wall. In this process, great care should be given to put the pedicle in an

6c)

6a)

7)

6b)

Fig. 6:Dissection of the perforators. (a) Marking of the course of the perforator under the fascia going to the pedicle and the wayof the deep inferior epigastric vessels under the rectus muscleand longitudinal incision of the fascia. (b) Rectus muscle af-ffter removing the fascia. (c) The two perforators are dissected through the muscle with a bipolar forceps.

Fig. 7:Pedicle under a preserved intercostal nerve which innervatesthe rectus muscle.

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adequate position without kinking and twisting the vessels. The vessels of the pedicle are prepared under the microscope for the anastomoses. The pedicle usually includes two veins and the smallervein in diameter is clipped. First, the microvascu-lar anastomosis of the vein is performed end-to-end to the cranial part of the internal mammaryvein with 9/0 nylon interrupted sutures (Fig. 9a). The caudal part of the mammary internal vein is ligated. The second vein of the pedicle is only anas-tomosed to the caudal part of the internal mam-mary vein in the presence of identical diameters inboth pedicle veins.

For bilateral reconstruction, the flap is prepared on both sides in the same way as described above forunilateral reconstruction. The artery is sutured inthe same manner as the vein, again with 9/0 nyloninterrupted sutures. Routinely, 2500 IU of intrave-nous heparin are given by the anesthesiologist after

9b)

8)

10a)

9a)

Fig. 8:Marking of the anterior part of the pedicle with a surgical marker for pedicle orientation when bringing the flap to the chest. Vascular pedicle (a) of the harvested DIEP flap with twoisolated perforators, (b) after preparation through the rectusmuscle. The pedicle is usually 10 to 12 cm in length.

Fig. 9:Microsurgical anastomoses and application of fibrin sealantfor stabilization. (a) Interrupted single-stitch sutures with 9-0Nylon are applied for the anastomoses. (b) After successfulmicrosurgical anastomoses, the vein and artery are stabilizedwith 2 ml of fibrin sealant. The fibrin sealant forms a stablematrix after one minute to secure the vessels in place.

Fig. 10:Forming of the breast with the DIEP flap, half-sitting position.(a) DIEP flap after successful anastomoses. Zone IV is common-ly removed. (b) Fixation of the flap in the submammary fold. If enough tissue is available, the inferior part of the flap can be folded under itself for improved projection of the lower part of the breast. (c) The lower part of the chest wall is de-epithelial-ized up to the submammary fold. (d) Forming the upper partof the breast. (e) After de-epithelialization, the upper part of the flap is removed in the subcutaneous pocket of the old base of the breast. (f) The patient after forming and temporary fixa-tion of the breast with a stapler before suturing.

183


completing the anastomoses. The flap is verified forcapillary refill and bleeding. As a routine procedure, the authors use 2 ml fibrin sealant (Tissucol®; Bax-ter Healthcare, Vienna, Austria) to support anasto-mosis sealing and mechanical stabilization (Fig. 9b). The resulting matrix stabilizes the anastomosis inthe precisely required position after approximately one minute without a kinking of the vessels.

The flap is inset horizontally or vertically depend-ing on the breast shape and base contralateral.Zone IV is typically removed. A Jackson Pratt drain-age is placed under the lateral part of the flapin a secure distance of the pedicle. The shape is checked in the sitting position. Excess tissue is re-moved and excess skin is carefully de-epithelial-ized in order to create a smooth tissue connection and avoid lumps in the upper parts of the recon-structed breast. In secondary reconstruction, the flap is inset with a visible skin island at the samelevel of the contralateral submammary fold. Af-ffter de-epithelialization of the caudal part of the breast base, the flap can also be folded under itself inferiorly to improve projection in the lower parts of the reconstructed breast (Fig. 10a-f). In cases of secondary reconstruction, after removal of a pros-theses or primary reconstruction, the completeflap is de-epithelialized with or without a smallskin island.

10d)

10b)

10e) 10f)

10c)

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OPS and Mastectomy

For postoperative monitoring, the perforator is lo-cated on the skin by using Doppler probe (Fig. 11). The point is marked either on the skin island or onthe intact breast skin. In the latter case, it is impor-tant to make sure that the Doppler sound comes from the flap and not from the healthy breast skin.

5.5 Donor site closure

The donor site is closed simultaneously with theprocedure of microvascular anastomosis. After un-dermining the superior abdominal flap up to the ribcage, the abdominal fascia is closed before using aJackson Pratt drainage and a Vipro® mesh in a sub-lay technique with 0 PDS interrupted single stitchsutures and a 2-0 prolene running suture (Fig. 12a, b). The lower part of the umbilicus is tacked down to the fascia with a 3/0 Vicryl single stitch suture. The patient is flexed, two suction drains are insert-ed, and the Scarpa’s fascia is approximated with 2/0Vicryl interrupted sutures. The umbilicus is broughtout through the abdominal flap and secured with a 5/0 Nylon running suture as in abdominoplasty.The skin is closed with 3/0 deep dermal and 4/0 in-tradermal running sutures. In bilateral breast recon-struction with a bilateral DIEP flap, the abdominal wall is closed on both sides as described above.


The patient is observed for one night at the surgi-cal intermediate care unit and is transferred to the ward in the morning of the first day postsurgery. The flap is closely observed once an hour for the first 24 postoperative hours and every second hour for thenext 48 hours by using Doppler ultrasound and clini-cal appearance of the flap. Should any postoperative complications occur, such as acute bleeding or ve-nous or arterial congestions, the patient is immedi-ately brought to the operating room for revision. The authors routinely give 500ml HAES® over 24 hoursfor three days to improve microcirculation. Intrave-

12a)

12b)

11)

185


nous cephalosporins 2g are administered for 3 days.After the third postoperative day, oral acetylsalicylicacid 100 mg per day is given for 6 weeks. Routine painmedication is given directly after surgery. The pa-tients are mobilized from the first postoperative daywearing a compression bra and a compression belt.

The patient is usually discarded on day 9 postsur-gery following unilateral reconstruction or day 11 following bilateral reconstruction. For patients hav-ing undergone unilateral breast reconstruction, con-tralateral breast reduction or mastopexy is offered4 to 6 months later, if necessary or desired. Without performing surgery on the contralateral breast, nip-ple reconstruction is generally carried out under local anesthesia with a star flap 4 to 6 months after breast reconstruction. The areola is pigmented 8 weeks thereafter. If the patient had surgery on the contral-ateral breast to achieve symmetry, the nipple is re-constructed another 3 months later as the adjusted contralateral breast will also have undergone slightpostoperative ptosis. In bilateral breast reconstruc-tion, the nipple is managed 4 months after recon-struction. At the same time as nipple reconstruction,smaller corrections such as liposuction can be carried out to reduce the volume of the flap.

13b)

14a)

14b)

13a)

Fig. 11:Marking of the point for the Doppler probe for postoperativemonitoring.

Fig. 12:Donor site closure after harvesting the DIEP flap on the pa-tient’s right side. The anterior rectus sheath is closed with aVipro® mesh in sublay technique and 0 PDS single-stitch su-tures and a 2-0 prolene running suture.

Fig. 13:53-year-old patient with planned skin-sparing mastectomy and primary DIEP flap breast reconstruction. (a) Patient be-fore surgery with preoperative markings. (b) Patient 12 months postsurgery with a reconstructed nipple-areolar complex.

Fig. 14:Secondary DIEP flap reconstruction (a) presurgery and postsur-gery. (a) 49-year-old patient before surgery with preoperativemarkings. (b) Patient 10 months postsurgery with a recon-structed nipple-areolar complex.

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7. Tips and tricks

� Pre- and intraoperative Doppler monitoring of the perforators generally saves a lot of operation time and should be performed in every patient.

� In order to avoid venous or arterial complications after the anastomoses, the authors prefer to intraoperatively and temporarily clip all perforatorswith bulldog clamps without the selected perforator/s. If venous or arte-rial blood supply is poor already at the donor site, other perforators couldbe included into the flap to improve circulation.

� Preparation with bipolar forceps facilitates bloodless and rapid dissection. � The authors routinely use 2 ml fibrin sealant (Tissucol®; Baxter Health-

care, Vienna, Austria) to support anastomosis sealing and mechanical stabilization. The fibrin sealant stabilizes the anastomosis in the re-quired position after approximately one minute. Kinking of the anasto-moses region and the pedicle vessels are to be avoided.

� Care should be taken after the anastomosis when forming the breast with the DIEP flap to avoid a twist or kinking of the pedicle.

Allen, R.J., P. Treece. (1994). “Deep inferiorepigastric perforator flap for breast recon-struction”. Ann Plast Surg 32: 32-8.

Allen, R., A. Heitland. (2003). “Autogenous augmentation mammaplasty with microsurgical tissue transfer”. Plast ReconstrSurg 112(1): 91-100.

Andree, C., B. Munder, et al. (2008). ”Im-proved safety of autologous breast reconstruction surgery by stabilisation of micro-surgical vessel anastomoses using fibrin sealant in 349 free DIEP or fascia-muscle-sparing (fms)-TRAM flaps: a two-centrestudy”. Breast 17(5): 492-8.

Behranwala, K.A., R.S. Dua, et al. (2006). “The influence of radiotherapy on capsule formation and aesthetic outcome afterimmediate breast reconstruction usingbiodimensional anatomical expanderimplants”. J Plast Reconstr Aesthet Surg59(10): 1043-51.

Blondeel, P.N., W.D. Boeckx. (1994). “Re-finements in free flap breast reconstruc-tion: the free bilateral deep inferior epi-gastric perforator flap anastomosed tothe internal mammary artery”. Br J PlastSurg 47: 495-501.

Blondeel, P.N., G.G. Vanderstraeten, et al.(1997). “The donor site morbidity of freeDIEP flaps and free TRAM flaps for breastreconstruction”. Br J Plast Surg 50: 322-30.

Blondeel, P.N. (1999). “One hundred freeDIEP flap breast reconstructions: a personal experience”. Br J Plast Surg 52: 104-11.

Busic, V., R. Das-Gupta, et al. (2006). “Thedeep inferior epigastric perforator flap forbreast reconstruction, the learning curveexplored”. J Plast Reconstr Aesthet Surg 59:580-4.

Feller, A.M. (1994). “Free TRAM: results andabdominal wall function”. Clin Plast Surg21: 223-32.

Feller, A.M., T.J. Galla (1998). “The deep infe-rior epigastric artery perforator flap”. Clinic Plast Surg 25(2): 197-206

Futter, C.M., M.H. Webster, et al. (2000).“A retrospective comparison of abdominalmuscle strength following breast reconstruction with a free TRAM or DIEP flap”. BrJ Plast Surg 53: 578-83.

Granzow, J.W., J.L. Levine, et al. (2005).“Breast reconstruction with the deep inferior epigastric perforator flap: history and

an update on current technique”. J PlastReconstr Aesthet Surg 59: 571-9.

Grotting, J.C. (1994). “Immediate breastreconstruction using the free TRAM flap”. Clin Plast Surg 21: 207-21.

Grotting, J.C. (1991). “The free abdomino-plasty flap for immediate breast recon-struction”. Ann Plast Surg 27: 351-4.

Hartrampf, C., M. Scheflan, et al. (1982).“Breast reconstruction with a transverseabdominial island flap”. Plast Reconstr Surg 69: 216-25.

Holm, C., M. Mayr, et al (2006). “Perfusion zones of the DIEP flap revisited: a clinical study”. Plast Reconstr Surg 117: 37-43.

Holmström, H. (1979). “The free abdomino-plasty flap and its use in breast reconstruc-tion”. Scand J Plast Reconstr Surg 13: 423-7.

Koshima, I., S. Soeda. (1989). “Inferior epigastric artery skin flap without rectus ab-dominis muscle”. Br J Plast Surg 42: 645-8.

Kroll, S.S., M.A. Schusterman, et al. (1995).“Abdominal wall strength, bulging andhernia after TRAM flap breast reconstruc-tion”. Plast Reconstr Surg 96: 616-9.

References

187

1. Concept

The transverse myocutaneous gracilis (TMG) flap is considered a possible tissue source in the case that autologous filling material in the form of a free flap is required to reconstruct a skin-sparing mastectomy defect. It isan alternative to the commonly used abdominal flaps and has its speci -ffic advantages, as well as disadvantages. The idea behind this concept isto take a skin island from the inner upper thigh together with the gracilismuscle. The muscle only serves as the pathway for the pedicle into the skin, but also contributes additional volume and helps to shape the flapin situ. The resulting scar can end up to be very inconspicuous, this beingthe most obvious advantage beside its easy-flap dissection.

2. Indications

� Small-breasted - slim patients who seek autologous breast recon-struction and accept the risk associated with free tissue transfer.

� Patients with insufficient volume on the abdomen. � Patients who have more volume on the thigh than on the abdo-

men (pear-shaped appearance). � Patients who prefer the inconspicuous donor site scar on the in-

ner upper thigh over the abdominal scar.

Transverse Myocutaneous GracilisFlap for Immediate Skin-SparingMastectomy Breast Reconstruction

Thomas Schoeller, Petra Pülzl

2.2.3.4

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� In general, patients who for whatever reasonare ineligible for free-tissue transfer or do notaccept the higher risk (heavy smokers, seriousco-morbidities, high-risk patients, et al.).

� Patients who do not accept an additional donorsite for reconstruction.

� Patients who gain more profit from an abdomi-noplastic procedure.

� Insufficient volume on the thigh and infeasibil-ity of bilateral TMG flap for single-breast recon-struction.


The flap drawing is performed in the standing, up-right position with the knee slightly abducted. Theskin island should show its upper border in the natural fold of the groin until it continues into theinfragluteal fold. It starts at the visible and palpable origin tendon of the adductor magnus muscle and ends at the posterior midline. The width of the skinisland depends on the laxity of the thigh. Some 8 to12 cm in width commonly can be closed directly with-out intraoperative tension with the leg adducted. For improved orientation, the anticipated projection of the gracilis and its main pedicle can additionally be drawn. The origin will be medial to the tendon of the adductor longus muscle, while the insertion can beeasily palpated at the pes anserinus on the knee (Fig. 1).The incision lines on the breast are done according to tumor requirements, but should facilitate access to the internal mammary vessels.

2)

3)

1)

Fig. 1:Preoperative drawing – flap landmarks: Palpable tendon of ad-ductor longus muscle, groin crease.

Fig. 2:Dissected flap on its main pedicle – circumflexa femoris medialis.

Fig. 3:Free TMG flap prior to microanastomosis towards the internal mammary vessels.

189


5. Surgery

The patient is placed in the supine position withthe knee slightly abducted. The use of the con-tralateral thigh is recommended, as the pediclepoints towards the internal mammary vessels af-ffter breast shaping. The marked edges of the skinisland are infiltrated with a vasoconstrictor toavoid unnecessary bleeding during dissection. Theisland is incised including the fascia of the thigh.At the anterior edge of the flap, care is taken notto sacrifice the greater saphenous vein (no lym-phatic complication must then be expected) – onthe posterior edge, care is taken to preserve the cutaneous nerves (rami clunei). This unfortunatelyis not always possible and will otherwise result ina numb area on the posterior thigh, but withoutgreater discomfort. As a next step, the distal graci-lis portion is mobilized underneath the fascia, thenthe distal gracilis pedicle is ligated once reached and the distal gracilis tendon dissected with long scissors. The origin is freed from the pubic bonein the next step. The major pedicle (A. circumflexafemoris medialis) is subsequently dissected. At this point, care must be taken to ligate the small branches into the adductor longus and magnus muscles. The pedicle is followed throughout to its origin from the A. profunda femoris and ligat-ed there. The flap is transferred to the breast andanastomosed to the internal mammary vessels in a microsurgical fashion. The skin island is folded to a cone to produce a “dog ear”. Depending on indi-vidual requirements, the skin is de-epithelialized leaving some island for monitoring purposes. Themuscle is folded underneath the skin cone for fur-ther projection. The donor site is closed as with athigh lift by mobilizing the distal skin edges prefer-ably using resorbable sutures.

Fig. 4:TMG flap after transfer to the breast, already sufficiently anasto-mosed. Skin island before folding to a projecting cone.

Fig. 5: Immediate postoperative result.

4)

5)

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OPS and Mastectomy

6. Tips and tricks

� For optimal breast projection, it is advisable toform a cone out of the skin island (thus deliber-ately creating a big dog ear).

� Maximize pedicle length and diameter by ves-sel exposure laterally from the adductor longusmuscle (Fig. 2).

� Use the vein coupler devise, as venous anasto-mosis helps to overcome diameter discrepancyand increases patency rates.

� Moderate volume overcorrection will end up ina favorable result after muscle atrophy has oc-curred.

� If a large breast needs to be reconstructed ac-cording to that method, a two-flap procedurecan be considered.

� A small monitoring skin island should be left,ideally replacing the resected nipple-areolacomplex (NAC).

6b)

6a)

Fig. 6:Long-term result after 3 years.

Fig. 7:(a) Close-up of the donor site, (b) donor scar only in the obliqueview with knee abducted visibly.

191


6d) 7b)

6c) 7a)

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ReferencesArnez, Z.M., D. Pogorelec, et al. (2004).“Breast reconstruction by the free transverse gracilis (TUG) flap”. Br J Plast Surg57(1): 20-6.

Fansa, H., S. Schirmer, et al. (2008). “Thetransverse myocutaneous gracilis muscle flap: a fast and reliable method forbreast reconstruction”. Plast Reconstr Surg 122(5):1326-33.

Fattah, A., A. Figus, et al. (2009, in print).“The transverse myocutaneous gracilisflap: technical refinements”. J Plast Recon-str Aesthet Surg.

Schirmer, S., I.C. Warnecke, et al. (2008).“Alternative autologous breast reconstruction using the free microvasculargracilis muscle flap with horizontal skin island”. Handchir Mikrochir Plast Chir40(4): 262-6.

Schoeller, T., G.M. Huemer, et al. (2008).“The transverse musculocutaneous gracilis flap for breast reconstruction: guidelinesfor flap and patient selection”. Plast Recon-str Surg 122(1): 29-38.

Schoeller, T., R. Meirer, et al. (2002). “Medial thigh lift free flap for autologous breast

augmentation after bariatric surgery”.Obes Surg 12(6): 831-4.

Wechselberger, G., T. Schoeller. (2004). “Thetransverse myocutaneous gracilis free flap:a valuable tissue source in autologousbreast reconstruction”. Plast Reconstr Surg J 114(1): 69-73.

Yousif, N.J. (1993). “The transverse gracilismusculocutaneous flap”. Ann Plast Surg31(4): 382.

193

Breast-conserving surgery (BCT) results in improved quality of lifeand enhanced self-esteem in women undergoing surgical treatmentfor breast cancer (Hopwood, Fletcher et al. 2001). The assessment of cosmetic outcome in breast surgery is especially pertinent, as patient satisfaction is a predominant factor in determining quality of life alongside oncologic outcome. Until today, none of the prospective randomized trials conducted in BCT have been able to assess cosmet-ic outcome on account of deficient reproducible, accurate and user-friendly scales.

To interpret cosmetic outcome, we should differentiate between sub-jective and objective measurements. Concerning subjective insights, we should furthermore compare the patient’s and the doctor’s views,as physicians commonly judge cosmetic results in a different fashion.Moreover, physicians are clearly to be divided into the groups of ex-perts and non-experts (Cardoso, Santos et al. 2005).

Subjective self-analyses given by patients are per se poorly reproduc-ible. Still, this variable is the most important to evaluate, as the mainobjective is to improve patients’ quality of life. In a recent review by Ching et al. (Ching, Thoma et al. 2003), the authors identified body-image and quality-of-life measures to be of the greatest value in de-termining surgical outcomes. This meta-analysis investigated various

Breast Cosmetic Analyses

Florian Fitzal

2.3.1Special Considerations2.3

194

Special Considerations

questionnaires and self-assessment tests. Although these methods seemed to be highly reliable, con-ducting repeated measurements and interpreting results may still prove difficult. Furthermore, analy-ses are highly time-consuming and may depend on the patients’ daily state of mind and age.

Regarding subjective analyses given by physicians,various scales have been used to assess body image.Unfortunately, none of these methods has achieved widespread use. Recently, Cardoso and collabora-tors demonstrated that subjective analyses by dif-ffferent experts working in different geographicalareas are only fairly reproducible (Cardoso, Cardosoet al. 2006). Thus, subjective methods seem to be inappropriate for scientifically based clinical trials to analyze cosmetic outcome after BCT.

With respect to objective analyses, Pezner et al (Pezner, Patterson et al. 1985) initiated the breastretraction index by measuring nipple location and comparing both sides with one another. They dem-onstrated a good correlation with subjective votesof breast symmetry - yet this index only comparednipple asymmetry. Thus, skin retractions introducedby BCT may be missed by this scoring system. Van Limbergen et al. combined nipple retraction with breast shape by additionally measuring distances to the breast borders. The authors demonstratedsatisfactory correlation with a subjective cosmeticscore. However, this method is unable to evaluateall breast deformities, especially those present in the upper quadrants, thus underestimating breast asymmetry (Van Limbergen, Rijnders et al. 1989;Van Limbergen, van der Schueren et al. 1989). In thisregard, objective tools still need to be improved forapplication in clinical trials.

Two respective tools have been generated over the past years. First, the breast-analyzing tool (BAT) (Fit-zal, Krois et al. 2007; Fitzal, Mittlboeck et al. 2008) uses a breast symmetry index (BSI) ranging from 1-11 (good to poor symmetry) for measuring sym-metry (Fig.1) which is known to be the most impor- 1)

195

Breast Cosmetic Analyses

Cardoso, M. J., J. Cardoso, et al. (2007).“Turning subjective into objective: TheBCCT.core software for evaluation of cos-metic results in breast cancer conservativetreatment.” Breast.

Cardoso, M. J., J. Cardoso, et al. (2006). “Interobserver agreement and consensusover the esthetic evaluation of conserva-tive treatment for breast cancer.” Breast15(1): 52-7.

Cardoso, M. J., J. S. Cardoso, et al. (2008). “Comparing two objective methods forthe esthetic evaluation of breast cancerconservative treatment.” Eur J Cancer 6(7(Suppl)): 209.

Cardoso, M. J., A. C. Santos, et al. (2005).“Choosing observers for evaluation of aesthetic results in breast cancer conservativetreatment.” Int J Radiat Oncol Biol Phys61(3): 879-881.

Ching, S., A. Thoma, et al. (2003). “Measur-ing outcomes in aesthetic surgery: a com-

prehensive review of the literature.” PlastReconstr Surg 111(1): 469-80; discussion481-2.

Fitzal, F., W. Krois, et al. (2007). “The use of abreast symmetry index for objective evalu-ation of breast cosmesis.” Breast 16(4): 429-35.

Fitzal, F., M. Mittlboeck, et al. (2008). “Breast-conserving therapy for centrallylocated breast cancer.” Ann Surg 247(3):470-6.

Hengartner, M. O. and H. R. Horvitz (1994).“C. elegans cell survival gene ced-9 en-codes a functional homolog of the mammalian proto-oncogene bcl-2.” Cell 76(4):665-76.

Hopwood, P., I. Fletcher, et al. (2001). “Abody image scale for use with cancer pa-tients.” Eur J Cancer 37(2): 189-97.

Pezner, R. D., M. P. Patterson, et al. (1985).“Breast retraction assessment. Multiple

variable analysis of factors responsiblefor cosmetic retraction in patients treatedconservatively for stage I or II breast carci-noma.” Acta Radiol Oncol 24(4): 327-30.

Van Limbergen, E., A. Rijnders, et al. (1989).“Cosmetic evaluation of breast conservingtreatment for mammary cancer. 2. A quan-titative analysis of the influence of radia-tion dose, fractionation schedules and sur-gical treatment techniques on cosmeticresults.” Radiother Oncol 16(4): 253-67.

Van Limbergen, E., E. van der Schueren, etal. (1989). “Cosmetic evaluation of breastconserving treatment for mammary can-cer. 1. Proposal of a quantitative scoringsystem.” Radiother Oncol 16(3): 159-67.

Waljee, J. F., S. Hawley, et al. (2007). “Patientsatisfaction with treatment of breast can-cer: does surgeon specialization matter?” JClin Oncol 25(24): 3694-8.

tant factor regarding psychological outcome (Waljee, Hawley et al. 2007). The second tool is the Breast Cancer Conservative TreatmentCosmetic results (BCCT.core) (Cardoso, Cardoso et al. 2007), also using skin texture and scar formation in addition to symmetry subdividedbetween 4 different states from good to poor.

Both tools show excellent correlation with the subjective scores giv-en by physicians and non-physicians. The advantage of the BAT is its user-friendly application with 11 different score points, irrespective of picture quality. The advantage of the BCCT.core is its accuracy whenusing perfectly similar images with similar lighting, flashlight and noshadow. However, failure may arise from shadows cast on the patient(Cardoso, Cardoso et al. 2008). Both tools should be used in the futurefor accurate and scientifically reproducible trials.

References

197

1. Concept

Apart from the reconstruction of an amputated breast itself, one of the main goals of the reconstructive procedure as a whole is to create sym-metry. In some instances, there is good match in size and shape between the reconstructed and the original contralateral breast. In the majorityof cases, an adaptation of the non-affected breast is required and there-fore proposed to the patient. This is more frequently necessary after im-plant reconstruction than after the use of autologous tissue for recon-struction. Some women nevertheless refuse to have the contralateralbreast “touched by a surgeon’s knife” and are satisfied with a certainamount of asymmetry. In most cases, the patient is to be informed thatperfect symmetry is hard to achieve. At any rate, reduction/mastopexyof the contralateral breast must also be seen from an oncologic point of view. Women with unilateral cancer have an increased risk of develop-ing disease in the contralateral breast. On the one hand, surgery on theopposite breast is considered to interfere with surveillance on accountof the scar or prosthesis. On the other hand, suspicious tissue regions can be removed during an adaptive operation (Kroll 1998). Occult carci-nomas have been found in approximately 4.5% of contralateral breastreduction specimens in patients undergoing a symmetry procedure forbreast reconstruction. Although the detection of occult carcinoma isnot a reason to perform contralateral breast reduction, it may still pro-vide a benefit for high-risk patients.

Nipple Reconstruction andContralateral Adaptation

Rupert Koller, Stefan Gärner

2.3.2

198


The same holds true for reconstruction of the nip-ple-areola complex (NAC) on the reconstructed side. Restoring the original body image makes it necessary to reconstruct this structure. Especially if the prominent nipple of the intact breast is visiblewhen the patient wears firm clothing, she may be disturbed because of the visible symmetry. In gen-eral, women after bilateral reconstruction more o -fften disclaim the restoration of the NACs as there is no lack of symmetry.

2. Indications and types of procedures

2.1 Contralateral symmetrization

There are three basic types of adaptive procedures in the contralateral breast. Mastopexy is indicated if there is only a difference in shape between the twobreasts. This can easily be estimated by letting thepatient put on a bra. Mastopexy should be done if the difference disappears. If tissue is lacking in the reconstructed breast, as well, reduction mammo-plasty of the contralateral organ must be performed.If the reconstructed breast is larger, it must eitherbe reduced by liposuction or resection of fat tissue,or the contralateral breast can be augmented by a prosthesis. Several women who had subjectively toosmall breasts before the outbreak of cancer seek alarger reconstruction and contralateral augmenta-tion. By finally having breasts of the desired size, the patient may perceive compensation for being affec-ted by a severe disease.

1b)

1a)

Fig. 1:Schematic drawing of mastopexy with vertical scar.

Fig. 2:Schematic drawing of reduction with medially based areolaaccording to Hall-Findlay. 2a)

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Nipple Reconstruction and Contralateral Adaptation

3. Nipple-areola complex (NAC)

The nipple can be reconstructed either with a com-posite graft from the contralateral nipple or a localflap. The first procedure requires a well projectingnipple in the contralateral breast and a patient who is willing to have her other breast be “cut”. This ismost frequently no problem if contralateral adap-tation in shape is to be done under general anesthe-sia. The local flaps require at least a small amount of excess skin and generally leave more scars.

Reconstruction of the areola is done with a graft of pigmented skin or a tattoo. The tattoo sometimes appears less natural but has the advantage of re-quiring no donor site. The preferred donor site areafor skin grafts is the inner side of the proximal thigh.The excess pigmented skin from the contralateral areola is also often recommended but may renderunfavorable scars in the reconstructed areola.

Personal algorithm: If the contralateral breast re-quires no adaptation and the patient is operated under local anesthesia, the present authors’ first choice is nipple sharing and tattoo. If the contra-lateral nipple is less strongly projected, a star flapor a skate flap is recommendable. Any of the men-tioned procedures can be recommended under general anesthesia. We never do flaps for the nip-ple and tattooing in one session, because recentlysutured donor sites of the flaps do not easily takethe tattoo and are in risk for infection from pig-ments that mostly are not absolutely sterile.

4. Technical considerations

4.1 Contralateral symmetrization

Simple mastopexy on the contralateral side can gen-erally be done with circumferential de-epthelializa-tion of skin around the nipple, which elevates the nipple to the preoperatively marked height (Fig. 1).

2b)

2c)

2d)

200


The cranial border of the skin resection is 2cm above the desired nipple position. The excess skin below the areola is de-epithelialized, as well, and the final result is mostly a vertical infraareolar scar. In cases of a larger distance of transposition, an additional horizontal scar in the inframammarycrease may become necessary. Nevertheless, this can be decided upon intraoperatively if the dis-tance between the lower border of the areola andthe inframammary crease cannot be adequately shortened to give a good shape by the vertical su-ture alone (Hamdi 2005).

Reduction mammaplasty of the breast is neces-sary if the reconstructed breast is significantly smaller than the contralateral one. The amount of resection is highly variable. Especially in the pres-ence of bilateral breast hypertrophy prior to theoutbreak of cancer, the amount of resected tissue may be up to 1000g and more. According to As-plund (Asplund, Svane 1983), patients with a high risk of bilateral breast cancer in need of size and/orshape symmetry correction should be considered for mastectomy and immediate reconstruction.

Exploration of the contralateral breast in the pres-ence of breast malignancy has been advocated by many investigators, based on an expected in-cidence of contralateral cancer ranging from 10to 15% (Petit, Rietjens et al. 1997; Lanfrey, Rietjenset al. 1997). However, recent data show an an-nual risk of contralateral breast cancer of about 0.5 to 0.8% (Wood 2008). Preoperative magnetic resonance imaging (MRI) may detect 4% of con-tralateral cancers (Lehman, Gatsonis et al. 2007).A recent study presented at the 2009 Annual

3b)

3a)

2e)

Fig. 3:(a) A woman after reconstruction of the left breast with amuscle-sparing transverse rectus abdominis myocutaneous(TRAM) flap. (a) The same patient after slight reduction of theright breast with a vertical scar and NAC reconstruction by freenipple-grafting and tattoo.

Fig. 4:Reduction with L-shaped scar according to Regnault’s B-technique.

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Meeting of the American Society of Clinical On-cology (ASCO) showed an approximately 1% risk of contralateral cancer after negative MRI seen in contralateral mastectomy specimens (Bernard, Vallow et al. 2009). The latest prophylactic mastec-tomy study demonstrated 1.5% of invasive carcino-ma in the contralateral breast (Yi, Meric-Bernstamet al. 2009). Thus, simple prophylactic mastectomyor reduction mastopexy is not warranted in allbreast cancer patients “just” for oncologic reasons.

The principles of skin resection are the same as inmastopexy procedures. The areola is pedicled on the horizontal septum as described by Würinger (2005) and the surrounding tissue is resected de-pending on the shape of the contralateral breast.

In general, we prefer a more medial pedicle of theareola with resection of the tissue cranially, later-ally and caudally, according to Hall-Findlay´s tech-nique (Hall-Findlay 2005) (Fig. 2, 3). The resectioncan at times be done with a purely vertical scar. Still, if excess tissue is present in the inframam-mary fold, one should be generous in setting theindication to a short horizontal scar.

If it becomes visible preoperatively that a purevertical scar will not prove sufficient, the L-shaped scar according to the method of Frey (1999) for mastopexy or Regnault (1980) for reduction aregood alternatives (Fig. 4, 5).

Regnault’s B-technique is often claimed to result ina considerably flattened breast. In contralateral ad-aptation, this may prove useful in the presence of areconstructed breast that sometimes is flat as well.

Augmentation of the contralateral breast is indi-cated only if reconstruction has been done with animplant alone or in conjunction with a latissimus flap. Standard subpectoral augmentation via an infraareolar or inframammary incision is recom-mended.

4b)

4c)

4a)

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4.2 Nipple reconstruction

The optimal positioning of the reconstructed nip-ple is of crucial relevance for the entire reconstruc-tive procedure. The degree of success of a good breast reconstruction can be impaired by a wrong positioning of the new nipple. Positioning the new nipple in the optimal location on the reconstruct-ed breast – the point with the highest projection – is more important than achieving complete sym-metry with the contralateral nipple. The positionis marked preoperatively in the sitting position. Incase of contralateral mastopexy, the position of the contralateral mamilla is elevated to the recon-structed one.

Nipple sharing. Under general or local anesthesia,a composite graft of skin and soft tissue is har-vested by a tangential cut through the contralat-eral nipple. The recipient site in the reconstructed breast is de-epithelialized and the graft is fixed by absorbable sutures. Small bleedings are cauter-ized in the donor site and the wound is left openfor granulation. In order to reconstruct the areola,a full-thickness skin graft from the very proximal medial region of the thigh or a tattoo can be donein the same operation.

Local flaps. Constantly good results can be achieved with the skate flap or star flap (Little 1998; Eskenazi1993) (Fig. 6, 7, 8).

Both techniques allow primary closure of the do-nor skin. The skate flap (Fig. 6) results in a vertical seam in the new nipple, whereas the scar in the star flap is horizontally orientated (Fig. 7, 8). The size of the contralateral nipple is transferred to the reconstructed breast. The flaps are optimally pedicled cranially, yet pre-existing scars must be considered.

5b)

5a)

Fig. 5:(a) A woman after reconstruction of the right breast witha muscle-sparing TRAM flap. (b) The same patient afterslight reduction of the left breast with a vertical scar ac-cording to Hall-Findlay and NAC reconstruction by freenipple-grafting and tattoo.

Fig. 6:Nipple reconstruction - skate flap.

203


6b)

6c)

6a) 6d)

6e)

6f)

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7a)

7d)7b)

7e)

7c)

Fig. 7:Nipple reconstruction - star flap.

Fig. 8:Nipple reconstruction - star flap incision lines (a and early postop) -erative result (b)

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8b)

8a)

5. Tips and tricks

� Contralateral reduction/mastopexy: Stick tothe horizontal septum as pedicle for the NAC.You can resect on either side of this pedicle in order to get an optimal shape.

� Be generous in converting from a pure, verti-cally orientated to a t-shaped scar in reductionmammoplasty, if you cannot easily dispose of the dog ear in the inframammary fold.

� NAC reconstruction: The optimal position on the reconstructed breast is more important than perfect symmetry. Use an electro-cardio-gram button to imitate the new nipple duringpreoperative evaluation of the new nipple site.

� Secondary nipple shrinking after reconstruc-tion with a flap must be considered and ex-plained to the patient.

� Use an adhesive tape into which you cut a holeof 40mm in diameter as template in the pro-cess of tattooing the areola.

206


ReferencesAsplund, O., G. Svane. (1983). “Adjustmentof the contralateral breast following breast reconstruction”. Scand J Plast ReconstrSurg 17(3): 225-32.

Bernard, J.R., L. A. Vallow, et al. (2009). “Innewly diagnosed breast cancer, is a contralateral prophylactic mastectomy neces-sary following a negative MRI?” J Clin Oncol27:15s, suppl; abstr 627.

Eskenazi, L. (1993). “A one-stage nipple re-construction with the “modified star” flapand immediate tattoo: a review of 100 cas-es”. Plast Reconstr Surg 92: 671-80.

Hall-Findlay, E.J. (2005). “Vertical reductionmammaplasty using the medial pedicle”.In: Hamdi M, Hammond DC, Nahai F (eds) Vertical Scar Mammaplasty, Springer, Heidelberg, pp 59-73.

Hamdi, M. (2005). “Indications and con-traindications of vertical scar mamma-plasty: general consensus”. In: Hamdi M, Hammond DC, Nahai F (eds) Vertical Scar

Mammaplasty, Springer, Heidelberg, pp143-4.

Kroll, S.S. (1998). “Options for the contralateral breast in breast reduction.

In: Spear SL (ed), Surgery of the breast:Principles and art, Lippincott-Raven, Phila-delphia, pp 653-9.

Lehman, C.D., C. Gatsonis C, et al; ACRINTrial 6667 Investigators Group. (2007).“MRI evaluation of the contralateral breastin women with recently diagnosed breastcancer”. N Engl J Med 356(13): 1295-303.

Little, J.W. (1998). “Nipple areola recon-struction”. In Spear SL (ed) Surgery of the breast: principles and art, Lippincott-Raven,Philadelphia, pp 661-9.

Petit, J.Y., M. Rietjens, et al. (1997). “Contral-ateral mastoplasty for breast reconstruc-tion: a good opportunity for glandularexploration and occult carcinomas diagno-sis”. Ann Surg Oncol 4(6): 511-5.

Regnault, P. (1980). “Breast reduction: Btechnique”. Plast Reconstr Surg 65(6): 840-5.

Wood. W.C. (2008). “Contralateral pro-phylactic mastectomy: should its use be increasing as it is?” St. Gallen ConsensusConference 2008.

Würinger, E. (2005). “Vertical scar mammaplasty with the inferior pedicle”. In: HamdiM, Hammond DC, Nahai F (eds) Vertical Scar Mammaplasty, Springer, Heidelberg,pp 75-82.

Yi, M., F. Meric-Bernstam, et al. (2009).“Predictors of contralateral breast cancerin patients with unilateral breast cancerundergoing contralateral prophylacticmastectomy”. Cancer 115(5): 962-71.

207

1. Introduction

Following Breast Conserving Surgery (BCS) and radiation therapy(RT), typical radiological changes are found in the postoperative fol-low-up (Kopans 2007).

These changes are further pronounced when more complex surgi-cal procedures such as reduction mammaplasty, rotation flaps ordistant flaps are used for breast defect remodelling and render the radiological follow-up more difficult.

Knowledge of potential radiological changes following BCS and RT is necessary to distinguish common postoperative changes such as scars, fatty tissue necrosis or calcifications from breast cancer recur-rence.

Radiological Findings Following Breast Conserving OncoplasticSurgery

Elisabeth Grafinger-Witt

2.3.3

208


Radiological follow-up of patients after oncoplas-tic surgery (OPS) comprises:

� Clinical examination: Provides information con-cerning the density of the breast, scars, edema, and assists in identifying palpable masses.

� Mammography in 2 or 3 projections combined with ultrasound and magnetic resonance im-aging (MRI) of the breast is recommended noearlier than 12 months following surgery / ra-diation (Lin, Eradat et al. 2008). The reason forthis recommendation is the rather painful ex-amination and difficulties to differentiate scartissue from early recurrence. In patients with anormal breast cancer risk, radiological follow-up is then suggested on a yearly basis.

In the postoperative follow-up, the radiologist should answer the following questions:

� Identification and description of radiologicalchanges found in postoperative follow-up.

� Are these findings related to typical / non-typicalfindings due to surgery and radiation therapy?

� Do these changes mimic or mask recurrence of cancer?

1b)

1a)

2a)

Fig. 1:Mammogram 4 years after cosmetic superior pedicle reduc-tion mammoplasty. CC projection (a) The scar is located in themidline. Calcifications, signs of fat necrosis and oil cysts may be found in this area. (b) In MLO projection, the tissue is lo-cated in the central or lower part of the breast. A fibrotic ringis found around the nipple area with occasionally typical small rounded calcifications in the subcutis (also cf. Fig. 3a).

Fig. 2:Mammogram 4 years after cosmetic inferior pedicle reduction mammoplasty. The CC projection (a) reveals a typical scar in thecentral part of the breast, similar to the radiological finding after re-duction mammaplasty with a superior pedicle. The MLO projection (b) shows a characteristic redistribution of the tissue in the upper region of the breast. Asymmetric distribution or an island of breasttissue separated from the parenchyma is found occasionally.

Fig. 3:CC projection (a) following reduction mammoplasty with asuperior pedicle showing typical small calcifications aroundthe nipple area. Round-shaped calcifications at the 6 o’clockposition in ML projection (b). Fatty tissue necrosis after surgerymay result in oil cysts of different sizes and shapes, with orwithout calcifications and a typical radiolucent center.

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Radiological Findings

2. Mammographic findings following cosmetic reduction mammoplasty

Reduction mammoplasty (RM) removes breast tissue from the superior quadrants (inferior pedicle-basedRM), the inferior quadrants (superior pedicle-based RM) or parts of both quadrants (central RM, combi-nation techniques with secondary pedicles), leading to a typical pattern of radiological changes (Danikas,Theodorou et al. 2001; Yalin, Bayrak et al. 2003).

Following breast reduction, a postoperative mam-mogram should be done one year after surgery todocument any mammographic changes resulting from surgery for future evaluation. Patients withnormal radiological findings continue with the routine breast cancer screening program.

The following changes may be found in the mam-mogram / sonogram after RM:

� Change and / or rotation in breast tissue lo-calization depending on the surgical technique (parenchymal redistribution)

� Scaring, architectural distortion, fibrosis � Calcifications � Oil cysts � Local fatty tissue necrosis � Granulomas (suture material) subsequent to

wound healing problems, late granulomas � Retroareolar fibrosis and typically small, well

shaped and round calcifications located around the nipple-areola complex

� Hematomas, seromas and later in time coarsegranulomas (chronic inflammatory reaction against suture material)

(Fig. 1a-1b, 2a-2b, 3a-3b)

Typical findings: � The scar at 6 o’clock and the calcifications in

this area, scars or fluid collections with or with-out fat necrosis prepectoral in the midline

(Fig. 3b, 8a-8c)

2b)

3a)

3b)

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� Seromas in the center and subcutaneous retro-areolar fibrosis and periareolar subcutaneous,well shaped small calcifications (Fig. 3a)

� Postoperative masses and fluid collectionsslowly diminish in size and density and will beradiolucent after 1 to 2 years.

(Fig. 4a-4c)

3. Mammographic finding following Breast Conser- ving Surgery for breast cancer

3.1 Standard Breast Conserving Surgery (quadrantectomy or lumpectomy) and radiation therapyStandard BCS removes the tumor with a margin of healthy tissue. Postoperative radiological findingsfollowing standard BCS (Dershaw 1995; Brenner, Pfaff 1996; Carlotti, Siragusa et al. 1993) are compa-rable to those seen after oncoplastic surgical proce-dures with no or minor shift of breast tissue within the breast (e.g. Batwing procedure, S-reduction).

4b1)

4a2)

4a1) 4b2)

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Early effects: � Skin thickening, hyperemia, lymph edema, high den-

sity of breast tissue, hematomas, seromas, fat necro-sis, granulations and fluid collections, architectural distortion with scarring causes palpable masses.

(Fig. 5a)

Late effects: � Asymmetries, typical scarring, radial scars, skin

and tissue retraction, skin thickening, fibrosis,fat necrosis, oil cysts.

� Decrease of tissue density by resolving the ede-ma and hyperemia.

� Fluid collections and architectural distortions resolve over the years (1 to 4 years) with a stabi-lized mammographic finding.

� Calcifications are usually late effects and are attrib-utable to sutures or tissue necrosis (fat necrosis). The incidence is reported at totalling approx. 30%. Calcifications appear 6 to 12 months after BCS butmay also be detected several years postsurgery.

(Fig. 5b)

4c)

5b)

5a)

Fig. 4:Routine mammography of a 39–year-old woman, 16 years after cos-metic reduction mammoplasty with an inferior-based pedicle. Clini-cally, the patient presented with a slightly denser right breast, but this was already noted one year after surgery. Mammography shows typical findings seen after reduction mammoplasty in both breasts in CC (a1, a2) and MLO projections (b1, b2), yet with an asymmetric tissue density on the right side. Breast MRI (c): Early and high increase of con-trast agent on the right side. The pattern of enhancement shows anextensive involvement of breast tissue (core needle biopsy revealed multicentric invasive carcinoma, mastectomy was performed).

Fig. 5:(a) Early effects after 1 year following surgery and radiation therapy (MLO projection). Skin and trabecular thickening from edema occursseveral weeks after radiation therapy and resolves over a period of months or years, but may also evolve into fibrotic tissue. The increased density and the architectural distortion, seromas, fluid collections and local fat necrosis caused by surgery make compression more painful and difficult while reducing mammogram quality. (b) Late effects two and more years later (MLO projection). The edema diminishes and thedensity decreases. Postoperative masses and fluid collections usuallyresolve within 1 to 2 years after surgery. Postsurgical scarring/fibro-sis appear with calcifications in various sizes and forms. Pleomorphiccalcifications are important markers for cancer recurrence and an in-creased density may be due to cancer recurrence.

212


Calcifications: � The presence of polymorphic/fine granular cal-

cifications represents a diagnostic challenge for the radiologist. This situation is further ren-dered difficult due to the fact that benign and malignant calcifications appear at the same time following surgery (6 to 24 months follow-ing treatment).

� All postoperative changes with the exceptionof calcifications will resolve with time (Brenner, Pfaff 1996; Carlotti, Siragusa et al. 1993), and theknowledge of the time course will facilitate in discriminating cancer recurrence.

(Fig. 6a-6d, 7a-7b)

6b)

6a)

6c)

Fig. 6:Time course of calcifications after quadrantectomy and radia-tion for breast cancer. (a) First mammogram (CC view) 1 yearafter surgery and radiation showing retraction of the skin and small calcifications. Some recurrences are evident by the de-velopment of new microcalcifications. These are usually notdifficult to distinguish from benign, dystrophic calcifications. However, should fine linear or heterogeneous calcifications be found, they should be considered as a recurrence. (b) Two yearsafter surgery / radiation, the calcifications are more distinctlypronounced and of a benign appearance (dystrophic calcifica-tion deposits and fat necrosis). (c) Three years after surgery /radiation, the calcification is well shaped with no signs of ma-lignancy. (d) Sonographic view of the scar area reveals fatty tis-sue and calcifications. No sign of malignancy.

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3.2 Oncoplastic surgery and radiation therapy

Oncoplastic Breast Conserving Surgery comprisesremoval of the tumor and immediate reconstruc-tion of the defect. Most patients undergo radiationtherapy following surgery.

While standard breast conservation results in skin und tissue retraction within the defect area – andtherefore a change of the anatomical breast – OPSpreserves the shape of the breast. This is also true for radiological imaging. Radiological changes af-ter OPS depend on the type of surgery performed. Basically, three types of surgical procedures are seen.

3.2.1 Oncoplastic surgery techniques with tumor resection and breast remodelling with no significant shift of breast tissue (e.g. Batwing procedure, S-reduction, round block)

The radiological findings following these tech-niques are comparable to those seen after stand-ard BCS and radiation therapy and have been de-scribed above.

6d)

7a)

Fig. 7:(a) Patient following quadrantectomy for invasive breast can-cer with large high-grade intraductal carcinoma in situ andradiation therapy in 2002. In 2008, the mammogram shows atypical scar in the 6 o’clock position with multiple polymorphiccalcifications requiring further evaluation. The polymorphic pattern and the increasing irregular scar indicate a pathologi-cal examination. (b) Magnification mammogram. Core needle biopsy revealed benign deposits of calcifications, no cancer.7b)

214


3.2.2 Complex oncoplastic surgery(e.g. reduction mammoplasty, Grisotti flap)

These techniques result in more profound chang-es, which are further pronounced by radiation therapy.

The most common techniques in use are: 1. Superior pedicle reduction mammaplasty

(Fig. 8a-8c)2. Inferior pedicle reduction mammaplastyff

(Fig. 9a-9c, 10)3. Combination of both techniques – superior

pedicle reduction mammaplasty and defectreconstruction with an inferior pedicle(Fig. 11a-11d)

Depending on the surgical technique applied, mam-mogram and ultrasound show characteristic post-traumatic findings and shifts of breast tissue withtypical locations of palpable masses, fluid collections, scars, fat necrosis, and benign calcifications, such as scattered polymorphic calcifications, thick calcifiedplaques, and thin arcs of calcified oil cysts and calci-fied suture material. In the literature there seems tobe an increase in BIRADS IV classifications and post-operative needle biopsies after complex oncoplastic surgery (Losken and Schaefer et al 2009).

3.2.3 Oncoplastic surgery and reconstruction of the partial mastectomy defect with distant flaps

In most cases, the latissimus dorsi flap is used fordefect remodelling (Fig. 12a-12b).

8b)

8a)

8c)

Fig. 8:CC (a) and MLO (b) projection following partial mastectomyand superior pedicle oncoplastic reduction mammaplasty.Postoperative radiological findings are similar to those seenwith cosmetic reduction mammaplasty with a superior pedi-cle. (c) Fatty tissue necrosis is frequently seen in the ultrasoundcentrally in the breast near the pectoralis major muscle fasciaand should be differentiated from breast cancer.

215


4. Tips and tricks

� Knowledge of the surgical technique per-formed, together with the previous location and histology of the tumor, are necessary forthe radiologist to differentiate common post-operative changes from cancer recurrence.

� Changes following surgery and radiation therapy are expected to be most pronounced 6 monthsafter radiotherapy. Mammography is thus asso-ciated with decreased sensitivity and specificity in the first year postsurgery but should be con-sidered the new standard baseline for interpret-ing future mammograms (Birrenbach, Miller etal. 2004; Mendelson 1992; Lin, Eradat et al. 2008).

� Breast MRI is not recommended for follow-up during the first year after surgery / radiationtherapy except in women with a high risk of cancer recurrence (Birrenbach, Miller et al. 2004;Heywang-Köbrunner, Schlegel et al. 1993; Müller, Barkhausen et al. 1998). However, 18 monthsafter surgery, there will be no more significantcontrast media enhancement-caused by surgeryor radiation therapy (Heywang-Köbrunner, Sch-legel et al. 1993; Müller, Barkhausen et al. 1998).

� Postoperative (post-irradiation) mammograms should be done using a slightly increased dose (kV)for these breasts showing a higher density and arenot as easy to compress as a normal breast.

� Fatty tissue necrosis: Fatty tissue necrosis may mimic breast cancer recurrence in the mam-mogram or ultrasound. In these patients, color Doppler ultrasound may help to distinguish be-tween fatty tissue necrosis and cancer, as it re-veals the typical vascularization of a malignantlesion (Fig. 13a-13c).

9a)

9b)

9c)

Fig. 9:CC (a), MLO (b) and ML (c) projection following oncoplastic sur-gery with inferior pedicle mammoplasty. Postoperative radio-logic findings are similar to those of cosmetic reduction mam-maplasty with an inferior pedicle. The calcifications are in the area of the scar and are typically benign calcifications.

216


� Scars or tumor recurrence?: Masses only seen in one mammo-graphic projection instead of 2 in most instances are scars. Bycontrary masses seen in two projections - mediolateral oblique(MLO) and craniocaudal (CC) projection - are suspicious for breast cancer (Fig. 14a-14f, 15a-15c, 16). Mammograms should thus bedone in different projections - CC, MLO, mediolateral (ML) - and spot-compression and / or magnification mammography may be helpful.

� Doppler ultrasound may assist in differentiating between tumorand scars: Scars show vascularization only in the periphery andthe lesion will minimize under pressure, whereas recurrences reveal vascularization also inside the lesion and do not change size under pressure. Additionally, malignant lesions often show afeeding vessel (Fig. 13a).

� The density of both breasts decreases with time after surgery, ra-diation therapy and chemotherapy / hormonal treatment. This de-crease is more pronounced in the non-tumor / non-radiated breast.Relapse is to be ruled out should the treated breast tissue not de-crease in density with time or should an increase be observed.

Birrenbach, S., S. Miller, et al. (2004). “Clini-cal value of mammography, ultrasoundand MR Imaging during the first year after breast conserving therapy of breast cancer.RöFo 176: 1423-30.

Brenner, R.J., J.M. Pfaff. (1996). “Mammographic features after conservation thera-py for malignant breast disease: serial find-ings standardized by regression analysis.Am J Roentgenol 167: 171-8.

Carlotti, G.A., A. Siragusa, et al. (1993). “The mammographic images of the irradiatedbreast after conservative therapy for carcinoma”. Radiol Med 86: 101-5.

Danikas, D., S.J. Theodorou, et al. (2001).“Mammographic findings following re-duction mammoplasty”. Aesthetic PlastSurg 25: 283-5.

Dershaw D.D. (1995). “Mammography in patients with breast cancer treated bybreast conservation (lumpectomy with orwithout radiation).” Am J Roentgenol 164:309-16.

Kopans, D.B. (2007). “The altered breast:pregnancy, abscess, post-biopsy changes, mastectomy, radiation, and implants”. Lip-pincott Raven, Chapter 18, pp 607-70.

Lin, K., J. Eradat J, et al. (2008). “Is a short-interval post radiation mammogram nec-essary after conservative surgery and ra-diation in breast cancer?” Int J Radiat OncolBiol Phys 15: 1941-1047.

Losken, a., Schaefer, T.G., et al (2009). The im-pact of partial breast reconstruction using re-duction techniques on postoperative cancer surveillance. Plast Reconstr Surg 124(1):9-17

Mendelson, E.B. (1992). “Evaluation of the postoperative breast.” Radiol Clin North Am 30:107-38.

Müller, R.D., J. Barkhausen, et al. (1998). “As-sessment of local recurrence after breast conserving therapy with MRI”. J Comput Assist Tomogr 22: 408-12.

Yalin, C.T., I.K. Bayrak, et al. (2003). “Breast changes after reduction mammaplasty: a case report with mammographic and ultrasonographic findings and a literature review”. Breast J 9: 133-7.

References

217

1. Concept

Although oncoplastic surgery has gained acceptance in Europe andis now widely practiced in dedicated breast units (Audretsch, Rezai et al. 1998; Petit, Rietjens et al. 1998; Petit, Garusi et al. 2002; Clough,Lewis et al. 2003), breast deformities and localized glandular defectsfollowing conservative treatment are still frequently observed. Fat grafting, first described by Coleman (Coleman 2001; Coleman 2004;Coleman, Saboeiro et al. 2007), is a simple technique that allows tocorrect small to medium-sized defects. As demonstrated by Rigotti(2007), grafted fat does more than simply restore fullness: It sub-stantially improves the quality of the skin overlying transplanted fat, especially in irradiated fields, owing to the activity of adipose-derived stem cells.

The method is simple, reproducible, can be performed under local an-esthesia and has the potential to initiate tissue regeneration and repair.

2. Indications

� Correction of small to medium-sized defects at the quadrantectomy site. � Restoration of irradiated skin and esthetic improvement of the scar. � Reduction of radiation-induced skin damage.

Lipofilling of Tissue DefectsFollowing Breast Conservation

Mario Rietjens, Francesca De Lorenzi

2.3.4

218



Fat grafting is contraindicated in cases of large glan-dular defects or severe breast asymmetries. Grafting large amounts of adipose tissue in the same sec-tion in fact bears the inherent risk of graft necrosis (liponecrosis) which results in local fibrosis and un-satisfactory results. In such cases, a flap and/or si-multaneous breast reduction is necessary.


� Preoperative mammogram and ultrasound examina-tion are strongly recommended before fat grafting.

� Patients are examined in the upright standing po-sition. Both donor and recipient areas are marked.

� Donor areas are those where fat is available to a sufficient extent (abdomen, lateral thighs, hips, gluteal region and internal knee area). The per-iumbilical area is the one mostly used in our expe-rience, since the stab skin incision in the umbilicusis easily hidden and fat is usually well represented.

� One or multiple defects (recipient areas) can be simultaneously corrected according to preopera-tive drawings.

� Each glandular defect is preoperatively measured(defect width and height, maximum depth) in or-der to assess more objective results and graftedfat reabsorption at follow-up (also consider use of the breast-analyzing tool, cf. chapter 2.3.1).

� Further markings are taken if combined proceduresare planned for the same session (i.e. nipple and areola reconstruction in case of central quadrants,scar correction or contralateral breast reduction).

2)

1)

Fig. 1:Preoperative drawing of the donor and recipient areas.

Fig. 2:Infiltration of the donor area using a needle.

Fig. 3:Fat harvesting from the umbilical area through a stab incisionin the umbilicus. 3)

219

Lipofilling of Tissue Defects

5. Surgery

Fat grafting can be performed under general or lo-cal anesthesia. The patient is usually in the supineposition, although different positions may be indi-cated according to the donor area.

We use the standard technique described by Cole-man (Coleman 2009), with minor modifications.Newer techniques such as the body-jet® may spare some time and increase usable adipocyteshowever prospective studies are still missing. Incases of general anesthesia, the recipient site is in-filtrated with a solution of Ringer’s lactate 500ccplus epinephrine 1mg, using a blunt 1mm cannula. For local anesthesia, the solution contains Ringer’slactate 500cc and mepivacaine 50cc with epine-phrine 1:400,000 and is infiltrated with an epidur-al needle. The fat is harvested through the same incision as the infiltration with vasoconstriction.

In harvesting, we use a 3mm Coleman cannula, 15or 23 cm in length, with a blunt tip. The harvestingcannula is connected to a 10-cc Luer-lok syringe.

The fat is centrifuged at 3000 rpm for 3 minutesusing the MPW Med Instruments model 223/e centrifuge. It allows to separate adipose cells from bloody components (blood, saline and anesthetic solution; the inferior fraction) and from oily com-ponents (the upper fraction).

4)

5a)

5b)

Fig. 4:The syringe with the lipoaspirate is closed with a dual function Luer-Lok plug.

Fig. 5:(a, b) The centrifuge

220


The injectable fat is directly transferred from the 10-cc syringe into the 1-cc syringe. In the recipi-ent area at the mastectomy site, local anesthesia with mepivacaine with 1:400.000 epinephrine is injected just around the periphery of the defect, if necessary. Blunt 7- to 9-cm Coleman cannulasare applied for fat grafting. A small amount of fat is injected at each passage in multiple retrogradepaths in the subcutaneous layer. It is crucial to use a 1cc-syringe for grafting in order to control theamount of fat released at the recipient site. We donot graft fat in the gland or in the pectoralis mus-cle. With this maneuver, single lines of adipocytes are placed into a well vascularized environment,permitting a satisfactory “take” of the fat grafts and thus avoiding fibrosis and liponecrosis.


Simple dressings are used, with Steri-Strips delim-iting the grafted area at the quadrantectomy siteand compressive dressings at the donor site.The dressings are removed three days after sur-gery. No antibiotics or catabolic steroids are rou-tinely used in the postoperative period, nor othertreatments such as massages or lymphatic drain-age, endermology.

6b)

7a)

6a)

Fig. 6:(a, b) Merocel® surgical patties are used to absorb and removeany remaining oily fraction in the centrifuge.

Fig. 7:(a, b) Fat grafting.

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Lipofilling of Tissue Defects

7. Tips and tricks

� Whatever the donor area, we always try to en-sure that the scar from fat harvesting is hiddenin natural folds.

� We strongly suggest to avoid grafting in theglandular tissue and or pectoralis major mus-cle. Microcalcifications subsequent to fat graft-ing may occur and are to be differentiated fromother calcifications. They are generally morpho-logically different from those suspicious for malignancies. Only in cases of doubts are ultra-sound examination, magnetic resonance (MR) imaging or fine needle biopsy helpful for diag-nosis (Spear, Henry et al, 2005; Abboud, Vadoud-Seyedi et al. 1995; Kim, Park. 2004) .

� Fat grafting in the subcutaneous layer does notinterfere with patients’ breast examination or oncologic follow-up (personal experience).

� Glandular defects are corrected subjectively un-til the site is seen as satisfactorily full and theamount of fat grafted is visually determined. Werecommend to overcorrect the defects (at least20% overcorrection) in order to avoid the incon-venience of variable fat reabsorption with time .

7b)

8)

9)

Fig. 8:Left breast defect in the external superior quadrant after quad-rantectomy and locoregional radiotherapy. Preoperative view.

Fig. 9:Postoperative view after grafting of 50cc of adipose tissue un-der local anesthesia.

222


Abboud, M., J. Vadoud-Seyedi, et al. (1995).“Incidence of calcifications in the breastafter surgical reduction and liposuction”. Plast Reconstr Surg 96: 620.

Audretsch, W., M. Rezai, et al. (1998). “Tu-mor-specific immediate reconstruction inbreast cancer patients: perspectives”. PlastSurg 11: 71-100.

Clough, K.B., J.S. Lewis, et al. (2003). “On-coplastic techniques allow extensive resections for breast-conserving therapy of breast carcinomas”. Ann Surg 237: 26-34.

Coleman, S.R. (2001). “Structural fat grafts: the ideal filler?” Clin Plast Surg 28: 111-9.

Coleman, S.R. (2002). “Hand rejuvenationwith structural fat grafting”. Plast ReconstrSurg 110: 1731-45.

Coleman, S.R. (2004). “Structural fat graft-ing”. St Louis, Mo: Quality Medical.

Coleman, S.R., A.P. Saboeiro. (2007). “Fat grafting to the breast revisited: safety and efficacy”. Plast Reconstr Surg 119: 775-85.

Kim, S.M., J.M. Park. (2004). “Mammo-graphic and ultrasonographic features afffter autogenous myocutaneous flap recon-struction”. J Ultrasound Med 23: 275.

Petit, J.Y., C. Garusi, et al. (2002). “One hun-dred and eleven cases of breast conser-vation treatment with simultaneous re-construction at the European Institute of Oncology (Milan)”. Tumori 88: 41-7.

Petit, J.Y., M. Rietjens, et al. (1998). “Integration of plastic surgery in the course of breast conserving surgery for cancer to

improve cosmetic results and radicality of tumor excision”. Recent Results Cancer Res152: 202-11.

Rietjens, M., F. De Lorenzi F, et al. (2009). “Secondary breast reconstruction“ In: Fatinjection from filling to regeneration. Edited by Coleman S, Mazzola R. 2009, QMPInc, San Louis, Missouri.

Rigotti, G., A. Marchi, et al. (2007). “Clinical treatment of radiotherapy tissue damageby lipoaspirate transplant: a healing proc-ess mediated by adipose-derived adultstem cells”. Plast Reconstr Surg 119: 1409-22.

Spear, S.L., B.W. Henry, et al. “Fat injection to correct contour deformities in the re-constructed breast”. Plast Reconstr Surg116: 1300-5.

References

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1. Introduction

Broadening the indications for breast conserving surgery (BCS) hasresulted in more patients with an inferior cosmetic result (Petit, Ri-etjens 1991). Defects following BCS largely depend on the amount of resected glandular tissue (defects are evident in patients with morethan 10-20% of breast tissue resected [Cochrane, Valasiadou et al.2003], but depend on the breast volume excised in relation to breast size). This applies irrespectively of whether or not skin is excised withthe tumor, the location of the tumor in the breast, postoperative ra-diation therapy or a history or previous breast surgery. Defects areeither evident immediately after surgery or develop with time (Petit,Rietjens 1991). Several techniques to reconstruct tissue defects after breast surgery have been described and include rearrangement of local tissue (local flaps, breast reduction), substitution of tissue loss using implants or autologous fat grafting, or distant flaps (Slavin,Love et al. 1992 ; Berrino, Campora et al. 1992 ; Clough, Cuminet et al. 1998; Spear, Wilson et al. 2005). Late reconstruction of partial mas-tectomy defects is more time-consuming and presents a challengeto the surgeon, is associated with increased costs, and bears a higher risk of complications and cosmetic failure. Therefore, deformities fol-lowing partial mastectomy should be corrected immediately during initial surgery using oncoplastic surgery (OPS).

Oncoplastic Breast ConservingSurgery for Late Reconstruction of Partial Breast Defects

Peter Schrenk

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2. Classification and treatment of partial mastectomy deformities

Berrino et al. published a classification of deformities following par-tial mastectomy and radiation (Berrino, Campora et al. 1987). In the present author’s opinion, Clough et al. have proposed a more practi-cable definition of postsurgical defects and their treatment (Clough,Cuminet et al. 2008).

3. Indications for Breast Conserving Oncoplastic Surgery (OPS – BCS) after BCS

� Defects following BCS with or without radiation therapy forbreast cancer (Fig. 1a, 2a).

� Patients after BCS with or without radiation and local tumor re-currence: Local recurrences are usually treated by total mastec-tomy. Redo BCS may be appropriate in selected patients (those treated in clinical trials, large or ptotic breasts, no previous radia-tion therapy, small cancer size, favorable histology and biology, patients choosing BCS) (Fig. 3a-3c).

� Glandular tissue defects due to surgical complications needing revision surgery (Fig. 4, 5).

Deformity Treatment

Type 1Assymetry between both breasts, no distortion or deformity

Contralateralsymmetrizationprocedure

Type 2 Breast deformity, partialreconstruction possible

Partial reconstruction with local or distantflaps, autologous fat grafting, implants

Type 3 Deformity requires mas-tectomy

Mastectomy andmyocutaneous flap

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3. Contraindications for OPS - BCS after BCS

� Large defects/unfavorable defect to breast size ratio. � Defects not confined to one breast quadrant or

two adjacent breast quadrants. � Small breasts without ptosis. � Distinct radiological sequelae with decreased

skin flap vascularization. � Risk factors for increased complication rate:

Obese patients, smokers, diabetes. � Local tumor recurrence (see above).

4. How to do it

� Evaluation of defect size after BCS: This is themost important part. Does the defect requiretotal mastectomy and reconstruction with a distant flap or can a partial mastectomy defectbe reconstructed with a local or distant flap, animplant or autologous fat transfer?

� Evaluation of the kind of defect: Glandular tis-sue retraction, nipple-areola complex (NAC) dis-tortion, radiation-induced changes, skin deficit,glandular deficit or both.

� Evaluation of local breast tissue quality: Radio-therapeutic sequelae, skin vascularization, fattytissue necrosis.

� Evaluation of the localization of the defect inthe breast.

� Evaluation of scars / prior incisions: They mayinfluence the technique of reconstruction used (in order to preserve blood supply to the NAC,the skin and the flap used for remodelling).

1a)

1b)

Fig. 1:(a) Glandular tissue and skin deficiency and distortion of the NAC in the lower outer quadrant of the left breast following BCS and radiation. (b) Postoperative view subsequent to cor-rection of the defect with superior pedicle mammaplasty.

Fig. 2 (a) Glandular tissue and skin deficiency, distortion of the NAC following BCS and radiation for cancer in the upper outer quadrant of the left breast. (b) Postoperative view: The defect was remodelled with a latissimus dorsi flap.

2b)

2a)

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4.1 Algorithm of reconstruction

� Defect size to breast size ratio: Small (favorable) defects may bereconstructed using local (in-breast) flaps, reduction mamma-plasty, a thoracoepigastric flap or autologous fat.

� Large (unfavorable) partial mastectomy defects are treated with distant flaps.

� Location of defect in the breast:

Locationof defect (quadrant) Procedure for correnction of defect

CentralSuperior pedicle with inferior pedicle used for defect reconstruction, Grisotti flap, batwing

Upper outerLD flap, S reduction, superior pedicle withinferior pedicle used for defect reconstruc-tion

Upper medialLD flap, S reduction, superior pedicle withinferior pedicle used for defect reconstruc-tion, round block, inferior pedicle, batwing

Upper innerSuperior pedicle with inferior pedicle used for defect reconstruction, S reduction, round block

Lower outerSuperior pedicle (rotated), superior pediclewith inferior pedicle used for defect recon-struction, thoracoepigastric flap

Lower medial Superior pedicle, thoracoepigastric flap

Lower innerSuperior pedicle (rotated), superior pediclewith inferior pedicle used for defect recon-struction, thoracoepigastric flap

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� Technique of reconstruction:Autologous fat transfer: Small glandular de-fect, no or minimal skin defect, no or mini-mal distortion of the NAC.Local breast flaps: Small defect, large or medi-um-sized breast, good quality of skin / glan-dular tissue, no gross distortion of the NAC.Implants: Minimal glandular tissue defectresulting in breast hypoplasia, no localizedgross loss of glandular tissue, minimal skin defect, no or minimal distortion of NAC.Distant flaps: Gross defects, skin and glan-dular deficiency, NAC distortion, poor qualityof tissue following surgery/radiation.3a)

3b)

3c)

Fig. 3:(a) Patient with recurrent cancer (6mm) in the upper outer quadrant 8 years following BCS for T1c cancer, no postopera-tive radiation. The hematoma is a result of core needle biopsy. (b) BCS scar in the upper outer quadrant with moderate tissue defect. Proposed treatment: Superior-based pedicle mamma-plasty with resection of the tumor in the upper outer quadrantand defect remodelling with an inferior pedicle. (c) Postopera-tive view 2 years following surgery and radiation.

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5. Tips and tricks

� Limit any surgery after breast radiation for thehigher risk for complications: Delayed woundhealing, skin flap necrosis, fatty tissue necrosis, fibrosis (Pezner, Lorant et al. 1992).

� Radiation-induced changes of breast tissue andskin stabilize after 1 to 2 years, re-operation sur-gery should be delayed to that time.

� Higher complication rate seen in obese pa-tients, smokers, diabetes.

� Avoid excessive undermining of (radiated) skinflaps; minimal undermining of the skin flaps just to allow closure of the skin pedicles with-out tension.

� Dissect skin pedicles with an adequate amount of viable tissue underneath the skin.

� Avoid excessive transposition of tissue flapswithin a radiated breast.

� Choose incisions that avoid disturbance of bloodsupply to skin, NAC, flaps used for remodelling.

� Complete resection of fibrotic tissue, skin withinsufficient blood supply.

� In the presence of doubtful tissue or skin vas-cularization, convert to total mastectomy andreconstruction with musculocutaneous flaps.

� Rule out cancer / local recurrence prior to de-fect reconstruction by core needle biopsy.

4a)

4b)

Fig. 4:(a) Patient following cosmetic reduction mammaplasty andpartial necrosis of the NAC and tissue defect in the lowerbreast quadrant of the right breast. (b) Closer view of the de-fect 9 months following initial surgery. (c) Postoperative view:Correction of the defect with redo superior pedicle mamma-plasty.

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� Avoid the use of implants in patients with BCS and radiation whenever possible, no subglan-dular position of implants.

� Knowledge of the type of previous surgery isimportant to avoid compromising the vascular supply of a flap used for reconstruction (e.g. pri-or surgery inferior pedicle – no superior pediclepossible in remodelling).

� Reuse the initial pedicle to maintain blood sup-ply (e.g. prior surgery superior pedicle – superi-or pedicle remodelling in re-operation surgery).

� Each defect should be reconstructed with larger skin / glandular tissue volume than the estimated defect size due to volume loss andshrinkage after radiation and prior surgery.

� Discuss with patient that the result of the re-construction may be poorer than the preopera-tive status.

� Provide patient with realistic expectations re-garding post-reconstruction outcome.

� Prevention of defects is preferred over secondaryreconstruction: Oncoplastic techniques at thetime of primary surgery help to avoid defects.

4c)

Fig. 5:Central breast defect following BCS for intraductal carcinoma in situ, radiation and open surgical biopsy for microcalcifica-tions (core needle biopsy could not exclude recurrence). Thispatient shows all the contraindications for a partial mastecto-my reconstruction: Gross glandular and skin deficiency, distor-tion of the NAC, small non-ptotic breast. Proposed treatment: Mastectomy and reconstruction with latissimus dorsi flap ordeep inferior epigastric perforator (DIEP). 5)

230


ReferencesBerrino, P., E. Campora, et al. (1987). “Post-quadrantectomy breast deformities: classification and techniques of surgical correc-tion”. Plast Reconstr Surg 79: 567-72.

Berrino, P., E. Campora, et al. (1992). “Correc-tion of type II breast deformities followingconservative cancer surgery”. Plast Recon-str Surg 90: 846-53.

Clough, K.B., J. Cuminet, et al. (1998). “Cos-metic sequelae after conservative treat-ment for breast cancer: classification andresults of surgical correction”. Ann Plast Surg 41: 471-81.

Cochrane. R.A., P. Valasiadou, et al. (2003).“Cosmetic and satisfaction after breastconserving surgery correlates with thepercentage of breast volume excised”. Br JSurg 90: 1505-9.

Petit, J.Y., M. Rietjens. (1991). “Deformitiesafter conservative breast cancer treat-ment”. In, Noone RB (ed). Plastic and recon-structive surgery of the breast. B.C. Decker:Philadelphia, pp 455-66.

Pezner, R.D., J.A. Lorant, et al. (1992). “Wound-healing complications following biopsy of the irradiated breast”. Arch Surg 127: 321-24.

Slavin, S.A., S. M. Love, et al. (1992). “Recon-struction of the radiated partial mastectomy defect with autogenous tissues”. PlastReconstr Surg 90: 854-65.

Spear, S.L., H.B. Wilson, et al. (2005). “Fat injection to correct contour deformities inthe reconstructed breast”. Plast ReconstrSurg 116: 1300-5.

231

1. Concept

Due to early detection, the use of neoadjuvant chemotherapy and the development of oncoplastic surgical refinements, the rate of breast conserving therapy (BCT) in women suffering from breast cancer has increased over the past 20 years. The procedure generally consists of partial mastectomy followed by radiotherapy. Althoughthe cosmetic results are mostly satisfactory, the incidence of consi-derable deformities is reported to amount between 20 and 30% (Kronowitz 2009).

Bajaj and coworkers showed that women who receive breast conser-vation therapy in the treatment of their breast cancer have notice-able treatment-related breast asymmetry (Bajaj, Kon 2004). Accor-ding to Matory, asymmetry and contour abnormalities are far morecommon than noted in the radiation therapy literature (Matory,Wertheimer 1990). Although patients’ satisfaction with lumpectomyand radiation is very high, this satisfaction is not necessarily based on objective criteria defining esthetic parameters, but is strongly in-fluenced by retainment of the breast as an original body part. Cloughpublished data according to which, after conservative treatment forbreast cancer, 20% to 30% of patients have a residual deformity that sometimes requires surgical correction (Clough, Cuminet 1998). Herecommends early integration of plastic surgical techniques at the

Defect Reconstruction AfterPartial Mastectomy With Flaps

Rupert Koller, Stefan Gärner

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time of initial lumpectomy, thus reducing the need for delayed re-constructive surgery. Because deformities are mainly postoperative phenomena, optimal treatment should be preventive - by performingimmediate remodelling of the treated breast before radiotherapy.

The poor outcome can be the result of an inadequate relation be-tween the size of the breast and the amount of resected tissue. Alternatively, it can represent the sequela of irradiation therapywhich may result in shrinking and scarring of the tissues. The spe-cial characteristics of a radiation-related deformity are that it mayfurther deteriorate with increased interval to the operation. Cor-rection of contour deformities should be done primarily in breast-conserving procedures. This is feasible by using modified reduc-tion mammaplasties, local flaps of the breast tissue, or switching a latissimus dorsi muscle flap. For secondary correction of defectsafter breast-conserving treatment, a latissimus dorsi muscle canbe used as well as z-plasty for scar contracture (Deutinger, Tairych 1999).

While a high percentage of patients after total mastectomy re-quest reconstruction, the percentage is much lower in those withcosmetically bad results following BCT. On the one hand, thesewomen are rarely referred to a reconstructive surgeon by their on-cologic surgeons. Additionally, many patients are satisfied simplyby the fact that their breast has been preserved and are reluctant to have further surgery done. Thus it is the radiologist or the med-ical oncologist who at times is the one to encourage the patientsto have a significant deformity corrected.

There is general agreement that following partial mastectomy, primary oncoplastic reconstruction with local tissue is preferable whenever possible (Kronowitz 2009). Secondary reconstructionsare often impaired mainly by the consequences of radiation ther-apy, thus resulting in a higher complication rate for local tissue ar-rangements and breast reduction techniques. Waiting to repair a large partial mastectomy deformity until radiation therapy is com-pleted usually necessitates a complex transfer of a large volume of autologous tissue. In addition, after radiation, the difficulties as-sociated with secondary repair within an irradiated surgical fieldlimit the use of adjacent irradiated breast tissue, and breast im-plants are not a preferable option. The cosmetic outcomes of total breast reconstruction after BCT are less than optimal, owing to the inelasticity of the irradiated breast skin envelope and the increased risk of mastectomy skin flap necrosis (Kronowitz 2009). On the

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Defect Reconstruction

other hand, the optimal time for the correction of a significant de-fect after BCT with a distant flap like a latissimus dorsi is discussed controversially. Unlike in cases of total mastectomy, the present authors’ personal strategy after partial mastectomy is to avoid dis-tant flap surgery for immediate reconstructions on account of thefollowing reasons:

1. Tumor margin status is not always clear at the time of resection. It is futile to spend a flap unless the resections margins are safelyconfirmed to be free of tumor by permanent histologic sections.

2. It is contraindicated to spend a distant flap and have it irradiated a -ffterwards, which often results in flap shrinking and inadequate cos-mesis.

2. Indications and types of procedures

Contralateral reduction mammoplasty is indicated in cases without significant deformity of the conservatively treated breast (smaller but normal shape) and contralateral C-cup.

If the operated breast shows significant deformities, such as asym-metries or grooves, replacement by non-irradiated tissue is indicat-ed. Local pedicled flaps, i.e. the latissimus dorsi flap or local perfora-tor flaps from the thoracic wall, are indicated for these procedures.

The correction of smaller defects by autologous fat transfer has re-cently become an interesting, yet controversially discussed alternative.

The use of local breast tissue arrangement for secondary correc-tions is not recommended. After radiotherapy, the incidence of de-layed wound healing and recurrent deformities is proven to be high(Kronowitz 2009). The same is true for reduction mammoplastiesin irradiated breasts, which can only be recommended after carefulexamination of the irradiated organ and meticulous informationprovided to the patient concerning possible consequences.

In the presence of severe distortions or deficits, it is often discussedwhether one should recommend a secondary resection of the re-maining breast and consecutive total reconstruction with a flap from the lower abdomen. Nevertheless, this procedure is in mostcases psychologically difficult to accept for a patient who has un-dergone radiation and at times neoadjuvant chemotherapy for the“benefit” of breast conservation.

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2.1 Operative procedures

2.1.1 Latissimus dorsi myocutaneous flap

The design and the location of the skin island main-ly depend on the position and the size of the defectin the breast. Comparative measurements with the contralateral intact breast must first be carried out. The amount of skin deficit is then determined. The skin island should be at least 1cm wider thanthe measured deficit on account of the convexityof the breast and secondary shrinking of the trans-ferred island. The borders of the latissimus muscleare drawn on the ipsilateral back and the skin islandis drawn into the desired position. It must be posi-tioned according to the location of the defect in thebreast. For more medially located defects, the skinisland must be more caudal and vice versa for later-ally located grooves (Fig. 1).

Flap harvest is performed according to chapter2.2.3.1. The amount of muscle which must be taken with the skin depends on the size of the defect. In some cases, a hemi-latissimus can be harvestedand the other half of the muscle can be preserved,provided that its innervation is maintained intact.Of course, it still remains more beneficial to haveredundant muscle volume than less. In case of re-dundancy, additional tissue of the irradiated breast can be excised in order to improve the recipient bed.

The muscle should not be fixed too firmly to therecipient bed in order to avoid new distortions. On the contrary, the skin island must be meticulouslyinserted and fixed. The difference between the irra-diated, relatively thin breast skin and the thick skin from the back would otherwise be too obvious.

1a)

1b)

Fig. 1:Preoperative view of a patient after quadrantectomy of theright breast with a (a) significant and painful volume defi-ciency. (b) Reconstruction with a pedicled latissimus flap.

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Defect Reconstruction

2.1.2 Perforator flaps

Although no significant donor site morbidity is at-tributed to the latissimus dorsi flap, the tendencyto sacrifice no muscle tissue has led to the devel-opment of perforator flaps (Hamdi, Van Landuyt 2004; Hamdi, Van Landuyt 2008). Their pedicles are prepared through the muscles to the stem ves-sels. Although versatility is increased with respect to flap design and transposition, the preparationis more demanding, thus requiring substantial ex-perience. The most frequently used perforator flapis the thoracodorsal artery perforator (TDAP) flap. The perforators are checked preoperatively by Dop-pler imaging in the same position as on the oper-ating table and the flap is centered around the perforator vessel. In the case of insufficient perfo-rators, it is advisable to take a muscle cuff aroundthe vessels and thus convert the perforator into a muscle-sparing latissimus flap. Perforator flaps are more suitable for defects in the lateral part of the breast.

2.1.3 Autologous fat transfer

Improvements in harvesting, processing and rein-jecting autologous fat tissue have led to an inten-sified use of this technique for partial or even totalbreast reconstruction. It is even said to improvethe quality of irradiated scars (Delay, Gosset 2008). Microcalcifications caused by poorly vascularized fat cells initially resulted in an intensive discussion whether the technique may interfere with post-operative mammography, potentially increasing biopsy rates. The American Society of Plastic andReconstructive Surgeons predicted in 1987 thatfat grafting would interfere with breast cancer detection and should therefore be prohibited. Re-cent studies have demonstrated the safety of this method, although it should still be used understrict conditions within an interdisciplinary teamincluding specially trained radiologists (Sinna, Gar-son et al. 2008; Gosset, Flageul et al. 2008; Cole-man, Saboeiro 2007).

2a)

2b)

Fig. 2:Fat transplantation in the right and laterally in the left breastfor volume deficiency: Preoperative (a), postoperative (b).

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The procedure can be carried out under either local or general an-esthesia (Fig. 2). Tumescent liposuction is performed and the fat may either be centrifuged (Coleman, Saboeiro 2007), or harvested withspecial syringes or devices such as the Body-jet® (Khouri, Del Vecchio 2009). It is reinjected with small needles in a criss-cross manner. As to the amount of injected fat, the postoperative decrease in size ne-cessitates a volume that is greater than temporarily called for. De-spite the above-mentioned problems, many reconstructive surgeonsbelieve that autologous fat grafting will prove to be the most impor-tant tool in reconstructing the partial mastectomy defect.

References Bajaj, A.K., P.S. Kon, et al. (2004). “Aesthetic outcomes in patients undergoing breastconservation therapy for the treatmentof localized breast cancer”. Plast ReconstrSurg 114(6): 1442-9.

Clough, K.B., J. Cuminet, et al. (1998). “Cos-metic sequelae after conservative treat-ment for breast cancer: classification andresults of surgical correction”. Ann Plast Surg 41(5): 471-81.

Coleman, S.R., A.P. Saboeiro (2007). “Fatgrafting to the breast revisited: safety and efficacy”. Plast Reconstr Surg 119: 775-85.

Delay, E., J. Gosset, et al. (2008). “Efficacy of lipomodelling for the management of se-quelae of breast cancer conservative treat-ment”. Ann Chir Plast Esth 53: 153-68.

Deutinger, M., G. Tairych, et al. (1999).“Contour defects after breast preserv-

ing therapy of breast carcinoma: primary and secondary possibilities of correction”.Strahlenther Onkol 175(11): 577-82.

Gosset, J., G. Flageul, et al. (2008). “Lipomod-elling for correction of breast conservativetreatment sequelae. Medicolegal aspects.Expert opinion on five problematic clinicalcases”. Ann Chir Plast Esthet 53(2): 190-8.

Hamdi, M., K. Van Landuyt, et al. (2004).“Pedicled perforator flaps in breast recon-struction: a new concept”. Br J Plast Surg57(6): 531-9.

Hamdi, M., K. Van Landuyt, et al. (2008).“Surgical technique in pedicled thoraco-dorsal artery perforator flaps: a clinical ex-perience with 99 patients”. Plast ReconstrSurg 121(5): 1632-41.

Khouri, R., D. Del Vecchio. (2009). “Breastreconstruction and augmentation using

pre-expansion and autologous fat trans-plantation”. Clin Plast Surg 36: 269-80.

Kronowitz, S.J. (2009). “Repair of the par-tial mastectomy defect”. In: NahabedianMY (ed) Procedures in reconstructive surgery, Cosmetic and reconstructive breastsurgery. Saunders, Philadelphia, pp 95-108.

Matory, W.E. Jr, M. Wertheimer, et al.(1990). “Aesthetic results following partial mastectomy and radiation therapy”. PlastReconstr Surg 85(5): 739-46.

Sinna, R., S. Garson, et al. (2008). “Fat graft-ing in the breast”. J Plast Reconstr AesthetSurg 62(5): 707-8.

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