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CHAPTER 8 Reduction Mammaplasty Techniques for Oncoplastic Surgery
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A
E
B
C
F
• Fig. 8.3 (A) Intraoperative view showing needle localization of breast cancer tumor in superior lateral
zone in patient marked out for right oncoplasty with superomedial pedicle reduction mammaplasty. (B)
Intraoperative view showing resection area in the superior lateral zone of the right breast, (C) Intraoperative
view showing resection cavity with wide margins. (D) Intraoperative view specimen removed with wide
margins and defect cavity. (E) Superomedial pedicle ready to be rotated up and in. (F) Intraoperative view
of patient with back raised and skin flaps tailor tacked together over superomedial pedicle to assess shape
and volume.
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A
B
C
• Fig. 8.4 (A) Preoperative view of a patient with right-sided breast cancer in the superior lateral zone.
(B) Postoperative view following right oncoplasty with superomedial pedicle reduction mammaplasty
approach 4 months after completing right breast external beam radiation. (C) Postoperative view 1 year
after right oncoplasty with radiation and left reduction mammaplasty for symmetry.
Alternative Pedicles
Although the superomedial and inferior pedicles are the
most commonly used for oncoplastic reduction, there are
other pedicles that can be considered. e use of these
alternative pedicles will ultimately depend on the location
of the partial mastectomy defect. In general, the pedicle
orientation is opposite or adjacent to the defect. Alternative pedicles include medial, lateral, superior, and central
mound techniques. ese pedicles may or may not include
the nipple–areolar complex and can be used as primary or
SL
S
SM
secondary pedicles. On occasion, two pedicles may be nec-
C
IL
IM
I
essary, and these may all serve as potential sources.
Inverted T Technique
• Fig. 8.5 Inferior pedicle approach: quadrants SL, S, and SM.
pedicle reduction mammoplasties tend to bottom-out more
over time when compared with the superomedial pedicle.
Despite these limitations, the inferior pedicle reduction
mammaplasty approach to oncoplasty is the technique of
choice for upper pole tumors (Fig. 8.6A–D).
e inverted T technique is reserved for tumors that are
centrally located and involve the nipple–areolar complex.
Because the area of resection is in the center of the breast,
there is a signicant reduction in the volume of the remaining breast tissue, and therefore this technique is best applied
to larger volume breasts. e skin pattern used is similar
to a Wise pattern except that it omits the keyhole on the
top of the pattern, as there is no nipple–areolar complex to
deliver13 (Fig. 8.7).
CHAPTER 8 Reduction Mammaplasty Techniques for Oncoplastic Surgery
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A
B
• Fig. 8.6 (A) Preoperative view of a patient with left-sided breast cancer in the superior medial zone. (B)
Postoperative view 1 month after left oncoplasty with markings for radiation planning. (C) Postoperative
view following left oncoplasty with an inferior pedicle reduction mammaplasty approach 4 months after
completing right breast external beam radiation. (D) Postoperative view 1 year after left oncoplasty with
radiation and right reduction mammaplasty for symmetry.
pillars are mobilized on their deep surface o the pectoralis
major to allow for closure of the defect. e breast tissues
are not separated from the skin aps as they come together
to close the wedge-shaped defect.
Management of the Contralateral Breast
e timing of surgery on the contralateral breast remains con-
S
SL
IL
SM
C
IM
I
• Fig. 8.7 Inverted T approach: quadrants C, IL, I, and IM.
e area of resection includes the central (C) section as
well as the entire inferior section including sections IL, I,
and IM. Following the excision of these sections, the breast
is left with a medial and lateral pillar of breast tissue. e
troversial. Most surgeons perform simultaneous contralateral
reduction at the time of the oncoplasty.14 e advantages of
this approach are that the patient is more symmetric at the
completion of the initial surgery, and there may be no need for
any additional procedures. ere are a few distinct disadvantages to simultaneous contralateral reduction. e rst is that
in the setting of postpartial mastectomy radiation, there can
be signicant and unpredictable further reduction in the size
of the breast that necessitates yet another surgery to improve
symmetry. Second, by performing a simultaneous reduction,
the length of surgical time is signicantly increased, potentially changing an outpatient procedure into an inpatient procedure. ird, there is still a potential for positive margins,
although unlikely, which would mean that additional reduction would need to be performed on the contralateral breast
that could have been avoided with a delayed technique.
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e alternative is to wait approximately 3–4 months
after the completion of postpartial mastectomy radiation to
perform the contralateral reduction. is technique allows
for a more stable target in the radiated breast so that there
is a higher likelihood of matching its size and shape in the
noninvolved reduced breast. e main two disadvantages of
this technique are that there is a signicant period of asymmetry following the initial oncoplasty that inconveniences
the patient, and a second surgery is required to achieve the
nal result. Despite these disadvantages, it is the author’s
preference to delay the contralateral reduction in the setting
of postpartial mastectomy radiation and not delay if radiation is not required.
Conclusion
Reduction mammaplasty techniques are an excellent way to
approach oncoplastic breast reconstruction. e vast majority of breast cancer patients can be addressed with three
reduction mammaplasty techniques: superiomedial pedicle,
inferior pedicle, and inverted T. Depending on the volume
of the breast, a circumvertical or Wise skin pattern can be
used with these reduction mammaplasty techniques to successfully reconstruct almost any partial mastectomy defect.
References
1. Munhoz AM, Montag E, Arruda EG, etal. Critical analysis of
reduction mammaplasty techniques in combination with conservative breast surgery for early breast cancer treatment. Plast
Reconstr Surg. 2006;117(4):1091–1103.
2. Clough KB, Lewis JS, Couturaud B, et al. Oncoplastic tech-
niques allow extensive resections for breast conserving therapy of
breast cancer. Ann Surg. 2003;237(1):26–34.
3. Losken A, Styblo TM, Carlson GW, etal. Management algorithm
and outcome evaluation of partial mastectomy defects treated using
reduction or mastopexy techniques. Ann Plast Surg. 2007;59(3):235.
4. Asgeursson KS, Rasheed T, McCulley SJ, etal. Oncological and
cosmetic outcomes of oncoplastic breast conserving surgery. Eur
J Surg Oncol. 2005;31(8):817–823.
5. Veronesi U, Casinelly N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast conserving
with radical mastectomy for early breast cancer. N Eng J Med.
2002;347:1227–1232.
6. Boetes C, Mus RD, Holland R, etal. Breast tumors: comparative
accuracy of MR imaging relative to mammography and US for
demonstrating extent. Radiology. 1995;197:743–747.
7. Ikeda T, Jinno H, Matsu A, etal. e role of neoadjuvant chemotherapy for breast cancer treatment. Breast Cancer. 2002;9(1):8–14.
8. Kronowitz SJ, Hunt KK, Kuerer HM, etal. Practical guidelines
for repair of partial mastectomy defects using the breast reduction
technique in patients undergoing breast conservation therapy.
Plast Reconstr Surg. 2007;120(7):1755–1768.
9. Losken A, Hart AM, Broecker JS, etal. Oncoplastic breast reduction technique and outcomes: an evolution over 20 years. Plast
Reconstr Surg. 2017;139(4):824e–833e.
10. Maxwell GP, Gabriel A. Breast reconstruction. In: Aston SJ,
Steinbrech DS, Walden JL, eds. Aesthetic plastic surgery. Philadelphia, Pa: Elsevier; 2009. Chapter 57.
11. Zhu VZ, Shah A, Lentz R, etal. A comparison of superomedial versus inferior pedicle reduction mammaplasty using three-dimensional analysis. Plast Reconstr Surg. 2016;138(4):781e–783e.
12. Hall-Findlay EJ, Shestak KC. Breast reduction. Plast Reconstr
Surg. 2015;136(4):531e–544e.
13. Chung TL, Schnaper L, Silverman R, etal. A novel reconstructive technique following central lumpectomy. Plast Reconstr Surg.
2006;118(1):23–27.
14. Chang E, Johnson N, Webber B. Bilateral reduction mammaplasty
in combination with lumpectomy for treatment of breast cancer in
patients with macromastia. Am J Surg. 2004;187(5):647–650.
9
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Mastopexy Techniques
STEVEN J. KRONOWITZ
Oncoplasty is state-of-the-art for repair of partial mastectomy defects and is optimally performed before the delivery
of radiotherapy.
intraoperative tumor margin assessment, or surgeon preference, oncoplasty can be performed immediately at the time
of partial mastectomy or delayed before radiation therapy,
which allows for review of the nal pathology before repair.
However, delayed repair before radiation requires two separate surgical procedures, and the aesthetic outcome is not
always as desirable as immediate oncoplasty. Immediate
oncoplastic dermoglandular repair before radiotherapy can
involve various creative designs to rearrange the remaining
breast tissue after partial mastectomy. Patients with largesized breasts, including those women with C-cup-sized
breasts and those with D-cup-sized breasts or larger, benet from the use of the remaining breast tissue to repair the
1
breast.
In patients with C-cup breasts with upper quadrant
tumors with some degree of breast ptosis, displacement concentric mastopexy can be an ideal option for repair (Fig. 9.1).
e advantage is that the repair elevates the position of the
nipple–areolar complex (NAC) and displaces the lower pole
breast tissue to ll upper pole defects. After radiotherapy, the
region of the defect may be fat grafted and the contralateral
breast may be made smaller with direct liposuction or surgical excision of skin and fat. However, because the defect
is repaired before radiotherapy, there is not usually a localized deformity, only a diuse volume loss to the breast from
radiotherapy. erefore, most often, the second stage of this
repair involves fat grafting to the entire breast after radiotherapy to replace the diuse volume loss and minor adjustment
to the contralateral breast for symmetry.
Mammoplasty is the optimal approach to repair partial breast deformities before radiotherapy in patients with
D-cup-sized breasts or larger.3 Standardization of technique has become an important initiative in the United
States and abroad as a means to encourage reconstructive
breast surgeons to routinely perform oncoplasty.4 Vertical oncoplasty is used in large, ptotic-shaped breasts with
narrow-base widths. Kronowitz Vertical Oncoplasty is a
systematic approach to using vertical oncoplasty to repair
partial mastectomy defects in all locations within the breast
1,2
Depending on the pathology, access to
(Fig. 9.2). In patients with upper pole defects, a superomedial or superolateral dermoglandular pedicle is used for
repair, whereby the lower central breast tissue is rotated into
the upper pole defect either clockwise or counterclockwise,
respectively (Fig. 9.3). With lower pole defects, the use of
dual-dermoglandular pedicles allows for both elevation of
the NAC and lling of the defect. For defects located within
the lower inner quadrant, both a superior and inferolateral
dermoglandular pedicle is utilized for the repair (Fig. 9.4).
Similarly, defects in the lower outer quadrant are repaired
with a superior pedicle and inferomedial pedicle. e superior dermoglandular pedicle elevates the NAC position and
the inferiorly based dermoglandular pedicle advances either
medially or laterally to ll the defect.
Kronowitz Inverted-T Oncoplasty is used for patients
with large, D-cup-sized breasts with wide-base widths in
which the lateral breast extends into the axilla (Fig. 9.5).
e designation of seven zones within the breast that correspond to straightforward dermoglandular designs has
simplied and organized the approach to the repair of partial mastectomy defects in patients with wide, D-cup-sized
breasts (Fig. 9.6).
moglandular pedicles, most commonly, the inferomedial
dermoglandular pedicle, provides the opportunity to debulk
the lateral breast and axillary region to redene and narrow
the breast, while providing additional blood supply to the
NAC and cleavage to the breasts.
e tumor resections are performed using an access incision along the inverted T skin pattern. After creation of the
dermoglandular pedicle, the inverted T skin ap is redraped
overlying the inferiorly based dermoglandular pedicle. With
lower inner and lower outer quadrant defects, the inverted T
skin ap serves as the reconstructive component by retaining the thickness of the breast tissue on the undersurface
of the medial or lateral aspect of the inverted T skin ap,
respectively. Upon closure of the inverted T skin ap, the
thick region of the skin ap lls the lower pole defect.
For tumors located within Zone 1, the dermoglandular
design preserves the medial wedge of breast tissue, usually
discarded with a standard breast reduction using an inferior
dermoglandular pedicle that not only lls the upper inner
quadrant defect when the inverted T skin pattern is closed,
5,6
e utilization of inferiorly based der-
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SECTION II Oncoplastic Breast Surgery – Surgical Techniques
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EF
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C
D
G
• Fig. 9.1 Concentric mastopexy technique to repair partial mastectomy defects. (A) Preoperative views of
a 37-year-old with C-cup-size, non-ptotic breasts who has a 2-cm invasive breast cancer in the 10 o’clock
position in the right breast. (B) Preoperative markings for bilateral concentric mastopexy. (C) Intraoperative
view of access incision the breast surgeon used to perform the partial mastectomy. (D) Defect after partial
mastectomy. (E) After direct repair of the defect and de-epithelialization of concentric region. (F) After
purse-string closure of the concentric region using permanent suture. (G) Postoperative views 6 weeks
after an immediate repair of the right breast using the concentric mastopexy technique and left concentric
mastopexy for symmetry.
ABC
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CHAPTER 9 Mastopexy Techniques
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DEF
• Fig. 9.2 Kronowitz Vertical Oncoplasty. (A) Designation of vertical oncoplasty design is based on five
tumor locations within the breast. (B) For tumors located within the upper outer aspect of the breast, a
superomedial dermoglandular pedicle is used with clockwise rotation. (C) For tumors located within the
upper inner aspect of the breast, a superolateral dermoglandular pedicle is used with counterclockwise
rotation into the defect. (D) Lower outer defects are repaired using two dermoglandular techniques: a
superior dermoglandular pedicle to reposition the nipple higher on the breast mound and an inferomedial
dermoglandular pedicle that is advanced laterally into the defect. (E) For lower central defects, the standard superior dermoglandular pedicle is utilized. (F) Similar to defects located in the lower outer aspect of
the breast, defects located in the lower inner quadrant are repaired using two deromglandular pedicles. A
superior dermoglandular pedicle is used to elevate the nipple–areolar complex and an inferolateral dermoglandular pedicle is used to fill the defect by medial advancement.
but also provides additional blood supply to the NAC
through the intercostal and internal mammary blood vessels (Fig. 9.7).6 e medial wedge is preserved for all tumor
locations, except for the lower inner quadrant in which it is
excised with the tumor, because breast tumor excisions tend
to follow the mammary ductal system that extends under the
NAC and denude the blood supply. Another region of the
breast common for breast tumors is located in Zone 6, the
upper outer quadrant of the breast. In Zone 6, an inferomediolateral dermoglandular pedicle is used for the repair. e
lateral wedge of the inferior dermoglandular pedicle, which
is usually resected with an inferior dermoglandular pedicle,
is retained and used to ll the upper outer defect upon closure of the inverted T skin ap. With this tumor location,
the medial wedge is also retained to maintain the cleavage
of the breast and to enhance the blood supply to the NAC.
Typically, the contralateral non-cancer mammoplasty is
performed simultaneously with the oncoplastic repair for
displacement mastopexy and for vertical oncoplasty. For
inverted-T oncoplasty, the patient decides if the contralateral
non-cancer mammoplasty is performed immediately or
6 months after radiotherapy.1 e contralateral mammoplasty for symmetry is performed using the same dermoglandular design that was used for the oncoplastic repair. In
contrast to concentric and vertical oncoplasty, the option
to postpone the contralateral mammoplasty for symmetry
with inverted-T oncoplasty is because inferiorly based dermoglandular pedicles allow for signicant resectional reduction in breast volume if required after radiotherapy. With
concentric and vertical mammoplasty, resectional reduction
in volume is limited, and if additional volume reduction is
required after radiotherapy to maintain symmetry with the
concentric or vertical oncoplastic breast, direct liposuction
is usually the best option. erefore, delaying the contralateral non-cancer mammoplasty with concentric or vertical
oncoplasty oers no benet to the patient.
Timing is an important consideration for oncoplasty;
immediate or delayed before radiotherapy are preferred with
whole breast radiotherapy.5 Delayed oncoplasty after whole
breast radiotherapy is discouraged because of the increased
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A
C
B
D
E
F
• Fig. 9.3 A 38-year-old female with right breast cancer. (A, B) Preoperative views. Vertical skin resection
pattern and location of cancer (red dashed line). (C) Intraoperative view. Access incision along vertical
skin pattern used for resection of tumor. (D) Intraoperative view. De-epithelialized vertical dermoglandular
pedicle. (E) Intraoperative view after creation of superomedial dermoglandular pedicle before clockwise
rotation (blue arrow) into superior defect. (F–H) Views after radiation therapy before planned revision breast
reconstruction.
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C
E
D
F
• Fig. 9.4 Dual-dermoglandular pedicle technique for lower pole defects. (A) Preoperative view of 35-year-
old female with right breast cancer. (B) Intraoperative view of the defect in the lower inner quadrant of the
breast. (C) Intraoperative view of design of dual-dermoglandular pedicles used for repair. (D) Intraoperative
view of the inferolateral dermoglandular pedicle being advanced medially into the defect. (E) Intraoperative view after superior advancement of the superior dermoglandular pedicle and inset of the inferolateral
pedicle. (F) Postoperative view 2 weeks after surgery. (G) Postoperative view 2 months after radiation
therapy. The patient is planned for fat grafting the right breast and symmetry procedure to left breast.
G
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Reconstructive Zones: 1 - 7
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AB
EF G
• Fig. 9.6 Zone designations of the breast based on tumor location
used to determine the design for the dermoglandular pedicle to repair
a partial mastectomy defect.
• Fig. 9.5 Straightforward dermoglandular pedicle designs to repair partial mastectomy defects using the
breast reduction technique that corresponds with the zone designations (tumor location). (A) Upper-inner
quadrant (Zone 1). Inferomedial dermoglandular pedicle. The retained medial component fills the defect upon
closure of the inverted T skin pattern and maintains the cleavage of the breast. (B) Lower-inner quadrant
(Zone 2). Inferolateral dermoglandular pedicle. The retained lateral component provides additional blood supply to the nipple–areolar complex if tumor resection encroaches on the inferior pedicle. A thick layer of subcutaneous tissue is maintained on the medial aspect of the inverted T skin pattern flap to fill the defect upon
closure of the skin and maintain cleavage of the breast. (C) Upper-central quadrant (Zone 3). Inferomedial
dermoglandular pedicle. Retained medial component provides a cosmetic advantage and additional blood
supply to the nipple–areolar complex in patients with very large ptotic breasts, possibly obviating the need for
a free nipple graft. (D) Middle-central quadrant (Zone 4). Amputative design with free nipple graft and maintenance of a thick layer of subcutaneous tissue on the central aspect of the inverted T skin pattern flap to
fill the defect and improve contour. (E) Lower-central quadrant (Zone 5). Vertical skin pattern with superiorly
based dermoglandular mammoplasty. The vertical mammoplasty can also be used to repair defects in Zones
1 and 7 by retaining the inferior aspect of the dermoglandular pedicle and basing the blood supply to this
region either medially with lateral advancement (Zone 7 repair) or laterally with medial advancement (Zone
1 repair). (F) Upper-outer quadrant (Zone 6). Inferomediolateral dermoglandular pedicle. The retained lateral
component fills the defect upon closure of the inverted T skin pattern, and the retained medial component
provides cosmetic advantage. (G) Lower-outer quadrant (Zone 7). Inferomedial dermoglandular pedicle. The
retained medial component provides a cosmetic advantage and additional blood supply to the nipple–areolar
complex if lateral resection encroaches on the blood supply to the nipple–areolar complex. A thick layer of
subcutaneous tissue is maintained on the lateral aspect of the inverted T skin pattern flap to fill the defect.
likelihood of adverse events. Unexpected deformities that
occur after partial mastectomy should be repaired before
1 3 6
4
2
5
7
radiotherapy (Fig. 9.8).6 e type of radiotherapy can signicantly aect the timing and technique for repair of partial
mastectomy defects. As opposed to whole breast irradiation,
which usually requires a ap for delayed repair radiotherapy
because dermoglandular oncoplasty is associated with high
rates of complications, partial breast irradiation allows for
delayed repair after radiotherapy using dermoglandular oncoplasty using the surrounding non-irradiated breast tissue.
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