Preoperative discussion with the breast surgeon should include where the incision should be placed, and markings should include bilateral nipple areolar complexes, inframammary folds, and the incision. Ideally, the lumpectomy incision can be located within a periaerolar incision or within planned skin excision sites. After the resection, the lumpectomy defect should be approached by first determining the blood flow to the NAC and then determining how the parenchyma can be rearranged to close the dead space. Tumors in the lower pole of the breast are often best approached via a vertical midline, subareolar incision that gives ideal access and also avoids the long-term stigmata of oncologic incisions and replaces them with incisions that are generally accepted for aesthetic purposes (e.g., reduction mammoplasty and mastopexy).
When approaching the defect you must first identify what quadrant is affected and how to rearrange the parenchyma to fill that defect while not deforming the breast or interrupting the blood supply to the NAC. Two separate flaps should be planned. The first should focus on providing a robust blood supply to the NAC. This should provide mobility to the NAC to allow for tension-free repositioning. These pedicles can utilize the blood supply from the perforators previously mentioned: superior, superiomedial, inferior, lateral, or the central mound.
The second flap should be a parenchymal flap used to fill the tumor dead space. This generally requires freeing the parenchyma from the skin but leaving the majority of it attached to the chest wall to preserve the blood supply. Once mobile enough to fill the dead space, one or two nonischemic absorbable sutures can be placed to hold it in place while completing the operation.
Excess skin can be removed and skin flaps designed to redrape over the rearranged parenchyma. The Wise pattern or vertical reduction markings are the most popular skin flaps to use and give the reconstructive surgeon many options for tissue rearrangement.
It is also important to always mark the tumor pocket with surgical clips to allow for optimal radiation therapy.15
The following cases provide a few examples for how to reconstruct several lumpectomy defects. The majority of defects are located in the lower quadrants. Figure 150-2 shows a patient who had a lower inner quadrant defect that was repaired by mobilizing the NAC on a superiomedial pedicle. A separate lateral parenchymal flap was used to fill the dead space. The skin was redraped using a Wise pattern reduction technique. Postoperative pictures are shown in Fig. 150-3.
Lower inner quadrant defect: superiomedial pedicle was utilized to mobilize the NAC and a lateral parenchymal flap was used to fill the dead space. The skin was redraped using a Wise pattern reduction technique.
Central mound defects account for approximately 20% of postlumpectomy defects.12 Figure 150-4 is an example of a central mound defect involving the NAC. The NAC defect was filled and reconstructed with an inferior parenchyma pedicle with a small skin island. A vertical reduction skin pattern was used to redrape the skin.
Central mound defect involving the NAC. A vertical reduction skin pattern was used to redrape the skin. The NAC defect was filled and reconstructed with an inferior parenchyma pedicle with a small skin island.
Figure 150-5 demonstrates a lower outer quadrant defect. The postoperative scar and defect can be appreciated in Fig. 150-5A. An inferior parenchymal pedicle was mobilized to fill the defect (dead space). The NAC was mobilized on a superiomedial pedicle and the skin was redraped using a Wise pattern reduction. A contralateral left breast reduction was also performed for symmetry as seen in Fig. 150-6.
Lower outer quadrant. A. Postoperative lumpectomy picture. B. Parenchyma pedicle being mobilized to fill defect space. NAC was mobilized on a superiomedial pedicle. Skin redraped using a Wise pattern reduction.
Postoperatively after a left breast contralateral reduction.
In general, these operations are well tolerated and have low complication rates. Wound infections and skin necrosis occur in less than 10% of patients but 1% to 2% of these complications do come at a cost of delaying the initiation of the radiation therapy.16,17 The most devastating complication would be partial or total necrosis of the NAC, which has been reported in 2% of patients.16 Smoking and obesity are the most significant risk factors for wound complications.17 Delayed reconstructions performed after radiation therapy has almost twice the risk of complication compared to immediate reconstruction.18 Kronowitz et al18 found that patients with delayed reconstruction had a 42% complication rate compared to 26% in a similar group of immediate reconstructions. They also demonstrated that when a patient requires delayed reconstruction after a poor outcome from BCT, it is best to bring in nonirradiated tissue via a pedicled latissimus dorsi myocutaneous flap.18
Management of Complications
Most infections can be managed conservatively with local wound care, and fat necrosis requires no immediate intervention. Rarely, revision operations are necessary to correct asymmetry that is persistent, but these should be performed 6 to 12 months after radiation therapy is completed.12 If additional tissue is required, a standard pedicled latissimus dorsi myocutaneous flap or a muscle-sparing thoracodorsal artery perforator flap can provide adequate skin coverage and allow implant-base reconstruction in a radiated field.19,20
The main goal of performing oncoplastic surgery is to mitigate the damaging effects of radiation therapy and improve the ultimate breast shape, aesthetic outcome, and patient self-esteem. Patients polled after having oncoplastic surgery had statistically significant better health status compared to a control group with regards to physical functioning, health perceptions, self-esteem, and mental health.21 Unlike the control group they did not have the asymmetry and deformities as a daily reminder of their breast cancer and were able to return to their preoperative levels of physical functioning and improve on their self-esteem and sense of emotional well-being.
The contralateral breast is often ignored in the breast conservation discussion. Over 35% of patients who have already completed their BCT and have acceptable results on the radiated breast are left with significant asymmetry due to the fibrosis effect of radiation.7 These patients should be referred for consultation for contralateral symmetry procedure, via a reduction mammoplasty or a mastopexy.
Oncoplastic surgery is a relatively low-risk operation that can significantly improve the lives of patients and help them feel better about themselves as they move on from their cancer treatment. Ideally this should be approached from a multidisciplinary team perspective with surgical, medical, and radiation oncologists as well as accurate imaging from the radiologist and reconstructive expertise from plastic surgeons. The plastic surgeon should be closely involved in the decision-making process for both patient selection and timing of reconstruction.12