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CHAPTER 16 Oncoplastic Variations Based on Tumor Location
EF
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133
A
C
B
D
• Fig. 16.6 This is an 80-year-old woman with small ptotic breasts who had a left-sided carcinoma arising
in an adenomyoepithelioma (A-D). She already had a lumpectomy with positive margins and a deformity
above the nipple. Mastectomy and reconstruction would have been difficult given her age and breast
shape. She had a 60-gram re-excision leaving a defect above and beneath the nipple (E,F). The nipple
was essentially flat on the chest wall following resection without any tissue above to fill the void.
SECTION II Oncoplastic Breast Surgery – Surgical Techniques
IJ
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134
G
Fig. 16.6, cont’d We used the medial and lateral dermatoglandular flaps in a rotation fashion to place
beneath and above the nipple demonstrating decent shape and nipple projection at the completion of the
case (G,H). A small central mound contralateral reduction was performed. She is shown 6 months following completion of left-sided breast irradiation (I,J).
non-breast local or distant aps. is is now well accepted
in the evolution of breast cancer surgery and provides
breast symmetry without remodeling the contralateral
breast.
Local aps are often indicated in small or moderate
volume breasts with insucient tissue remains following resection for volume displacement techniques. e
usual techniques included (1) rhomboid aps, (2) subaxillary ap, (3) superior-based lateral thoracodorsal ap,
(4) inferior-based lateral thoracodorsal ap, and (5) the
extended lateral thoracodorsal ap (see Fig. 16.8). Small
lateral defects (less than 10% of breast size) can be closed
with local aps. Clough11 described using the subaxillary
area as a transposition ap, and Munhoz has more recently
demonstrated how the lateral thoracodorsal ap (LTDF) is
ideal for lateral defects, especially in obese patients.12 ese
aps essentially rotate or transfer skin and subaxillary fat
or skin and breast parenchyma into the defect. e same
principles can be applied to local aps taken from outside
the breast as described previously, or even from within the
H
breast (volume displacement techniques). Attention to
ap design is important to ensure ap survival, cosmesis,
and appropriate conversion to a completion mastectomy
if necessary. e latissimus dorsi (LD) musculocutaneous
ap is a common local option for lateral, central, inferior,
and even medial defects (Fig. 16.9).13 It has excellent blood
supply and provides both muscle for lling of glandular
defects and skin for cutaneous deciencies. Avoiding a scar
on the back can be achieved by harvesting the LD without
skin through the lateral breast incision. e use of an endoscope can assist in raising the muscle.14 A denervated and
radiated LD will undergo postoperative atrophy. To compensate for the expected loss in muscle volume, a ap much
larger than the defect should be harvested, possibly preserving subscarpas fat on the muscle. A similar skin island to
the classical LD musculocutaneous ap can be raised as a
pedicled perforator ap either from the thoracodorsal or
intercostal vessels. Sparing the underlying muscles or using
perforator aps have reduced the donor site morbidity to a
minimum, with no seroma formation at the donor site.15
CHAPTER 16 Oncoplastic Variations Based on Tumor Location
AB
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135
C
D
• Fig. 16.7 (A, B) This is a 51-year-old female with a left lower lateral quadrant DCIS with a left lower lateral
quadrant DCIS. (C, D) She had wire localization and was marked with the Wise pattern.
SECTION II Oncoplastic Breast Surgery – Surgical Techniques
GH
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136
E
Fig. 16.7, cont’d (E) After a 60-gram partial mastectomy, she was left with a large lateral defect. (F, G)
This was reconstructed with an extended superomedial pedicle and an additional 30-gram resection from
the left side. A contralateral reduction of 120 grams was performed. (H, I) She is shown 1 year following
completion of left-sided radiation therapy.
e thoraco-dorsal artery perforator (TDAP) ap can easily reach defects in the lateral, superolateral, and central
regions of the breast. If no suitable perforators are found,
the ap is easily converted to a muscle-sparing TDAP or
muscle-sparing LD ap. e lateral intercostal artery perforator (LICAP) ap is another alternative to the TDAP
ap for lateral and inferior breast defects. e lateral intercostal artery perforators are found at 2.7–3.5 cm from the
anterior border of the LD muscle. e anterior intercostal
artery perforator (AICAP) ap is similar to the randomdesigned thoraco-epigastric skin ap in that the skin paddle
can be harvested as an AICAP ap. e AICAP is based on
perforators originating from the intercostal vessels through
the rectus abdominis or the external oblique muscles.
Because it has a short pedicle, the AICAP ap is suitable to
F
cover close defects that extend over the inferior or medial
quadrants of the breast. e superior epigastric artery perforator (SEAP) ap is based on perforators arising from the
superior epigastric artery or its supercial branch. It has the
same indications as the AICAP ap; however, the SEAP
ap has longer pedicles, and therefore it can cover more
remote defects in the breast.
Large medial defects are among the more dicult areas
to reconstruct. e supercial inferior epigastric artery free
ap has been described for this location.16 In situations such
as this, or when the partial mastectomy defect is signicant
with minimal residual breast tissue, a decision needs to be
made whether to complete the mastectomy and perform
total breast reconstruction for both cosmetic and oncologic
reasons.
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CD
E
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A
B
a
b
F
G
• Fig. 16.8 (A) This is a 48-year-old woman with moderate breast size and ptosis who presented with a right
lateral infiltrating ductal carcinoma. She underwent wire localization (B) and a 55-gram partial mastectomy (C).
The defect was lateral to the nipple and all the way down to the chest wall (D). A standard central mound or
inferior pedicle reduction might not have given her sufficient tissue to fill the defect high enough. A decision
was made to use the lower pole breast tissue to create a secondary inferiorly based pedicle to fill the tumor
defect. A superomedial pedicle was created to move the nipple independently to its proposed location. (E, F)
Including the lumpectomy specimen, the total volume removed from that side was 175 grams. A contralateral
reduction was performed removing 190 grams using a superomedial pedicle. She is shown 1 year following
completion of right radiation therapy (G) with decent preservation of volume and lateral breast contour.
SECTION II Oncoplastic Breast Surgery – Surgical Techniques
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138
A
C
B
D
E
• Fig. 16.9 This 65-year-old patient with DCIS medially underwent a left partial mastectomy removing 60
grams. Her defect is shown and the plan was to perform a superolateral pedicle. A total of 242 grams of
tissue was removed from the left side. A contralateral reduction was performed removing 340 grams. The
intraoperative result demonstrates the left breast being larger in anticipation of radiation therapy. Her result
is shown at 1 year postoperative with improved shape and symmetry.
F
CHAPTER 16 Oncoplastic Variations Based on Tumor Location
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139
Various other techniques have been described to ll partial mastectomy defects, however, these are currently less
common. ey include abdominal adipofascial aps, omental aps, and autologous fat injections.
17-20
Summary
In conclusion, tumor location plays a pivotal role in the
planning and execution of oncoplastic breast reconstruction. ere are a variety of reconstructive options that can
be used based on the size and location of the partial mastectomy defect. is chapter has provided a framework and
algorithm that all surgeons can use when oering oncoplastic breast surgery to their patients.
References
1. Pukancsik D, Kelemen P, Újhelyi M, et al. Objective decision
making between conventional and oncoplastic breast-conserving
surgery or mastectomy: an aesthetic and functional prospective
cohort study. Eur J Surg Oncol. 43(2):303–310.
2. Losken A, Hart AM, Broeker JS, Styblo TM, Carlson GW.
Oncoplastic breast reduction technique and outcomes: an evolution over 20 years. Plast Reconstr Surg. 2017;139(4):824e.
3. Kronowitz SJ, Kuerer HM, Buchholz TA, etal. A management
algorithm and practical oncoplastic surgical techniques for repairing partial mastectomy defects. Plast Reconstr Surg. 2008;122:1631.
4. Anderson BO, Masetti R, Silverstein MJ. Oncoplastic approaches
to partial mastectomy: an overview of volume replacement techniques. Lancet Oncol. 2005;6(3):145–157.
5. Losken A, Hart AM, Chatterjee A. Updated evidence on the
oncoplastic approach to partial breast reconstruction. Plast Recon-
str Surg. 2017:14S–22S.
6. Losken A, Hart AM, Dutton JW, Broecker JS, Styblo TM,
Carlson GW. e expanded use of auto-augmentation techniques
in oncoplastic breast surgery. Plast Reconstr Surg. 2018;141(1):
10–19.
7. McCulley SJ, Dourani P, Macmillan RD. erapeutic mam-
maplasty for centrally located breast tumors. Plast Reconstr Surg.
2006;117(2):366–373.
8. Berrino P, Campora E, Santi P. Postquadrantectomy breast
deformities: classication and techniques of surgical correction.
Plast Reconstr Surg. 1987;79(4):567–572.
9. Clough KB, Kroll SS, Audretsch W. An Approach to the repair of
partial mastectomy defects. Plast Reconstr Surg. 1999;104(2):409.
10. Munhoz AM, Montag E, Arruda EG, etal. e role of the lateral thoracodorsal fasciocutaneous ap in immediate conservative
breast surgery reconstruction. Plast Reconstr Surg. 2006;117:1699.
11. Munhoz A, Montag E, Fels KW, et al. Outcome analysis of
breast-conservation surgery and immediate latissimus dorsi ap
reconstruction in patients with T1 to T2 breast cancer. Plast
Reconstr Surg. 2005;116(3):741–752.
12. Losken A, Schaefer TG, Carlson GW, Jones GE, Styblo TM,
Bostwick J 3rd. Immediate endoscopic latissimus dorsi ap: risk
or benet in reconstructing partial mastectomy defects. Ann Plast
Surg. 2004;53(1):1–5.
13. Hamdi M, Van Landuyt K, Monstrey S, Blondeel P. Pedicled
perforator aps in breast reconstruction: a new concept. Br J Plast
Surg. 2004;57(6):531–539.
14. Spiegel AJ, Khan FN. An intraoperative algorithm of use of
the SIEA ap for breast reconstruction. Plast Reconstr Surg.
2007;120(6):1450–1459.
15. Zaha H, Inamine S, Naito T, etal. Laparoscopically harvested
omental ap for immediate breast reconstruction. Am J Surg.
2007;192:789–791.
16. Ogawa T, Hanamura N, Yamashita M, etal. Usefulness of breast
volume replacement using an inframammary adipofascial ap
after breast conservation therapy. Am J Surg. 2007;193:514–518.
17. Kitamura K, et al. Stem cell augmented reconstruction: a new
hope for reconstruction after breast conservation therapy. Breast
Cancer Res Treat. 2007;106(supp1). Abstract 4071.
18. Rageth CJ, Tausch C. Intramammarian ap reconstruction (IFR)
technique in breast conserving surgery. Breast. 2009;18:387.
19. Munhoz AM, Montag E, Arruda E, etal. Assessment of immediate conservative breast reconstruction: A classication system of
defects revisited and an algorithm for selecting the appropriate
technique. Plast Reconstr Surg. 2008;121:716–727.
20. Clough KB, Nos C, Salmon RJ, Soussaline M, Durand JC. Conservative treatment of breast cancer by mammaplasty and irradiation: a new approach to lower quadrant tumors. Plat Recon Surg.
1995;96(2):363–370.
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17
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Complications of Oncoplastic
Breast Surgery
HANI SBITANY
e surgical management of breast cancer has evolved signicantly over recent years, commonly trending away from
radical procedures, toward those with less extensive resections and decreased patient morbidity. Such types of breast
conservation therapy have also been accompanied by simultaneous reconstructive procedures to the breasts, allowing maintenance of ideal aesthetics to preserve the breast
mound. ese joint oncoplastic procedures have allowed for
improved aesthetic outcomes and quality of life for patients,
while still ensuring oncologic safety.
A variety of techniques have been described for oncoplastic partial mastectomy reconstruction, including local tissue
rearrangement, reconstruction through reduction mammaplasty or mastopexy approaches, and transfer of local/
regional aps.3 e individual procedure is chosen based on
the preoperative breast size and ptosis, percentage of breast
parenchyma excised, location of tissue removal in the breast,
and potential need for adjuvant chemotherapy or radiation.
e rapidly expanding body of literature on outcomes following oncoplastic surgery has shown numerous benets to
this reconstructive approach, including improved aesthetic
outcomes, better control of tumor margins, high patient
satisfaction, and the ability to extend the option of breast
conservation for previously unt candidates.
With such techniques, potential complications must
be considered by the reconstructive surgeon and discussed
with both patients and oncologic surgeons. Although some
potential risks apply to all oncoplastic procedures, some are
unique to individual procedures performed in this setting.
1,2
4,5
most common complication in Wise pattern techniques is
delayed healing of the T junction. Although wound-healing
complications may delay time to adjuvant radiotherapy,
this is a rare occurrence in all series reported to date. ese
procedures do have longer operating times than wide local
excision alone, which should be taken into consideration
when evaluating patients to ensure they are appropriate candidates for oncoplastic reconstruction.
For individual complications, the most commonly
reported rates apply to hematoma/seroma (6% range),
wound dehiscence requiring management (4% range), and
breast asymmetry requiring revision (5% range). ese
rates apply to all types of oncoplastic procedures and are
within similar ranges to most types of post-mastectomy
breast reconstruction options. e undertaking of a bilateral oncoplastic reconstruction has not been shown to result
in higher complication rates when compared with unilateral
procedures.
Although these quoted complication rates are higher
than those for breast conservation without reconstruction,
the aesthetic outcomes must always be considered when
considering risk. Without oncoplastic reconstruction, any
contour deformity will likely require future revisionary surgery. Furthermore, if the patient receives adjuvant radiation,
the postoperative contour deformity will become magnied, and the surgical options for correction will be limited.
When attempts are made at correcting deformities following breast conservation and radiation rather than upfront
with oncoplastic surgery, the reported overall complication
rates are in the 40–50% range.6
Acute Complications Following
Oncoplastic Reconstruction
Overall complication rates for oncoplastic reconstruction range from 15–30%.6 e complications unique to
this type of surgery include skin/ap necrosis, nipple and
nipple–areolar complex (NAC) necrosis, seroma, hematoma, infection, wound dehiscence, and fat necrosis. e
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Local Tissue Rearrangement
Local tissue rearrangement is an essential component of
many oncoplastic procedures. is may shift the defect to
a less conspicuous location by taking advantage of healthy
breast parenchyma, subcutaneous fat, and skin elsewhere
in the breast, regardless of breast size. ese approaches
often involve raising of skin/subcutaneous aps to allow for
mobilization of the underlying glandular tissue to ll the
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glandular defect. Glandular aps may allow defects in all
areas of the breast to be lled, even in the dicult-to-repair
upper inner quadrant defect, provided there is sucient
tissue.
e complication rates following local tissue rearrangement are the lowest reported for any method of oncoplastic surgery. e most frequently reported are seroma (12%
range) and local infection (7% range). And although these
may require further invasive treatment, the majority can be
successfully treated with aspiration, drainage, and antibiotic
therapy. In the event of a hematoma, management usually
requires operative exploration, especially when acute. e
use of a surgical drain is not preventative but may be diagnostic and prevent excessive tension on the incision and
NAC. Seroma management is usually achieved with observation or aspiration. If the seroma interferes with the delivery of radiation, surgical management or placement of an
indwelling catheter by the interventional radiologists may
be appropriate. Delayed healing is usually managed by local
wound care; however, if extensive, surgical excision may be
necessary, especially if the timing of radiotherapy will be
impacted. Local infection can be in the form of cellulitis
or an abscess. Cellulitis is usually successfully treated with
intravenous or oral antibiotic therapy. Abscess management
requires incision and drainage.
When compared with partial mastectomy alone, the use
of immediate local tissue rearrangement is not an independent predictor of overall complications. In either cohort,
the independent predictors of overall post-surgical morbidity are body mass index (BMI), American Society of Anesthesiologists (ASA) class 3 or 4, bleeding disorder, chronic
obstructive pulmonary disease, and greater operative times.
Oncoplastic Reduction Mammaplasty
Reduction mammaplasty is an ideal treatment option for
breast cancer in women with macromastia. Based on tumor
location, a skin pattern and NAC pedicle are designed preoperatively to allow for resection of the tumor within the
typical resection pattern for the specic reduction technique
and lling of the planned tumor defect with the remaining
breast tissue. Once the amount of required tissue resection
is determined on the ipsilateral side, the contralateral breast
can also be reduced to match. Furthermore, this technique
can be applied to tumors in other areas of the breast by shifting tissue and rotating the reduction pattern and pedicle
location.
e most commonly employed oncoplastic reduction
technique is the inverted T pattern with inferior pedicle
reduction mammaplasty. e orientation of the pedicle ultimately depends on the location of the tumor and the area
of excision. When the tumor is located in the upper pole of
the breast, a wide upper pole tumor excision with glandular resection followed by parenchymal rearrangement will
often result in an improved aesthetic outcome for the large
or ptotic breast. e incision pattern maintains viability of
CHAPTER 17 Complications of Oncoplastic Breast Surgery
• Fig. 17.1 A common complication is delayed healing at the trifurcation
point following inverted T oncoplastic reduction mammaplasty.
the skin aps while providing adequate access and exposure
for the partial mastectomy. Whenever possible, it is prudent
to maintain perfusion to the NAC on a dermoglandular
pedicle.
For these techniques, the most commonly reported complications include delayed wound healing (10% range),
infection (5% range), and symptomatic fat necrosis (1.4%
range).7 Other less commonly reported complications of
these techniques include seroma (1% range), symptomatic fat necrosis (1–2% range), and nipple necrosis (1–2%
range). e most common area for delayed healing is the
trifurcation point associated with the inverted T pattern
(Fig. 17.1). is is an area of relatively poor vascularity
and increased tension. Management is usually achieved by
local wound care; however, if delayed healing interferes with
radiotherapy timing, surgical debridement and secondary
closure is considered. Delayed healing of the NAC is also a
risk and usually managed with local wound care (Fig. 17.2).
Excision is reserved for cases with total necrosis of the NAC
(Fig. 17.3).
Fat necrosis is another potential complication associated
with oncoplastic surgery and more problematic in women
with mild to moderate hypertrophy associated with a moderate volume partial mastectomy (Fig. 17.4). Parenchymal
rearrangement can be pushed to the limits of vascularity and
result in less perfusion to the parenchymal ap, resulting
in fat necrosis. When palpable, options include ultrasound
and ne needle aspiration for diagnosis and either observation or surgical excision. When extensive, additional rearrangement may not be an option, and a local ap such as a
latissimus dorsi may be necessary.
Cellulitis and hematoma following oncoplastic reduction mammaplasty is an uncommon event and usually amenable to conservative management (Figs. 17.5 and 17.6).
Most infections are preventable by using copious irrigation techniques and prophylactic intravenous antibiotics.
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