Indications and Controversies in Partial Mastectomy Defect Reconstruction

Breast cancer surgical treatment nowadays includes oncoplastic surgery. It is a reliable oncologic surgical treatment, which also prevents functional and aesthetic sequelae, thus improving the patient’s quality of life and satisfaction. Numerous techniques have been described, with different levels of complexity and technicality. Their indications differ depending on the global breast volume and the degree of ptosis, on the tumor volume compared with the breast volume, and on the tumor location. This article describes the authors’ many years of experience of breast cancer treatment using oncoplastic surgery. They also established a decision-making guide, whose implementation enables treatment of every patient.

Key points

  • Sequelae after breast conservative treatment are unpredictable and related to the surgery and radiotherapy. Oncoplastic surgery is the best way to minimize the risk of functional and cosmetic sequelae.

  • Nowadays, an oncoplastic breast reshaping should be performed in every case of breast conservative surgery.

  • Various techniques have been described depending on the size and the ptosis of the breast and the tumor location.

  • In the case of large and ptotic breast, a therapeutic inverted-T mammoplasty should be performed, even in the case of small sized tumor.

  • The concept of replacement perforator flaps has pushed the limits of the oncoplastic surgery. Large tumors can be resected in patients with small to moderate breast size with low morbidity on the donor site.

Introduction

In the field of oncologic breast surgery, breast conservation therapy (BCT) is now the gold standard in the treatment of localized breast cancer. BCT associates surgery, aiming to ensure complete tumor resection with adequate margins, and radiotherapy on the remaining breast. Many studies and meta-analyses have demonstrated that conservative treatment is comparable to mastectomy in terms of local recurrence rate, overall survival, and event-free survival regarding invasive carcinoma as well as carcinoma in situ.

Beyond the efficacy of the oncologic treatment, the psychological consequences of BCT are also undeniably better compared with those of a mastectomy. As a matter of fact, compared with radical treatment, conservative surgery results in an improved body image, self-esteem, and sexuality, and therefore, in a better quality of life for the patients.

For the surgeon, 2 elements are critical when performing a conservative treatment: first, to ensure a complete oncologic resection, with negative margins; and second, to obtain a satisfying aesthetic result, preventing the occurrence of sequelae. These aftereffects can be a consequence of surgery, but they can also be worsened by postoperative adjuvant radiotherapy.

A long-term optimal cosmetic result substantially depends on the initial breast volume, the size of the tumor, and its localization within the breast tissue. Indeed, it has been clearly established that there is a correlation between the volume of the resected specimen and the aesthetic results. Some situations are commonly at risk for unsightly outcomes: for example, patients with a small breast volume, or tumors localized within the inner or inferior quadrants.

These sequelae have been classified, and even though these classifications are rarely used, they reflect objectively the degree of severity, from breast asymmetry to complete and major breast distortion, associating fibrosis and debilitating pain ( Fig. 1 ).

Fig. 1
Cosmetic sequelae after breast conservative treatment: lumpectomy without oncoplasty technique associated with postoperative radiotherapy. These sequelae lead to breast shape distortion, NAC retraction and breast volume asymmetry. Different degrees of severity can be observed, depending on the tumor location.

Correction of these sequelae is possible in most cases, but remains complex in an irradiated area, leading to unpredictable outcomes. Autologous fat transfer is now used to correct some of these deformations. However, in the most severe cases, fibrosis is so developed that a complementary mastectomy, coupled with an immediate breast reconstruction, is required ( Fig. 2 ). The delayed treatment of these sequelae implies further surgeries, sometimes long after the initial treatment. The time between carcinologic surgery and reconstruction is often a great source of stress and anxiety for the patients.

Fig. 2
Surgical delayed correction technique related to the degree of sequelae. In most simple cases, an asymmetry in volume and NAC position can be corrected with contralateral mammoplasty. In the case of skin retraction and breast deformity, fat grafting is often used in delayed reconstruction, but postoperative outcomes are unpredictable in the irradiated field. Surgical correction of these defects often needs further surgery procedures. In the case of complete fibrosis, the resection of the fibrotic tissue is mandatory, associated with autologous reconstruction.

The best treatment for these sequelae is therefore to prevent them during conservative surgery, as a one-stage procedure.

Oncoplastic surgery simultaneously meets the oncologic and aesthetic requirements. Using classic plastic surgery techniques for oncologic surgery positively improves the cosmetic outcomes after BCT while preserving oncologic safety. A larger amount of tissues can be resected, consequently decreasing both the surgical revision rate for positive margins and the mastectomy rate.

The surgical techniques are based on 3 main principles, as follows:

  • Simple breast reshaping using dermoglandular flaps,

  • Breast reduction mammoplasty and mastopexy techniques,

  • Locoregional pedicled flaps.

The purpose of this article is to describe the authors’ experience and the oncoplastic surgery techniques they use for BCT.

Introduction

In the field of oncologic breast surgery, breast conservation therapy (BCT) is now the gold standard in the treatment of localized breast cancer. BCT associates surgery, aiming to ensure complete tumor resection with adequate margins, and radiotherapy on the remaining breast. Many studies and meta-analyses have demonstrated that conservative treatment is comparable to mastectomy in terms of local recurrence rate, overall survival, and event-free survival regarding invasive carcinoma as well as carcinoma in situ.

Beyond the efficacy of the oncologic treatment, the psychological consequences of BCT are also undeniably better compared with those of a mastectomy. As a matter of fact, compared with radical treatment, conservative surgery results in an improved body image, self-esteem, and sexuality, and therefore, in a better quality of life for the patients.

For the surgeon, 2 elements are critical when performing a conservative treatment: first, to ensure a complete oncologic resection, with negative margins; and second, to obtain a satisfying aesthetic result, preventing the occurrence of sequelae. These aftereffects can be a consequence of surgery, but they can also be worsened by postoperative adjuvant radiotherapy.

A long-term optimal cosmetic result substantially depends on the initial breast volume, the size of the tumor, and its localization within the breast tissue. Indeed, it has been clearly established that there is a correlation between the volume of the resected specimen and the aesthetic results. Some situations are commonly at risk for unsightly outcomes: for example, patients with a small breast volume, or tumors localized within the inner or inferior quadrants.

These sequelae have been classified, and even though these classifications are rarely used, they reflect objectively the degree of severity, from breast asymmetry to complete and major breast distortion, associating fibrosis and debilitating pain ( Fig. 1 ).

Fig. 1
Cosmetic sequelae after breast conservative treatment: lumpectomy without oncoplasty technique associated with postoperative radiotherapy. These sequelae lead to breast shape distortion, NAC retraction and breast volume asymmetry. Different degrees of severity can be observed, depending on the tumor location.

Correction of these sequelae is possible in most cases, but remains complex in an irradiated area, leading to unpredictable outcomes. Autologous fat transfer is now used to correct some of these deformations. However, in the most severe cases, fibrosis is so developed that a complementary mastectomy, coupled with an immediate breast reconstruction, is required ( Fig. 2 ). The delayed treatment of these sequelae implies further surgeries, sometimes long after the initial treatment. The time between carcinologic surgery and reconstruction is often a great source of stress and anxiety for the patients.

Fig. 2
Surgical delayed correction technique related to the degree of sequelae. In most simple cases, an asymmetry in volume and NAC position can be corrected with contralateral mammoplasty. In the case of skin retraction and breast deformity, fat grafting is often used in delayed reconstruction, but postoperative outcomes are unpredictable in the irradiated field. Surgical correction of these defects often needs further surgery procedures. In the case of complete fibrosis, the resection of the fibrotic tissue is mandatory, associated with autologous reconstruction.

The best treatment for these sequelae is therefore to prevent them during conservative surgery, as a one-stage procedure.

Oncoplastic surgery simultaneously meets the oncologic and aesthetic requirements. Using classic plastic surgery techniques for oncologic surgery positively improves the cosmetic outcomes after BCT while preserving oncologic safety. A larger amount of tissues can be resected, consequently decreasing both the surgical revision rate for positive margins and the mastectomy rate.

The surgical techniques are based on 3 main principles, as follows:

  • Simple breast reshaping using dermoglandular flaps,

  • Breast reduction mammoplasty and mastopexy techniques,

  • Locoregional pedicled flaps.

The purpose of this article is to describe the authors’ experience and the oncoplastic surgery techniques they use for BCT.

Indications

The surgical indication of an oncoplastic procedure must be established in a collegial manner and approved during a multidisciplinary meeting. A breast surgeon or a plastic surgeon should assess the possibility of oncoplasty. During the preoperative consultation, the surgeon must collect the following data: tumor size, patient’s bra size, height, weight, and body mass index, as well as the surgical history of the breast. Risk factors also have to be noted: active smoking, diabetes, arterial hypertension, and other cardiovascular risk factors. The surgeon has to clinically evaluate the tumor size and localization, and whether it is palpable or not. Diagnostic imaging examinations are required to determine the tumor size and localization precisely: a standard 2-view mammogram, a breast ultrasound, and an MRI, based on the French recommendations.

With these clinical and radiologic examinations results, the surgeon should then be able to assess whether an oncoplastic procedure is necessary, in order to prevent any standard BCT sequelae.

Oncoplastic surgery is also relevant for lesions that might be incompletely resected: extensive microcalcifications, invasive lobular carcinoma, or multifocal breast cancer.

Most investigators agree that, for a tumoral volume representing more than 15% to 20% of the total breast volume, the risk of cosmetic sequelae is important.

For cases in which a conservative and oncoplastic surgery would still lead to an aesthetic compromise, a neoadjuvant treatment with chemotherapy or hormonotherapy can be initiated. Depending on the tumor’s biological characteristics, targeted therapies may reduce the volume of the tumor and therefore enable a conservative treatment. Preoperative clinical and imaging reassessments are required to confirm that a conservative surgery has become possible. Nowadays, neoadjuvant chemotherapy offers a conserving surgery procedure to about 70% of patients.

Every oncologic breast surgery procedure should involve oncoplasty. The level of complexity of this surgical step depends on the following characteristics:

  • The tumor volume, compared with the total breast volume

  • The breast volume

  • The degree of breast ptosis

  • The tumor location.

Simple breast reshaping

When the tumor volume is less than 20% of the total breast volume, a simple lumpectomy can be performed. Nevertheless, the aesthetic results after such procedures are unpredictable. Some tumor locations are associated with a higher risk of cosmetic sequelae, especially the inner quadrants in which the glandular volume is inferior compared with the outer quadrants. Likewise, the inferior quadrant tumors may be a source of breast distortion related to skin and glandular retraction.

In order to avoid or at least minimize the risk of such postoperative deformations, it is necessary to perform an oncoplastic procedure with a glandular reshaping. Choosing the skin incision and the surgical approach must be an integral part of the oncoplasty procedure. Incisions within the upper inner quadrant must not be used, because they might be visible in the neckline. Also, transverse incisions in the lower quadrants inevitably lead to a scar retraction associated with a typical “beak-shaped” breast deformation, the NAC being drawn downwards ( Fig. 3 ). Less visible incisions must be chosen: hemi-periareolar incisions, which can be associated with an external radially orientated incision, or incisions located within the breast lateral fold or the inframammary fold. A large subcutaneous undermining enables access to the tumor easily, but also to reposition or lift the skin. This cutaneoglandular dissection also helps mobilize glandular flaps in order to fill the tissue loss.

Fig. 3
Typical “beak-shaped” breast deformation after resection of tumor located in the inferior quadrant.

Therapeutic reduction mammoplasty

For patients with large and ptotic breasts, the ratio between the tumor size and the size of the breast is not necessarily an indication for a complex oncoplastic procedure. Nevertheless, for these patients, a therapeutic reduction mammoplasty is often recommended. Besides the expected aesthetic advantages and improvement of the quality of life, a reduction mammoplasty allows for a large tissue resection, thus decreasing the positive margin rate and avoiding a surgical revision. Moreover, a larger tumor volume can be resected, sometimes avoiding mastectomy. Reducing the glandular volume also decreases the volume of irradiated tissues, which may lessen the radiation therapy morbidity, and ultimately, reducing the breast glandular volume decreases the risk of ipsilateral recurrence.

The authors mainly use the Wise pattern inverted-T reduction mammoplasty technique, which can be applied regardless of the tumor location ( Fig. 4 ). In the most basic cases, the tumor is located within the cutaneoglandular resection area, enabling a large en-bloc resection. The defect is then filled by bringing the lateral and medial breast segments together, as described in the classic technique. However, this technique can also be used when the tumor is located outside the theoretic pattern. In such cases, the approach is included in the Wise pattern. A subcutaneous undermining enables access to the tumor easily. The tissue loss is then filled using the remaining breast tissue as rotating flaps.

Fig. 4
Therapeutic reduction mammoplasty. ( A ) Preoperative view. ( B ) Tumor located at the superior inner quadrant. Therapeutic mammoplasty with symmetrization in the same procedure is the best option even the volume ratio is lower than 20%. It improves cosmetic and functional result and reduces volume of radiation. ( C , D ) Postoperative outcome after therapeutic ( left ) inverted-T mammoplasty and reduction ( right ) inverted-T mammoplasty.
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Nov 21, 2017 | Posted by in Dental Materials | Comments Off on Indications and Controversies in Partial Mastectomy Defect Reconstruction
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