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CHAPTER 12 Breast Augmentation Technique (Biplanar) for Oncoplasty
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Fig. 12.1, cont’d (D) This reduces the surgical dead space of the breast. (E) Subpectoral insertion of the
implant is made through an inframammary fold incision to further reduce the dead space and to preserve
the breast shape.
the glandular tissue can be approximated (Fig. 12.1C). Care
is taken to limit the undermining of the tissue and approximate it with minimal tension to prevent fat necrosis. e
skin is sutured (Fig. 12.1D), and a new and separate incision is made in the inframammary fold. en, a new and
separate pocket is dissected in the subpectoral plane, taking
care that there is no direct connection to the tumor bed.
A subpectoral pocket is formed on the contralateral healthy
breast as well. Breast implant sizers are inserted, and the
larger implant with higher projection is chosen for the breast
that underwent lumpectomy to match it to the contralateral breast. e patient is then placed in a seated position
for intraoperative assessment of symmetry and for further
adjustments. Permanent silicone implants are selected and
inserted after irrigation and hemostasis (Fig. 12.1E). In cases
of previous augmentations, the incision is made in the inframammary scar, old implants are removed, and a new subpectoral pocket is dissected after partial capsulectomy. No
drains are used for the breast surgery itself, but a drain is
placed in the axilla for patients who had undergone axillary
lymph node dissection.
Outcome
e objective of BCT is to remove the tumor with free surgical margins. A second lumpectomy procedure is typically
required in cases of tumor-positive surgical margins. In the
oncoplastic biplanar breast augmentation technique, the
re-lumpectomy procedure is performed through the previous lumpectomy incision, and the defect is reconstructed
with local tissue rearrangement with no violation of the
implant’s subpectoral pocket. In our series of 21 patients
who underwent this technique with contralateral breast
adjustment, 3 patients (14%) had tumor-positive surgical
margins and required a re-lumpectomy procedure.27 None
of them needed a mastectomy as a second procedure due to
involved margins. However, when a mastectomy is required,
all options are feasible (e.g., nipple-sparing or skin-sparing
mastectomy), depending on the oncologic assessment. For
implant-based reconstruction, the subpectoral pocket can
be reused, with an ADM graft to support the lower pole.
e patients in our series reported a high degree of satisfaction with the surgical outcome in terms of improved
breast shape, volume, and position, all of which were
retained after radiation therapy.27 Seventeen patients (81%)
were either very satised or satised with their overall results,
whereas 2 patients (10%) were disappointed and regretted
having undergone the surgery. e independent observers’ evaluation of the 16 patients who completed follow-up
(76%) was that most of the patients had a very good to
good surgical outcome in terms of breast shape, NAC position, and breast symmetry. Clinical cases are presented in
Figs. 12.2 and 12.3. Cases of mild post-radiation asymme-
try and irregularities can be treated with minor adjustments
to the contralateral non-radiated breast or by ancillary fat
grafting to the radiated breast.
In another series using this breast augmentation or biplanar technique, Nahabedian etal published their experience
in 10 patients.
12,28
As in the Barnea series, these patients all
had smaller breast volume that preferred breast conservation
to mastectomy. Simultaneous volume displacement and
replacement was carried out in all. e preferred incisional
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A
C
• Fig. 12.2 (A) A 27-year-old patient with right breast cancer in the upper lateral quadrant. (B) She under-
went right lumpectomy with a periareolar incision and the OBA technique with an implant (225 cc, high
profile), as well as left augmentation (200 cc, moderate-plus profile). The patient just after termination of
radiation therapy (C) and 1 year after radiation therapy (D).
approach was circumvertical through which both the ablative and reconstructive could be performed. Resection volumes ranged from 50–100 grams. e volume displacement
portion consisted of parenchymal rearrangement taking care
to ensure not to compromise the vascularity of the NAC.
Volume replacement was performed using implants or tissue expanders placed in the subpectoral position. Implant
volumes were typically 100–125 cc, and tissue expanders
were 250–300 cc.
e mean patient age was 56 years, and the average
body mass index was 24.1 kg/m2. Mean resection volume
was 76 grams. Eight patients had permanent implant and
two patients had tissue expander patients with ADM use in
9/10. Radiation therapy was delivered in 9/10 patients with
a mean duration of 32 days. Mean follow-up was 21 months.
Postoperative complications included infection (1/10), incisional dehiscence (1/10), and a positive margin requiring
B
D
mastectomy (1/10). A satisfaction survey conducted posttreatment using a 5-point Likert scale (1—worst, 5—best)
demonstrated a mean response of 4/5 regarding satisfaction
with outcome and undergoing the procedure again, a mean
response of 4.3/5 regarding recommending this procedure
to other women, a mean response of 3.1/5 regarding breast
symmetry, and a mean response of 3.6/5 regarding nipple
sensation.
Complications
Major complications for this technique include severe capsular contracture and infection. In our series, ve patients
(23.8%) developed capsular contracture after radiation
therapy, and three of them underwent a capsulectomy and
exchange of the implant.27 ere was no recurrence of capsular contracture in any of the revised cases. In refractory
CHAPTER 12 Breast Augmentation Technique (Biplanar) for Oncoplasty
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CD
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• Fig. 12.3 (A) A 46-year-old patient with left breast cancer in the upper lateral quadrant. (B) She under-
went left lumpectomy and the OBA technique with an implant (255 cc, full profile), as well as right augmentation (235 cc, moderate profile). The surgical outcome at 1 year after radiation therapy (C) with no
capsular contracture (D).
cases of capsular contracture, either an autologous reconstruction or the use of an ADM in combination with
implant exchange can be oered to the patient.
23,24
Breast infection is treated with antibiotics and salvage
procedures as needed, with priority given to the timing of
the oncologic treatment. Infection appearing before radiation therapy usually requires implant removal to prevent
position and skin contracture are unpredictable after radiation therapy in ptotic breasts, thus excluding those cases as
well. A limitation of breast tumors in the lower pole near the
inframammary fold is that they do not allow the separation
of the implant and the lumpectomy pockets.
Conclusion
delay in oncologic treatment. However, infection appearing after radiation therapy can be treated with appropriate
salvage procedures. We had two cases of infection (10%) in
our series27: one was detected before the patient underwent
radiation therapy and the implant was removed, and the
other was detected after radiation therapy and the patient
underwent a salvage reconstruction by means of a latissimus
dorsi myocutaneous ap and exchange of the implant.
ere are several limitations associated with this technique. One is that it is reserved for patients with small and
non-ptotic breasts whose tumors take up less than 25% of
the breast volume and do not involve the NAC. Nipple
e oncoplastic biplanar breast augmentation technique
helps achieve the adjustment of shape and volume in smallbreasted patients before radiotherapy, without the added
morbidity associated with the use of regional autologous
aps or late reconstructions. Careful patient selection, coordinated planning with the breast surgeon, and meticulous
intraoperative management are the keys to a favorable surgical outcome of this technique, as testied to by high patient
and surgeon satisfaction rates. e incidence of capsular
contracture is similar to the values cited in studies on immediate reconstruction and radiotherapy.
22-24
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is technique aims to achieve volume compensation
and maximum obliteration of the lumpectomy defect
before radiotherapy. e combination of local glandular
tissue rearrangement around the lumpectomy site and the
subpectoral implant placement allows volume restoration of
the reconstructed breast and minimizes the dead space by
tightly packing the glandular tissue between the pectoralis
major and the skin aps. Furthermore, simultaneous augmentation oers immediate volume replacement and volume enhancement, adding to patient satisfaction.
References
1. Veronesi U, Cascinelli N, Mariani L, etal. Twenty-year follow-
up of a randomized study comparing breast conserving surgery
with radical mastectomy for early breast cancer. N Engl J Med.
2002;347:1227–1232.
2. Jeevan R, Cromwell DA, Browne JP, etal. Findings of a national
comparative audit of mastectomy and breast reconstruction surgery in England. J Plast Reconstr Aesthet Surg. 2014;67:1333–
1344.
3. Katipamula R, Degnim AC, Hoskin T, etal. Trends in mastec-
tomy rates at the Mayo Clinic Rochester: eect of surgical year
and preoperative magnetic resonance imaging. J Clin Oncol.
2009;27:4082–4088.
4. Hill-Kayser CE, Vachani C, Hampshire MK, Di Lullo GA, Metz
JM. Cosmetic outcomes and complications reported by patients
having undergone breast-conserving treatment. Int J Radiat
Oncol Biol Phys. 2012;83:839–844.
5. Krishnan L, Stanton AL, Collins CA, Liston VE, Jewell WR.
Form or function? Part 2. Objective cosmetic and functional correlates of quality of life in women treated with breast conserving
surgical procedures and radiotherapy. Cancer. 2001;91:2282–
2287.
6. Cochrane RA, Valasiadou P, Wilson AR, Al-Ghazal SK, Macmil-
lan RD. Cosmesis and satisfaction after breast-conserving surgery
correlates with the percentage of breast volume excised. Br J Surg.
2003;90:1505–1509.
7. Berry MG, Fitoussi AD, Curnier A, Couturaud B, Salmon RJ.
Oncoplastic breast surgery: a review and systematic approach.
J Plast Reconstr Aesthet Surg. 2010;63:1233–1243.
8. Clough KB, Lewis JS, Couturaud B, Fitoussi A, Nos C, Fal-
cou MC. Oncoplastic techniques allow extensive resections
for breast-conserving therapy of breast carcinomas. Ann Surg.
2003;237:26–34.
results of breast conservative treatment with oncoplastic surgery.
Breast. 2007;16:387–395.
10. Losken A, Hamdi M. Partial breast reconstruction: current per-
spectives. Plast Reconstr Surg. 2009;124:722–736.
11. Anderson BO, Masetti R, Silverstein MJ. Oncoplastic approaches
to partial mastectomy: an overview of volume-displacement techniques. Lancet Oncol. 2005;6:145–157.
12. Nahabedian MY, Patel KM, Kaminsky AJ, Cocilovo C, Miraliak-
bari R. Biplanar oncoplastic surgery: a novel approach to breast
conservation for small and medium sized breasts. Plast Reconstr
Surg. 2013;132:1081–1084.
13. Harcourt DM, Rumsey NJ, Ambler NR, etal. e psychological
eect of mastectomy with or without breast reconstruction: a prospective, multicenter study. Plast Reconstr Surg. 2003;111:1060–
1068.
14. Spear SL, Majidian A. Immediate breast reconstruction in two
stages using textured, integrated-valve tissue expanders and breast
implants: a retrospective review of 171 consecutive breast reconstructions from 1989 to 1996. Plast Reconstr Surg. 1998;101:53–
63.
15. Colwell AS, Damjanovic B, Zahedi B, Medford-Davis L, Hertl
C, Austen Jr WG. Retrospective review of 331 consecutive immediate single-stage implant reconstructions with acellular dermal
matrix: indications, complications, trends, and costs. Plast Recon-
str Surg. 2011;128:1170–1178.
16. Elton C, Jones SE, Jones PA. Initial experience of intramammary prostheses in breast conservation surgery. Eur J Surg Oncol.
1999;25:138–141.
17. omas PR, Ford HT, Gazet JC. Use of silicone implants after
wide local excision of the breast. Br J Surg. 1993;80:868–870.
18. Speers C, Zhao S, Liu M, etal. Development and validation of
a novel radiosensitivity signature in human breast cancer. Clin
Cancer Res. 2014;64:135–152.
19. Jagsi R. Progress and controversies: Radiation therapy for invasive
breast cancer. CA Cancer J Clin. 2014;64:135–152.
20. De Lorenzi F, Lohsiriwat V, Barbieri B, etal. Immediate breast
reconstruction with prostheses after conservative treatment plus
intraoperative radiotherapy: long term esthetic and oncological
outcomes. Breast. 2012;21:374–379.
21. Rietjens M, De Lorenzi F, Veronesi P, etal. Breast conservative
treatment in association with implant augmentation and intraoperative radiotherapy. J Plast Reconstr Aesthet Surg. 2006;59:532–
535.
22. Cordeiro PG, Pusic AL, Disa JJ, McCormick B, VanZee K. Irradiation after immediate tissue expander/implant breast reconstruction: outcomes, complications, aesthetic results, and satisfaction
among 156 patients. Plast Reconstr Surg. 2004;113:877–881.
23. Anderson PR, Hanlon AL, Fowble BL, McNeeley SW, Freedman
GM. Low complication rates are achievable after postmastectomy
breast reconstruction and radiation therapy. Int J Radiat Oncol
Biol Phys. 2004;59:1080–1087.
24. Nahabedian MY. AlloDerm performance in the setting of prosthetic breast surgery, infection, and irradiation. Plast Reconstr
Surg. 2009;124:1743–1753.
25. Victor SJ, Brown DM, Horwitz EM, etal. Treatment outcome
with radiation therapy after breast augmentation or reconstruction in patients with primary breast carcinoma. Cancer.
1998;82:1303–1309.
26. Prabhakaran S, Elston JB, Lleshi A, Kumar A, Sun W, Khakpour
N, Dayicioglu D. Single institution review of patients with prior
breast augmentation undergoing breast conservation therapy for
breast cancer. Ann Plast Surg. 2017;78(6S suppl 5):S289–S291.
27. Barnea Y, Friedman O, Arad E, Barsuk D, Menes T, Zaretski A,
Leshem D, Gur E, Inbal A. An oncoplastic breast augmentation
technique for immediate partial breast reconstruction following
breast conservation. Plast Reconstr Surg. 2017;139:348e–357e.
28. Kaminsky AJ, Patel KM, Cocilovo C, Nahabedian MY, Miralakbari R. e biplanar oncoplastic technique case series: a 2-year
review. Gland Surgery. 2015;4(3):257–262.
13
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Oncoplastic Breast Reconstruction
Using a Three-Dimensional Absorbent
Coil
COSTANZA COCILOVO AND MAURICE Y. NAHABEDIAN
Introduction
Advancements in oncoplastic breast surgery have enabled
many women to conserve their natural breast tissue and
avoid mastectomy. e available techniques can be applied
to the majority of women and provide outcomes that range
from good to excellent.
displacement include reduction mammaplasty, adjacent
parenchymal rearrangement, and mastopexy, which are
usually indicated for women with mammary hypertrophy.
Techniques related to volume replacement typically include
the use of local or remote aps and are indicated for women
with smaller breast volumes in whom reduction techniques
may not be possible. By performing the reconstruction
before the radiation, postablative deformities are minimized
and adverse events are fewer.
e use of breast implants as a volume replacement
procedure during the early years of oncoplasty was fraught
with complications and adverse events.
ous caveats with the use of implants was the long-term outcomes due to the presence of an implant in the setting of
radiation therapy. Prior studies that reported on outcomes
of implant-based oncoplasty demonstrated higher complication rates and less favorable outcomes when compared
with oncoplastic reduction mammaplasty. Elton etal demonstrated that the intracavitary placement of an implant was
associated with a 27.8% rate of patient dissatisfaction and
explantation following radiation therapy.
Recent advancements in radiation oncology have focused
on reducing the untoward eects of radiation on the soft
tissues. ese include hypofractionation, partial breast
irradiation, intensity modulation, and three-dimensional
(3D) conformal and intraoperative radiation delivery.
e benets of these innovations are that prosthetic devices
in the setting of radiation therapy can provide acceptable
outcomes in the majority of patients without a dramatic
1,2
Techniques related to volume
3,4
One of the obvi-
4
5-7
increase in reconstructive failure. Reish et al. demonstrated
that radiation therapy in the setting of nipple-sparing mastectomy and prosthetic reconstruction was associated with
increased rates of capsular contracture (12% vs 2.3%, p <
0,001) and secondary revision with fat grafting (13.6% vs
3.9%, p < 0.001).8 Preoperative radiation had an increased
likelihood of complications (p = 0.04), and postoperative
radiation had an increased likelihood of explantation (8.9%
vs 1%, p = 0.015).
Given the improved outcomes with total mastectomy, prosthetic devices, and radiation therapy, the
next advancement was to provide women the option
of using prosthetic devices in the setting of oncoplastic
breast surgery. e reasons for this are that some women
with smaller breasts may choose to avoid the traditional
replacement procedures such as a ap due to the risk of
complications and prolonged recovery. In addition, they
are usually not candidates for displacement procedures
such as reduction because of the lack of tissue. From a
historical perspective, these patients were given the sole
option of a mastectomy to avoid the disgurement that
would occur with breast conservation alone. However,
many of these patients did not want to have a mastectomy and therefore posed a unique set of challenges for
the aforementioned reasons.
Based on the increased use of prosthetic devices and
improved outcomes associated with radiation and implants,
the biplanar technique was described that included simultaneous volume displacement and replacement.9 Instead of
using a ap for volume replacement, a small implant would
be placed below the pectoralis major muscle. is would
occur at the same time as parenchymal rearrangement that
would occur above the pectoralis major muscle. Hence, the
name biplanar was introduced. Early experience with the
biplanar technique was favorable, demonstrating good to
excellent results.
9-11
97
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A second option, and the focus of this chapter, is one that
also incorporates simultaneous volume displacement and
replacement; however, rather than using a breast implant,
an implantable, resorbable, 3D coil is used. e initial
indication for use of this coil was to assist the radiation
oncologists for precise localization of the tumor extirpation
site following breast conservation therapy (cross). e coil
itself comes in a variety of sizes and included metallic studs
imbedded to the coil that allows the radiation oncologists to
readily identify the coil and target the delivery of radiation
therapy more accurately.
12-15
e coil that is currently in use
is known as the BioZorb (Focal erapeutics, Aliso Viejo,
CA, USA).
An incidental benet of the BioZorb is that it serves as a
ller material and partially replaces the volume loss from the
tumor extirpation.16 e dierence between this approach
and the biplanar approach is that this technique is uniplanar with the volume replacement and displacement occurring above the pectoralis major muscle. e device is placed
within the partial mastectomy defect, and the soft tissues
above it are closed. With this technique, volume and contour abnormalities can be minimized.
• Fig. 13.1 Preoperative image demonstrating a woman with right
breast cancer scheduled for oncoplasty via a circumlateral incisional
pattern and a left reduction mammaplasty for symmetry.
Patient Selection
is technique of simultaneous volume displacement and
replacement is best suited for women with small to moderate breast volume in which reduction mammaplasty techniques are not possible and autologous aps are not possible
or declined. e technique is not indicated in patients with
a prior history of radiation due the increased likelihood
of adverse events with placement of prosthetic devices in
a previously radiated eld. Patient comorbidities should be
assessed to ensure that they are in good general health. In
patients with diabetes mellitus, HbA1c levels should be less
than 7 and glucose levels on the day of surgery should be
less than 200. Patients should avoid tobacco products for 1
month before and following the scheduled procedure.
Beginning the Operation
e patient is marked in the preoperative area in the standing position (Fig. 13.1). e preferred incisional approach
is a periareolar with a lateral or vertical extension. e lateral periareolar extension is considered for lateral or superior
tumors, and the vertical periareolar extension is considered
for inferior or medial tumors. ese incisional patterns will
allow for optimal exposure for all quadrants of the breast.
e position of the nipple–areolar complex on the breast
mound can be elevated or modied using mastopexy patterns as needed. A scalpel is used to create the incisions
through dermis. Electrocautery is used to elevate and separate the subcutaneous layer from the underlying parenchyma in the area of the tumor. It is not recommended to
undermine the entire breast parenchyma from the subcutaneous tissues. e partial mastectomy is completed in the
standard fashion.
• Fig. 13.2 Intraoperative image demonstrating the right lateral partial
mastectomy defect.
Technique of Coil Placement
Following the partial mastectomy, the breast defect and the
specimen are assessed and measured (Figs. 13.2 and 13.3).
Linear and volumetric measurements are important, and
the segmental nature of the defect is assessed. When radiolucent markers are placed at the tumor site, radiographic
imaging will conrm that the targeted location has been
excised (Fig. 13.4). Defects that are square to circular in
conguration are best suited for the BioZorb device. If the
defects are rectangular and greater than 30% of the estimated volume of the breast, the technique may be less successful because of the diculties of rearranging a limited
amount of tissue due to the risk of devascularization and fat
CHAPTER 13 Oncoplastic Breast Reconstruction Using a Three-Dimensional Absorbent Coil
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• Fig. 13.3 The specimen is removed and measures 6 × 6 cm.
99
• Fig. 13.5 The tray containing the various BioZorb sizers is depicted.
• Fig. 13.4 The radiograph of the specimen demonstrates the metallic
clips confirming accurate excision with adequate margin.
necrosis. e use of uorescent angiography can be considered to better assess skin and parenchymal perfusion.
e BioZorb devices come in a variety of sizes and shapes
ranging from at to coiled (Fig. 13.5). Its resorption spectrum
is slow and takes approximately 1 year. Although the BioZorb
comes in at and coiled congurations, only the coiled version
is useful in the setting of oncoplasty. ere are several sizes in
which the BioZorb coils are manufactured that are based on
two-dimensional measurements. e sizers are constructed
with a handheld component for easy placement into the partial mastectomy defect to decide which will be most appropriate. If the reconstructive plan is to rearrange the adjacent
• Fig. 13.6 A BioZorb coil is placed into the partial mastectomy defect
and sutured to the pectoralis major muscle
local parenchyma, it is prudent to underestimate the volume
of the device selected to allow for additional soft tissue coverage without creating a secondary contour abnormality. If,
however, the BioZorb is being used as a ller device only without tissue rearrangement, then it is selected to optimally ll
the defect. For more detailed information on the device, the
reader is referred to the company’s website (www.focalrx.com).
Once the sizing is complete, the specic BioZorb is
selected and placed into the partial mastectomy defect
(Fig. 13.6). When the BioZorb is used following breast
conservation or lumpectomy, it is placed within the defect
and sutured. In the setting of partial mastectomy in which
the defect extends to the pectoralis major muscle, the BioZorb is positioned and sutured to the muscle using an
absorbable suture and 3-point xation.
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• Fig. 13.7 The adjacent parenchyma is mobilized and sutured above
the BioZorb device for optimal coverage.
• Fig. 13.8 Following closure of the skin, there is no discernable con-
tour abnormality.
Technique of Oncoplastic Tissue
Rearrangement
In the patient with small to moderate breast with a segmental defect in whom the use of a BioZorb device is indicated
and appropriate, adjacent tissue rearrangement is frequently
necessary to ensure adequate coverage of the device using
local parenchymal and adipose tissue. is is best achieved
by partial and limited undermining along the parenchymal–
pectoralis major muscle interface on the lateral and medial
aspect of the defect. e junction of the parenchyma and
the subcutaneous tissue is also identied and undermined.
It is important to perform this undermining gradually and
systematically assess mobility and excursion frequently.
Excessive undermining can result in compromised perfusion to the mobilized tissue with ultimate fat necrosis. e
use of a tissue perfusion device can be considered.
Once the undermining is sucient and the medial and
lateral parenchymal pillars are suciently approximated,
the BioZorb device is positioned and sutured into place.
e pillars are then sutured together above the BioZorb to
ensure complete soft tissue coverage (Fig. 13.7). Absorb-
able monolament sutures are usually used. e skin edges
are aligned to ensure as minimal a contour abnormality as
possible (Fig. 13.8). e wound is irrigated and hemostasis
obtained. e use of a small closed suction drain is considered when tissue rearrangement has been performed; however, a drain is not necessary when it has not.
Postoperative Care
Postoperative management in these cases is similar to traditional oncoplastic cases. When a drain has been used, it is
• Fig. 13.9 An early postoperative image demonstrating acceptable
volume and contour of the breast.
typically removed when the output is < 30 mL/day, which
usually occurs between postoperative days 5 and 7 (Fig.
13.9). In general, postoperative antibiotics are not used when
BioZorb is used as a ller following lumpectomy; however, a
2–3 day course of postoperative oral antibiotics are considered in the setting of parenchymal rearrangement.
Complications
Complications following oncoplastic reconstruction using
the BioZorb are similar to the complications following
device-based reconstruction and include infection, delayed
healing, seroma, palpability, and premature removal. In the
event of delayed healing or supercial necrosis, debridement
is advised early to prevent exposure and to minimize the risk
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• Fig. 13.10 A patient with delayed healing is demonstrated. This
required debridement and secondary closure.
of delayed radiation treatments (Fig. 13.10). In the event
of cellulitis, patients are started on postoperative antibiotics. Should there be increased and progressive pain, swelling, and erythema, surgical exploration and explantation is
considered. Seroma management consists of observation or
aspiration. In most patients, the BioZorb device is palpable,
and patients may require reassurance that this is normal and
that resorption takes about 1 year. It is important to minimize the risk of delaying adjuvant treatments; therefore,
surgical intervention is considered when that risk is present.
Outcomes
Given the novelty of this technique, long-term outcomes are
forthcoming. However, this technique is gaining acceptance
among the radiation oncology, breast surgery, and plastic
surgery communities. Radiation oncologists have reported
more consistent and accurate identication of the surgical margins for radiation delivery.12 ey have also demonstrated statistically signicant reductions in clinical and
planning target volumes without increasing ipsilateral lung
or heart irradiation.15 Breast surgeons have reacted favorably as well reporting that re-excision is simplied having
the 3D marker in place, low complication rates with infections occurring in <1% of patients, with good to excellent
cosmetic appearance in more than 90% of patients.16 To
date, plastic surgeons have not published their experience
using this device; however, our experience in more than 80
patients has been favorable as a volume replacement device.
Conclusions
e use of the BioZorb seems to be an excellent tool for
plastic and breast surgeons to use as a volume replacement
device in the setting of oncoplastic breast surgery. Its benets are noted for radiation oncology, breast surgery, and
plastic surgery. Its short-term benets have been noted, and
long-term outcomes will be forthcoming.
101
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doi.org/10.1186/s13014-018-1079-x.
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https://t.me/medicina_free
Lipolling and Oncoplasty
ALEXANDRE MENDONÇA MUNHOZ
Funding Sources/Financial Disclosures
is work was not supported by any external funding. Dr.
Alexandre Mendonça Munhoz is a consultant to Motiva/
Establishment Labs Corporation.
Contributor’s Statement
Dr. Alexandre Mendonça Munhoz is the principal investigator of this study. e principal investigator made signicant contributions to the conception and design of this
study and made substantial contributions to the acquisition,
analysis, interpretation of data, and manuscript preparation.
e author revised the article for intellectual content, gave
nal approval of the version to be published, and has suciently participated in the work to take public responsibility
for appropriate portions of the content.
Introduction
Breast-conserving surgery (BCS) for early breast cancer
treatment continues to be one of the most frequently performed oncologic surgeries worldwide.1 e introduction
of the oncoplastic approach as well as new surgical techniques have led to widespread acceptance of immediate and
delayed reconstruction following BCS.
Advances in oncoplastic surgical techniques have reduced
surgical morbidity and can thus preserve breast shape and
lead to better aesthetic outcomes.
tial mastectomy defects can be treated with primary closure,
the outcome may be aesthetically unpredictable and result in
contour abnormalities.4 Oncoplastic techniques are classied
as volume displacement or replacement procedures.
is no consensus as to the best approach, and the criteria for
selecting an optimal technique are determined by the surgeon’s
experience and the size of the defect relative to the remaining
6,7
breast.
should include reproducibility, low interference with oncologic treatment, and acceptable long-term results. Surgical
planning should include an assessment of patient preference,
addressing individual reconstructive requirements and to custom tailor each individual reconstruction.
e advantages of oncoplastic breast reconstruction
2,3
2,4
Even though most par-
2,4-6
7
ere
Even though it is widely used today, lipolling or lipomodeling (more specically described as autologous fat
grafting/transfer, AFG) is an old concept.8 Despite the
advantages AFG oers, its use in reconstructing BCS defects
is controversial, particularly with regard to aesthetic results
and oncologic outcomes. As of this writing, few clinical
studies have assessed outcomes after AFG to an unfavorable
recipient site,
with immediate AFG are similarly lacking.
maintain that this is because AFG is usually performed by
plastic surgeons, whereas oncologic/breast surgeons perform
BCS.9 Today, a new generation of oncoplastic surgeons is
emerging with training in both breast and plastic surgery,
and the number of studies on this topic is expected to
increase in the coming years.
Although reconstruction following BCS has a high rate
of patient satisfaction, some patients may present unsatisfactory results and require surgical revision.
experience, many of these reoperations are required for
problems related to the soft tissue such as local irregularities
and implant visibility/rippling rather than reconstruction
failure.7 As with total breast reconstruction, there has been
a resurgence in the use of AFG following BCS for a variety
of indications over the past 10 years.
ment in AFG procedures has improved reproducibility, a
standardized technique is lacking, and its relevance as an
associated technique has yet to be investigated. It can be
assumed that if AFG, BCS, and oncoplastic reconstruction
are equally reproducible and involve similar risk and surgical time, the feasibility of combining all of these techniques
is now realistic.
e objective of this chapter is to provide an overview of
BCS reconstruction incorporating oncoplastic techniques
and AFG. Although all these techniques are well-studied
procedures, few detailed clinical reports specically address
the operative planning, outcomes, and complications following AFG. As a result, this chapter presents a detailed
description of our method, including the preoperative
evaluation and intraoperative care for patients undergoing
primary and secondary reconstruction. e surgical technique, advantages, and limitations are also discussed. When
8-14
and studies focused on breast conservation
9
8-15
Some authors
2,4,5
10-15
Although rene-
In our
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