In this section, the immediate as well as the staged-immediate oncoplastic reduction mammaplasties for both the ipsilateral and contralateral breasts are described. Also included is a description of contralateral reduction mammaplasty following total unilateral reconstruction as well as reduction mammaplasty in the previously radiated breast. All descriptions include breast markings with the inverted T pattern, as this is the author's preferred approach to reduction mammaplasty (Fig. 153-1).
Immediate Oncoplastic Reduction Mammaplasty
Following the initial breast markings, the ablative surgeon is asked to keep the incisions within the delineated pattern if possible. The partial mastectomy is performed and typically includes a specimen that weights anywhere from 150 to 300 g. In many patients the anticipated resection weight for the reduction mammaplasty is in excess of 500 g, thus additional tissue resections are usually necessary. The reconstructive goals are to fill the ablative cavity, maintain vascularity to the NAC, safely excise additional tissue, and contour the breast into a natural shape. The first decision is to decide on the pedicle orientation and to safely transpose the NAC. In general, medial and laterally based pedicles are preferred based on improved vascularity; however, the shorter the pedicle, the more likely that perfusion will be maintained. The diameter of the NAC is usually marked such that it is between 42 and 45 mm. The pedicle is de-epithelized to permit burial under the inverted T skin flaps. The second decision is to decide how to fill the ablative cavity. Sometimes this can be accomplished by the primary pedicle for NAC transposition; however, in most situations it will require a secondary tissue rearrangement maneuver. Usually this is performed with an adjacent tissue transfer that is composed of a parenchymal flap. Often times, the vascularity of this flap is random and not based on a named artery. In circumstances where tissue perfusion is uncertain, fluorescent angiography is an excellent modality to directly visualize perfusion. If compromised, debridement is indicated to minimize the occurrence of fat necrosis. It is recommended to place surgical hemoclips using a disposable autoapplier along the base of the ablative defect to allow for radiographic identification of the area to be targeted for radiation (Fig. 153-2). Once the partial mastectomy defect has been filled, the third decision is about where to resect additional tissue in order to adequately reduce and optimally shape the breast. Usually this involves removing additional tissue opposite the ablative cavity and frequently includes removal of additional inferiorly and laterally based parenchymas. Parenchymal suturing techniques using an absorbable suture are useful. Placement of a closed suction drain is recommended to reduce fluid accumulation. Figure 153-3 represents the process of parenchymal flap rearrangement to fill a partial mastectomy defect.
Gold beads or surgical clips are used to delineate the partial mastectomy defect to allow for radiologic identification of the radiation target.
A. An upper lateral partial mastectomy defect has been created. B. The upper lateral breast deformity is depicted. C. A medially based parenchymal flap is elevated to fill the upper lateral breast defect. The parenchymal flap is transposed into the upper lateral defect.
The contralateral breast is usually reduced following the ipsilateral breast. Given that the tumor breast will be radiated, the contralateral breast reduction is usually performed such that it is slightly smaller because the radiated breast will be slightly atrophy over time. It is important to remember that the resection weight of the cancerous breast includes the specimen and the additional parenchymal resection. This should closely approximate the parenchymal resection of the contralateral breast. The inverted T pattern and the vascular pedicle orientation are delineated. The authors preferred patterns that include a medial, superomedial, or central mound technique if the distance of NAC elevation is <6 cm. A medial pedicle is preferred if the distance for NAC elevation is >6 cm (Fig. 153-4). For maximal vascularity, the medial pedicle is elevated on a dermoparenchymal base (Fig. 153-5). For severe mammary hypertrophy, a free nipple graft is considered. The NAC is delineated to a diameter of 42 to 45 mm to match the opposite side and the pedicle is de-epithelized. Dermoglandular wedge excisions are performed and usually include inferior and lateral parenchymal tissue. Following the glandular rearrangement, the skin on both sides is temporarily closed and the anesthesiologist is instructed to raise the head of the table to 50 to 60 degrees to assess for contour and symmetry. Minor adjustments are made at this time. Figure 153-6 illustrates a patient with right breast cancer that had immediate bilateral oncoplastic reduction mammaplasty.
A medial pedicle is delineated on the inverted T pattern. This pedicle allows for optimal rotation and easy inset.
The medial pedicle is elevated as a dermoparenchymal flap to optimize vascularity.
A. Preoperative image of a patient with right breast cancer scheduled for immediate oncoplastic reduction mammaplasty. An inverted T pattern is delineated. B. Postoperative image following bilateral immediate oncoplastic reduction mammaplasty. The right breast has been irradiated representing good symmetry and 2-year follow-up. C. Right lateral view of the irradiated breast. D. Left lateral view of the nonradiated breast.
Staged-Immediate Oncoplastic Reduction Mammaplasty
The initial markings for the reduction mammaplasty are identical to that of the immediate procedure. When the tumor margins are in question and cannot be positively confirmed following frozen section analysis, a staged-immediate approach is preferred. Usually the reconstructive portion of the operation will occur 1 to 2 weeks following the ablative portion. In some ways, the reduction mammaplasty portion is facilitated because the subsequent breast contour can be appreciated and the exact location of the ablative defect is known. The previously mentioned measurements and landmarks are delineated. The operation is initiated much like a typical reduction mammaplasty with the pedicle de-epithelized followed by the inverted T-skin incisions. The ablative cavity is identified and entered (Fig. 153-7). Usually it is filled with serosanguineous fluid that has not had sufficient time to resorb. The serosalized cavity is debrided and the defect essentially recreated. At this juncture, the same principles and concepts for reconstruction and reduction used for the immediate approach will apply. The contralateral breast is reduced in the same fashion as during the immediate. Figure 153-8 represents a patient with right breast cancer that had a staged-immediate bilateral oncoplastic reduction mammaplasty.
The serosalized cavity following the partial mastectomy is identified and excised.
A. Preoperative image of a woman with right breast cancer prior to partial mastectomy. B. Postoperative image 14 days following partial excision of the right breast demonstrating the contour abnormality. C. Postoperative photo following staged-immediate bilateral oncoplastic breast reduction. The right breast has been irradiated demonstrating excellent contour and symmetry with 2-year follow-up. D. Lateral view of the irradiated right breast. E. Lateral view of the nonradiated left breast.
Delayed Contralateral Reduction Mammaplasty Following Unilateral Breast Reconstruction
Following total reconstruction of a single breast, many women will experience breast asymmetry. In some situations, the natural breast is hypertrophic and requires reduction mammaplasty to achieve symmetry. The primary goal of this operation is to match the reconstructed breast in terms of volume and contour. It is very important to assess and understand patient expectations in these situations because additional scars will be created on the opposite breast. The type of reduction mammaplasty performed will depend on the degree of asymmetry, the estimated resection volume, and the distance that the NAC has to be elevated. In some situations where the resection volume may be <200 g and the NAC needs to be elevated 2 to 3 cm, a circumvertical pattern may be considered. However, when the estimated resection volume and length of NAC elevation are high, an inverted T approach is preferred. The preferences for pedicle orientation are identical to that of the contralateral breast following the oncoplastic procedures. Figure 153-9 illustrates a patient that had right breast reconstruction and a delayed contralateral reduction mammaplasty.
A. Preoperative image of a patient that had a right radical mastectomy, skin graft, and radiation therapy. B. Postreconstruction image following a right transverse rectus abdominis muscle (TRAM) and latissimus dorsi flap demonstrating a significant breast asymmetry. C. Postoperative image following a left reduction mammaplasty using a medial pedicle with a resection volume of 950 g. The follow-up was 1 year.
Delayed Reduction Mammaplasty Following Breast-Conservation Therapy
In women with mammary hypertrophy who have had breast-conservation therapy and are considering reduction mammaplasty, the discussion must focus on the potential for morbidity and complications.6 In general, the delayed approach is not advocated because the outcomes are not as aesthetically pleasing as the immediate or staged-immediate approach. However, in patients that are uncertain about treatment or in patients with unrealistic expectations, the delayed approach may be considered months to years after breast-conservation therapy. In all situations, patient expectations and reasons for having a reduction should be ascertained and reviewed. If considered a good candidate with realistic expectations, the preoperative markings and landmarks are delineated as previously described. The technical aspects of the operation are modified, however, to account for the decreased vascularity and increased fibrosis. All pedicles are created such that they are short, broad, and wide. The selected pedicle should be away from the lumpectomy site. Parenchymal undermining is minimized to preserve vascularity. Parenchymal resection is performed in a wedge-type excision. Closed suction drains are inserted and remain in place for a few days or until output is <30 cc/d. Figure 153-10 illustrates a patient following left lumpectomy and radiation that has chosen to have a bilateral reduction mammaplasty.
A. Pre-reduction image of a woman following left lumpectomy and postoperative radiation therapy. There is a noticeable contour abnormality. B. Preoperative image demonstrating the inverted T pattern and the location of the breast deformity. C. Postoperative image following delayed reduction mammaplasty at 2-year follow-up. In previously irradiated patients, asymmetries are more likely. D. Left lateral view of the irradiated breast. E. Right lateral view of the nonradiated breast.