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CHAPTER 7 Volume Displacement and Volume Replacement Techniques
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A
B
• Fig. 7.1 A 42-year-old with left breast cancer referred for partial
mastectomy reconstruction. Due to concerns for positive margins, a
staged-immediate reconstruction was performed. (A) Lumpectomy
incision shown in upper outer quadrant. (B) Volume displacement
technique with mastopexy approach and simultaneous symmetry procedure before radiation. Lumpectomy incision excised through Wise
pattern approach.
the oncologic team. is involves proper planning and communication between the resecting surgeon, reconstructive
surgeon, and radiation oncologist. Many studies have shown
higher success rates in immediate reconstruction than those
reconstructions performed in the delayed setting.
12-14
More
importantly, immediate reconstruction does not pose a problem with postoperative cancer surveillance. Local recurrence
rates have been shown to be as low as 5%.
15,16
ere are,
however, potential limitations of the immediate approach,
which include delayed wound healing, positive tumor margins, longer surgery time, and poor result. All of these factors
may also delay the onset of radiation therapy.
When there is concern for positive tumor margins such
as with large or multicentric tumors, or multifocal disease,
then a staged immediate approach should be considered.
is allows for conrmation of negative margins and, when
necessary, re-excision of positive margins before radiation
therapy (Fig. 7.1).
Once scarring and brosis has set in following radiation
therapy, manipulation of the breast parenchyma is limited. Higher complication rates have been seen in delayed
reconstruction groups with diculties including wound
breakdown, scar contracture, cellulitis, and seroma.17
A
B
• Fig. 7.2 A 47-year-old with right breast cancer referred for delayed
oncoplastic reconstruction. She was never offered an immediate
reconstruction. (A) Shown following partial mastectomy and radiation therapy without reconstruction. (B) Postoperative result following
delayed reconstruction with volume displacement technique.
Even the most optimal result in the delayed setting fares
poorly when compared with immediate reconstructions
(Figs. 7.2 and 7.3).
e timing of the symmetry procedure is up to the
reconstructive surgeon; there is no existing standard. It is my
practice to delay the symmetry procedure until the radiation therapy of the aected breast has been completed. is
approach optimizes breast symmetry, reduces surgical time,
and eliminates the possibility of delaying radiation treatment due to healing issues in an otherwise healthy breast.
e obvious limitation of this approach is the need for a
second surgery. e potential changes in the radiated breast
may be an increase in size from chronic edema related to
impaired lymphatic drainage or a decrease in size due to atrophy from radiation-induced fat necrosis.18 Allowing time
for observation of these potential changes ensures the most
accurate symmetry. Consideration must also be given to the
patient’s emotional state and quality of life. For patients
with severe macromastia, a simultaneous symmetry procedure is oered, and the possibility of postoperative asymmetry due to radiation changes is explained. Some have also
reported leaving the ipsilateral radiated breast roughly 10%
larger during simultaneous reductions to allow for radiation
brosis correction.22 Otherwise, the symmetry procedure is
oered 2–3 months after the completion of radiation.
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A
B
• Fig. 7.3 A 42-year-old with right breast cancer referred for immedi-
ate oncoplastic reconstruction. (A) Preoperative views showing large,
ptotic breasts. (B) Twelve months following immediate partial mastectomy reconstruction with reduction technique and symmetry procedure performed 3 months after radiation.
Classification of Partial Breast Defects
e variability in partial mastectomy defects range from
small to large. erefore, their respective reconstructive
needs have led to numerous classication systems and algorithms for repair.
19-22
e various classications systems
share in common the evaluation of initial breast volume,
the extent and location of the anticipated defect, and the
remaining available breast tissue (Table 7.2). In addition
to the extent of the defect, the classication system should
reect how much skin is removed and where the defect is in
relation to the nipple–areolar complex.
Partial Mastectomy Reconstruction
Techniques
ere are two fundamental concepts of partial mastectomy
reconstruction, which include volume displacement and
volume replacement. e decision to use the most appropriate technique is often multifactorial: breast size, tumor
size, defect size, tumor location, and patient desire.
Moderate- to large-sized breasts are ideal for partial mastectomy reconstruction as there typically will be sucient breast
tissue following resection amenable to reshaping or volume
displacement techniques. Large resections can be possible,
especially when the tumor is located within the standard
inverted T pattern marking in a mastopexy or reduction-type
approach. In smaller breasts or those without ptosis, additional tissue is often required to maintain the preoperative
breast size or shape, thus utilizing a volume replacement technique. Large, quadrantectomy-type resections in small breasts
are likely to require ap reconstruction to preserve shape. In
this scenario, consideration should be given for mastectomy
and reconstruction with implant-based or autologous tissue
22,23
TABLE
Classication of the Partial Mastectomy Defect with Potential Outcome and Treatment Options
7. 2
Description Potential Outcome Treatment
Type 1
(favorable)
Type 2
(unfavorable)
Type 2a Small breasts, with or without ptosis Volume replacement procedures
Type 2b
Type 3
(unfavorable)
From Losken A, Hamdi M. Partial breast reconstruction: current perspectives. Plast Reconstr Surg 2009; 124(3):722–736.
Small, peripheral defect
Large or small breasts
Medium to large defect
Central defects
Medium to large breasts, with or
without ptosis
Extensive resection with little remaining
breast tissue
Large or small breasts
Breast shape is preserved with
acceptable symmetry
Size and shape deficiency with
noticeable distortion and asymmetry
Quadrantectomy defect outside
standard Wise pattern
Any lumpectomy defect
Quadrantectomy defect within standard
Wise pattern
Major deficiency Mastectomy and reconstruction
Primary closure, breast tissue
advancement flap
Volume replacement technique
Volume displacement techniques
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techniques. is could potentially eliminate the need for
radiation and decrease the frequency and intensity of postoperative tumor surveillance. When contemplating the reconstructive techniques, other issues should always be taken into
consideration including health risk factors (smoking, diabetes, etc.), tumor biology, and comfort levels of both the resecting and reconstructive surgeon with the various techniques.
Volume Displacement Techniques
e repair of small- to moderate-sized defects is accomplished
through advancement, rotation, or transposition of remaining
breast parenchyma into the defect. Essentially, tissue adjacent
to the defect is mobilized by breast ap advancement techniques.24 Full thickness parenchymal aps are dissected over
the pectoralis and advanced to minimize dead space. Drains
are typically not required, and a contralateral symmetry procedure is also not usually necessary. Local tissue rearrangement
to reshape the breast also minimizes the need for additional
skin incisions. is is initiated rst by dissecting within the
subcutaneous plane between the breast skin and the underlying parenchyma. e remaining parenchyma is then plicated together to recreate the contour of the breast mound.
As there may be a decrease in volume, excess skin will likely
need to be redraped and optimally contoured. is is usually
accomplished by de-epithelialization of excess skin around
the nipple–areolar complex and by maintaining a tension-free
closure. is technique is ideal for small, non-ptotic breasts in
which nipple position is already ideal. If breast skin excision
is not necessary, a circumareolar incision will allow access to
most tumors for completion of the partial mastectomy.
e most popular and reproducible options for volume
displacement are the mastopexy and reduction techniques.
e ideal patient is one with ptosis, a moderate- to large-sized
breast, and will likely have sucient tissue left behind following
resection. e defect should be located within the anticipated
resection specimen or inverted T pattern. ese techniques
allow for excellent exposure for the resecting surgeon, generous resections, low morbidity, good aesthetic outcomes, and
sound oncologic treatment. It is well established that although
there is no survival dierence between breast conservation surgery and simple mastectomy, there is a slightly higher locoregional recurrence rate.
25,26
However, some data suggest that,
with reduction volume displacement techniques, there may be
no dierence in locoregional recurrence compared with simple
mastectomy.27 is is likely due to the removal of larger portions of breast tissue before whole breast irradiation.
e most important factor in designing the dermoglandular pedicle is the location of the tumor. e circumferential blood supply to the breast allows for various vascularized
pedicle designs based more or less opposite from the tumor
location.
17,28
Kronowitz has described these zone designations to determine the optimal design for the dermoglandular pedicle to repair the partial mastectomy defect (Fig. 7.4).
For example, a tumor located superiorly in Zone 3 would
favor an inferiorly based pedicle with an inverted T pattern
skin excision. Additional wedges of tissue can be retained
medially, laterally, or both to enhance perfusion and volume
18
• Fig. 7.4 Kronowitz zone designations of the breast are based on
tumor location, which assists in determining the optimal design for the
dermoglandular pedicle to repair a partial mastectomy defect.
needs if the breast resection is more extensive. e patient
presented in Fig. 7.5 had a left breast cancer located around
the 1 o’clock position and elected to undergo partial mastectomy. A 225-gram defect was created in the superior pole
and reconstructed with an inferior pedicle.
When a tumor is inferiorly located, I prefer a superomedial pedicle (Fig. 7.6). is allows for extensive resection of the entire lower pole and decreases the chance for
positive margins. In addition, with the pedicle suspended
superiorly, there may be less potential for bottoming out
of the breast long term when compared with an inferior
pedicle.
29,30
Because of the pedicle’s robust vascular supply
o the internal mammary artery perforators, it can be safely
undermined when needed to secure clear margins. e lateral skin ap can also be left thicker to compensate for any
volume loss following the resection.
Volume Replacement Techniques
Women with large tumor-to-breast ratios and who have
small to moderate breast size present unique challenges for
the reconstructive surgeon. From the start, there is likely
to be insucient breast tissue remaining for tissue rearrangement or any other displacement techniques previously described. erefore, the tissue must be replaced with
adjacent or distant aps. Although these options may help
retain the volume and shape of the breast, they do so at the
expense of a donor site and require more surgery and recovery time. Local fasciocutaneous aps such as rhomboid aps,
subaxillary aps, and lateral thoracodorsal aps have been
described.11 ese are especially useful for lateral defects but
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1
2
3
5
A
6
7
B
C
D
• Fig. 7.5 Volume displacement technique with an inferior pedicle reduction. (A) Tumor between Zones 3
and 6. (B) Inverted T pattern skin markings with needle localization wires present superiorly. (C) 225-gram
specimen. (D) Inferior pedicle preserved before de-epithelialization and generous access provided for
tumor resection. (E) Inferior pedicle being mobilized superiorly. (F) Pedicle transposed into defect and skin
redraped.
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A
C
• Fig. 7.6 (A) A 38-year-old woman with an inferiorly located right breast cancer. (B) Inverted T pattern
reduction with superomedial pedicle. Needle localization wires placed in inferior pole and located within
standard Wise pattern markings. (C) Postoperative result after an 800-gram oncoplastic reduction.
may be limited by their respective arcs of rotation. e thoracodorsal artery perforator (TDAP) ap has the added advantage of a longer perforator allowing for more breast coverage.
It also eliminates the need for muscle harvest from a latissimus ap when less volume is needed (Fig. 7.7). Hamdi
etal have described other perforator aps based o the anterior and lateral intercostal artery and the superior epigastric
31,32
artery.
ese aps require extensive experience and are
not commonly employed by most reconstructive breast surgeons. A latissimus muscle ap with or without skin can
provide coverage for the whole breast and can be done in
an immediate or delayed setting. More recent advancements
such as endoscopic harvest of the latissimus ap and the dissection of less muscle have contributed to lower seroma rates
and morbidities commonly associated with its use.
Munhoz et al reviewed their 7-year experience in 209
partial mastectomy reconstructions. e six most common techniques used were (1) breast tissue advancement
aps (displacement), (2) lateral thoracodorsal artery aps
(replacement), (3) mastopexy (displacement), (4) reduction
techniques (displacement), (5) latissimus dorsi myocutaneous
ap (replacement), and (6) abdominal aps (replacement).19
B
Although use of abdominal aps such as a pedicled TRAM,
free TRAM, or DIEP are acceptable reconstructive options
for breast conservation surgery, their use should be limited,
especially in the immediate setting. Positive tumor margins
may necessitate a completion mastectomy, and it is best to
preserve those reconstructive options. It is my practice to
reserve abdominal aps for total mastectomy reconstruction.
Generally, the use of implants for volume replacement
has been discouraged due to high complication rates associated with radiation therapy. However, the option to use an
implant to replace lost volume in a small breast treated with
breast conservation surgery has re-emerged. Nahabedian etal
reported a biplanar technique that incorporated both volume
displacement techniques by use of glandular tissue rearrangement and volume replacement techniques with a subpectoral
implant.33 Barnea et al also reported their experience with
the biplanar approach in 21 patients who underwent oncoplastic breast augmentation. eir complications included
positive margins in 14.3%, grade III/IV capsular contracture
in 23.8%, and a 10% infection rate.34 In carefully selected
patients, implant use for volume replacement in the small
breasted can be a viable option (Fig. 7.8).
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• Fig. 7.7 Thoracodorsal artery perforator flap. The main perforators are located along the course of the
descending branch of the thoracodorsal artery or from the lateral branch. The most proximal perforator
reaches the subcutaneous tissue in a point located 2 or 3 cm posterior to the lateral edge of the muscle
and 8 cm below the posterior axillary fold. DB, descending branch; TD, thoracodorsal. From Neligan, P,
Song, DH. Plastic Surgery, Volume Four: Lower Extremity, Trunk, and Burns, Fourth Edition, Elsevier, 2018.
A
B
• Fig. 7.8 (A) 68-year-old with left breast cancer who elected to undergo breast conservation therapy and
immediate oncoplastic reconstruction. (B) Biplanar oncoplasty with mastopexy technique and subpectoral
augmentation. (C, D) 10 months following radiation therapy and symmetry procedure.
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Conclusion
e volume displacement and replacement techniques
oer options for patients with varying breast and tumor
sizes to allow for the most aesthetically pleasing result. It
is important to identify the appropriate patient for each
specic technique and to look at all confounding variables
to their individual plan. A successful reconstructive outcome is supported by eective communication between all
providers of the treatment team and with the patient. e
surgical technique and advancements in technology will
continue to support the use of oncoplastic reconstruction
with breast conservation therapy and further options for
the patient.
References
1. Nahabedian MY. Oncoplastic surgery of the breast. Amsterdam,
Netherlands: Elsevier Health Sciences; 2009.
2. Spear SL, Willey SC, Robb GL, etal. Surgery of the breast: prin-
ciples and art two volume set. Lippincott, Williams & Wilkins;
Philadelphia, PA.
3. Conce WG, Carey LA, Calvo BF, etal. Long term outcome of
neoadjuvant therapy for locally advanced breast cancer. Ann Surg.
2002;236:295.
4. Shen J, Valero V, Buchholz T, etal. Eective local control and
long term survival in patients with T4 locally advanced breast
cancer treated with breast conservation therapy. Ann Surg Oncol.
2004;11:854.
5. Chen AM, Meric-Bernstam F, Hunt KK, etal. Breast conservation after neoadjuvant chemotherapy: the MD Anderson Cancer
Center Experience. J Clin Oncol. 2004;22:2303.
6. Delaney G. Recent advances in the use of radiotherapy to treat
early breast cancer. Curr Opin Obstet Gynecol. 2005;17(1):27–33.
7. Sacchini V, Beal K, Goldberg J, et al. Study of quadrant high
dose intraoperative radiation therapy for early-stage breast cancer.
Br J Surg. 2008;95(9):1105–1110.
8. Munhoz AM, Aldrighi CM, Ferreira MC. Paradigms in oncoplastic breast surgery: a careful assessment of the oncological need
and aesthetic objective. Breast J. 2007;13:326–327.
9. Audretsch WP, Rezai M, Kulotas C, etal. Tumor-specic immediate reconstruction in breast cancer patients. Persp Plast Surg.
1998;11:71–100.
10. Cocilovo C. Breast conservation: oncologic issues. In: Spear
SL, Willey SC, Robb GL, etal., eds. Surgery of the breast: prin-
ciples and art two volume set. Lippincott, Williams & Wilkins;
2006:118–122.
11. Losken A, Hart AM, Chatterjee A. Updated evidence on the
oncoplastic approach to breast conservation therapy. Plast Recon-
str Surg. 2017;140(5s):14–22.
12. Patel KM, Hannan CM, Gatti ME, etal. A head-to-head comparison of quality of life and aesthetic outcomes following immediate, staged-immediate, and delayed oncoplastic reduction
mammoplasty. Plast Reconstr Surg. 2011;127:2167–2175.
13. Munhoz AM, Aldrighi CM, Montag E, etal. Outcome analysis
of immediate and delayed conservative breast surgery reconstruction with mastopexy and reduction mammoplasty techniques.
Ann Plast Surg. 2011;67:220–225.
14. Papp C, Wechselberger G, Schoeller T. Autologous breast reconstruction after breast conserving cancer surgery. Plast Reconstr
Surg. 1998;102:1932–1999.
15. Losken A, Elwood ET, Styblo TM, etal. e role of reduction
mammoplasty in reconstructing partial mastectomy defects. Plast
Reconstr Surg. 2002;109:968.
16. Kronowitz SJ, Feledy JA, Hunt KK, etal. Determining the optimal approach to breast reconstruction after partial mastectomy.
Plast Reconstr Surg. 2006;117:1.
17. Kronowitz SJ, Kuerer HM, Buchholz TA, etal. A management algorithm and practical oncoplastic surgical techniques for repairing partial mastectomy defects. Plast Reconstr Surg. 2008;122:1631–1647.
18. Kronowitz SJ. Breast reconstruction: repair of the partial mastectomy defect. In: Nahabedian MY, ed. Cosmetic and reconstructive
breast surgery. Philadelphia, PA: Elsevier; 2009:95–108.
19. Munhoz AM, Montag E, Arruda E, etal. Assessment of immediate conservative breast surgery reconstruction: a classication
system of defects revisited and an algorithm for selecting the
appropriate technique. Plast Reconstr Surg. 2008;121:716–727.
20. Berrino P, Campara E, Santi P. Postquadrantectomy breast
deformities: classication and techniques of surgical correction.
Plast Reconstr Surg. 1987;79:567–572.
21. Clough KB, Kroll SS, Audretsch W. An approach to the repair of
partial mastectomy defects. Plast Reconstr Surg. 1999;104:409.
22. Losken A, Hamdi M. Partial breast reconstruction: current perspectives. Plast Reconstr Surg. 2009;124(3):722–736.
23. Losken A. Reconstruction of partial mastectomy defects: classication and methods. In: Spear SL, Willey SC, Robb GL, etal.,
eds. Surgery of the breast: principles and art two volume set. Lippincott, Williams & Wilkins; 2006:140–164.
24. Anderson BO, Masetti R, Silverstein MJ. Oncoplastic approaches
to partial mastectomy: an overview of volume replacement techniques. Lancet Oncol. 2005;6(3):145–157.
25. Jackson JA, Danforth DN, Cowan K, etal. Ten year results of a
comparison of conservation with mastectomy in the treatment of
Stage I and II breast cancer. N Engl J med. 1995;332:907–911.
26. Von Dongen JA, Voogb AC, Fentiman IS, etal. Long-term results
of a randomized trial comparing breast conserving therapy with
mastectomy: European Organization for Research and Treatment
of Cancer 10801 Trial. J Natl Cancer Inst. 2000;92:1143–1150.
27. Lorenzi MFD, Loschi P, Bagnardi V, etal. Oncoplastic breast conserving surgery for tumors larger than 2 centimeters; is it oncologically
safe? A matched cohort analysis. Ann Surg Oncol. 23(6):1852–1859.
28. Kronowitz SJ. State of the art and science in postmastectomy breast
reconstruction. Plast Reconstr Surg. 2015;135(4):755e–771e.
29. Davison SP, Mesbahi AN, Ducic I, etal. e versatility of the
superomedial pedicle with various skin reduction patterns. Plast
Reconstr Surg. 2007;120(6):1466–1476.
30. Nahabedian MY, McGibbon BM, Manson PN. Medial pedicle
reduction mammaplasty for severe mammary hypertrophy. Plast
Reconstr Surg. 2000;105(3):896–904.
31. Hamdi M, Van Lunduyt K, de Frene B, etal. e versatility of
the intercostal artery perforator (ICAP) aps. J Plast Reconstr Aes-
thet Surg. 2006;59(6):644–652.
32. Hamdi M, Van Lunduyt K, Uleus S, etal. Clinical applications of
the superior epigastric artery perforator (SEAP) ap: anatomical
studies and preoperative perforator mapping with multidetector
CT. J Plast Reconstr Aesthet Surg. 2009;62(9):1127–1134.
33. Nahabedian MY, Patel KM, Kaminsky AJ, etal. Biplanar oncoplastic surgery: a novel approach to breast conservation for small and
medium sized breasts. Plast Reconstr Surg. 2013;132(5):1081–1084.
34. Barnea Y, Friedman O, Arad E. An oncoplastic breast augmentation technique for immediate partial breast reconstruction following breast conservation. Plast Reconstr Surg.
2017;139(2):348e–357e.
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Reduction Mammaplasty Techniques
for Oncoplastic Surgery
MARK VENTURI
Introduction
Oncoplasty is a popular technique for managing partial
mastectomy defects that continues to gain momentum
among plastic surgeons and oncologic breast surgeons alike.
It is now widely accepted as a superior approach for reconstructing partial mastectomy defects, especially in the setting of postpartial mastectomy radiation. e advantages
are that oncoplasty expands the candidacy for breast conservation therapy to patients with larger tumors who would
otherwise require a mastectomy.1 Oncoplasty reduces the
chances of having positive margins by increasing surgical
exposure and allowing for a larger more comprehensive
resection.2 e reconstructive component of oncoplasty signicantly improves the cosmetic outcomes compared with
lumpectomy or partial mastectomy alone.3 Larger defects
can be reconstructed with local breast tissue to obliterate
any dead space created by the partial mastectomy. is creates a stable breast mound that can better tolerate external
beam radiation.
By expanding the role of breast conservation therapy,
oncoplasty provides patients with a less invasive option.
is option eliminates the need for an overnight stay in the
hospital and decreases both the operative time as well as the
time for recovery. ere is no need for either an external
breast prosthesis or an internal breast implant that might be
required for a mastectomy reconstruction. Oncoplasty also
often allows patients to maintain nipple sensation following
their reconstruction.4 ese characteristics all contribute
to the popularity that oncoplasty has gained as a successful
reconstructive option.
ere are a variety of methods by which oncoplastic
breast reconstruction can be performed. ese include volume replacement techniques as well as volume displacement
techniques. Volume replacement methods include the use of
remote aps such as the latissimus dorsi or the thoracodorsal
artery perforator aps and are usually performed in women
with smaller breast volumes. Volume displacement methods
include the use of adjacent tissue rearrangement, mastopexy,
and reduction mammaplasty, and are usually performed in
women with moderate to large breast volume.
Reduction mammaplasty is arguably the most common
form of oncoplastic reconstruction and can be performed
in a variety of ways. Although standard reduction mammaplasty techniques are diverse and can be performed using
a variety of pedicles, oncoplastic reduction is dierent in
that the orientation of the pedicle will depend on the location of the partial mastectomy defect. In other words, a
superior defect is usually repaired with an inferiorly based
pedicle. is chapter will review the fundamental principles and concepts associated with oncoplastic reduction
mammaplasty.
Patient Assessment
When a patient is diagnosed with breast cancer, they are
usually given two treatment options: either a partial mastectomy in conjunction with external beam radiation or a
mastectomy that may or may not require radiation based on
lymph node involvement.5 Most patients who opt for the
partial mastectomy or lumpectomy choice are candidates
for oncoplasty. Evaluating these patients typically amounts
to three key factors:
1. Tumor location and characteristics
2. Need for adjunct therapy
3. Goals and overall health of the patient
Once these three factors have been evaluated and discussed with the patient and the treatment team, then a successful oncoplastic plan can be formulated.
Tumor Location
e location of the tumor or the area needing resection is
key to designing the best approach to reduction mammaplasty oncoplasty. For strategic purposes the breast can be
divided into seven areas as shown in Fig. 8.1. Preoperative
magnetic resonance imaging is extremely useful to determine
50
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rst to shrink the tumor down before resection.7 is strategy allows the treatment team to validate that the chemotherapy is eective against the tumor and also reduces the
size of the resection. In smaller breasted patients, this can be
helpful to preserve as much breast tissue as possible to maintain a stable breast mound through postpartial mastectomy
radiation without compromising oncologic principles.
Another important consideration following oncoplas-
S
SL
SM
tic reduction mammaplasty is the need for postoperative
radiation therapy. e rationale behind this is, although
a partial mastectomy is likely to eradicate the bulk of the
tumor, microscopic cells may remain, and therefore radia-
C
IL
IM
I
tion therapy is recommended. e type of radiation will
vary based on the tumor and breast characteristics as well as
the recommendations of the radiation oncologist. Options
include intraoperative radiation therapy, brachytherapy,
A
partial breast irradiation, or whole breast irradiation. A
more detailed explanation is provided in the chapter on
oncoplasty and radiation therapy.
Goals of the Patient
• Fig. 8.1 Stock figure showing circumvertical and inverted T patterns.
the extent of the tumor in the breast or if there is any other
underlying pathology, like ductal carcinoma in situ (DCIS),
in another area of the breast that would also benet from
resection.6 Once all the areas that require resection have
been delineated and pathology has been conrmed or ruled
out by core needle biopsy, then the extent of the defect can
be categorized to one or more of the seven areas.
Need for Adjuvant Therapy
Once the diagnosis of breast cancer is made and the patient
is determined to be a candidate for breast conservation
therapy, then there are other tumor characteristics that can
aect the timing and extent of the resection and subsequent
oncoplastic reconstruction. For example, in the setting of
triple negative breast cancer, the tumor is typically highly
sensitive to chemotherapeutic agents. In this scenario, it is
often helpful to proceed with neoadjuvant chemotherapy
Oncoplastic breast reconstruction is no dierent from any
other plastic surgery procedure where it is paramount to
understand and account for the goals of the patient. e
ideal candidate for a reduction mammaplasty approach to
oncoplasty is a patient who would benet from a reduction mammaplasty alone. In this regard, the reconstructive
surgeon can oer the patient a treatment option with benets that extend beyond breast cancer therapy. It might be
that the patient has always wanted to reduce the volume of
her breasts and this clinical situation provides an opportunity, albeit unplanned, for this to happen. Patients have the
option of performing an ipsilateral oncoplastic reduction
alone or choosing to have a contralateral reduction mammaplasty for symmetry. e majority of patients choose the
latter to minimize the number of future operations.
It is important that the patient understands the amount of
reduction that will take place with the resection and subsequent
radiation so that they can truly make an informed decision.
Patients with smaller breasts who prioritize breast volume may
not be well served with a reduction-based oncoplastic operation. However, patients with macromastia who hold nipple
sensation to be a priority will likely benet from this approach.
Having an in-depth conversation about the expected outcomes
and reviewing before and after photographs of the procedure
will increase patient understanding and likely increase patient
satisfaction.8 It is therefore important to thoroughly review the
risks and benets of these procedures and discuss the potential
complications. Complications include but are not limited to
bleeding, infection, and scarring as well as fat necrosis, delayed
healing, loss of sensation, and asymmetry.
Operative Technique
Reduction mammaplasty techniques for oncoplastic breast
reconstruction are based on volume displacement.9 ese
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techniques utilize advancement, rotation, or transposition
of the remaining breast tissue following a resection to obliterate the dead space created by the resection. Conceptually,
it is a strategic breast reduction where the part of the breast
that is normally discarded contains the pathological breast
tissue needing resection.
Numerous reduction mammaplasty techniques have
been described in the plastic surgery literature, and they are
all certainly applicable in oncoplasty. For the purposes of
this chapter, it is helpful to simplify the approach to the skin
pattern and distill down the reduction mammaplasty techniques to three approaches that can be utilized successfully
in almost every partial mastectomy. If the requirements for
resection and reconstruction cannot be met by these techniques, then the patient is likely not a good candidate for
oncoplasty and would be better served with a mastectomy.
One of the most important considerations when performing oncoplastic reduction mammaplasty patterns is
an appreciation of the vascularity of the breast. ere are
several dominant sources that can perfuse the breast in a
segmental fashion. e vascularity to the breast is primarily
derived from the internal and lateral mammary perforators
as well as the thoracoacromial trunk, intercostal perforators,
and thoracoepigastric systems. e primary blood supply
to the nipple–areolar complex is via the fourth intercostal,
aka artery of Wuringer, that courses through the horizontal
septum. e third and fourth perforators derived from the
internal mammary system will also contribute to the vascularity when a superomedial or medial-based pedicle is used.
Skin Pattern
e skin incision approach to the breast can vary depending on the size of the breast and the ability to successfully
access the tissues requiring resection. For smaller breasts, it
is often sucient to use a circumvertical skin pattern to gain
access to the breast tissues. Larger breasts usually require an
inverted T pattern to allow the surgeons to both mobilize
the tissues for reconstruction and redrape the skin aps
around the newly reconstructed breast mound. e type of
skin pattern selected is completely independent of the type
of reduction mammaplasty used for the oncoplastic reconstruction. Any skin pattern can be used with the dierent
types of reduction mammaplasty pedicles as long as care is
paid to preserving the subdermal plexus on the skin aps
(see Fig. 8.1).
Superomedial Pedicle
e superomedial pedicle reduction mammaplasty is the
author’s preferred approach for oncoplastic breast reconstruction. e advantages of this approach are that it
can be used for a wide range of resection locations that
include superolateral, inferolateral, inferior, and inferomedial (Fig. 8.2). e superomedial pedicle maintains the
internal mammary perforators, which provide the majority of the blood supply to the breast. e robust blood
S
SL
IL
• Fig. 8.2 Superior medial pedicle approach: quadrants SL, IL, I, and IM.
SM
C
IM
I
supply from theses vessels can support a longer pedicle and
adequately profuse the nipple–areolar complex in largebreasted patients.10 Rotating this pedicle superior medially
allows the surgeon to increase medial fullness in the reconstructed breast and creates a stable breast mound that can
tolerate postsurgical radiation (Fig. 8.3A–F). ere is also
less bottoming-out long term with this technique compared with other reduction mammaplasty techniques11
(Fig. 8.4A–C).
When determining the optimal pedicle, it is important
to ensure that the pedicle is well perfused and that the arc of
rotation is sucient to ll in the partial mastectomy defect.
e use of uorescent angiography is an ideal tool to assess
perfusion of these parenchymal aps. In some cases, secondary pedicles may be considered to completely ll the
defect and minimize the risk of a contour abnormality. It is
important to secure the pedicle in position using absorbable
sutures.
Inferior Pedicle
e inferior pedicle reduction mammaplasty is likely the
most commonly performed approach to breast reduction in the United States. e pedicle is designed inferiorly along the central aspect of the inframammary fold.12
When dissecting out this pedicle, it is important to bevel
out away from the pedicle to preserve the blood supply.
is approach is well suited for resections located in the
superior, superolateral, and superomedial quadrants. e
mobile nipple–areolar complex at the superior end of the
pedicle allows for a high degree of versatility when placing
the nipple–areolar complex (Fig. 8.5; Fig. 8.1 with shading
of regions listed).
Despite its versatility, the inferior pedicle approach
does have some drawbacks. Specically, the majority of
the volume is based inferiorly, which can result in a hollow upper pole in the reconstructed breast. Also, inferior
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