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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_832_Библиотеки_им_академика_М_И_Перельмана
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P. Rudnicki et al.
2 Anatomy
The blood supply of the breasts includes several named arteries, which include the
thoracoacromial artery, internal mammary perforators, lateral thoracic artery, subscapular artery, and the terminal branches of the third to eighth intercostal perforators [6, 7]. The arterial supply from the internal mammary perforators supply the
medial and central portions of the breast, which is the largest arterial source supplying over 50–60% of total perfusion [8]. The second largest source comes from the
lateral thoracic artery which arises from the axillary artery, supplying the superolateral aspects of the breast. The lateral portion also receives blood supply from the
lateral intercostal vessels. Medial intercostal perforators supply the inferior central
portion of the breast. The pectoral artery originating from the thoracoacromial
artery supplies the posterior surface of the breast. The breast skin is supplied by the
subdermal plexus which communicate with the deep underlying arterioles that supply the breast parenchyma. Thus, the perfusion of skin aps depends on the preservation of major glandular tissue vascular supply and the subdermal vessels. The
nipple areolar complex receives its blood supply from a combination of the subdermal plexus and parenchymal supply. The parenchymal arterial supply can vary
among patients and commonly includes the internal mammary, lateral thoracic, and
intercostal arteries. With the rich vascular supply and collateralization, the division
of breast tissue can often be performed safely as long as one or more of the major
vascular pedicles are preserved [8].
The venous drainage of the breast is divided in two systems: the supercial and
the deep [8]. The supercial system mainly consists of the internal mammary vein.
The supercial system anastomoses with the deep system which parallels with the
parenchymal arterial supply. The deep system drains into the internal mammary and
lateral thoracic veins.
Innervation to the breasts comes primarily from the intercostal nerves and cervical plexus. The central region of the breast receives innervation from the anterolateral and anteromedial nerve bers of intercostal nerves T3–T5 [6]. The nipple
areolar complex primarily receives its innervation from the lateral cutaneous nerve
of the fourth intercostal nerve [8]. The branches of the cervical plexus provide
innervation to the superomedial breast. The intercostal nerves also provide sensation to the medial and lateral border of the breast.
3 Pre-operative Evaluation
Careful planning before oncoplastic breast reduction is essential for a successful
outcome. Multiple factors must be considered when deciding on a surgical approach,
including individual patient characteristics, tumor characteristics, and patient preferences. Oncoplastic reduction should be considered for all patients with macromastia and early breast cancer conned to one region of the breast. Patients who
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desire a reduction in their breast size, experience symptoms of macromastia, and
require a large-volume resection that will likely result in breast deformity are ideal
candidates [3, 9].
The volume of breast tissue to be resected should be estimated in the preoperative period. This is highly variable and depends on the size of the lesion, the size of
the breast, and the patient’s desired cosmetic outcome. A study conducted by
Cochrane etal. demonstrated that 10% of the total breast volume can be removed
during BCT without signicant deformity, whereas Bulstrode and Shrotria found
that resections greater than 20% typically result in a poor cosmetic result [10, 11].
Using advanced oncoplastic techniques, resection of up to 50% of the entire breast
tissue can be performed with good aesthetic outcomes [12]. If the total excision
volume required to achieve an acceptable oncologic result is anticipated to be
greater than 10–20% of the total breast volume, than an oncoplastic procedure such
as reduction mammoplasty should be considered. However, reduction mammoplasty can also be performed on women with smaller tumors that do not require
large excision volumes if that patient desires a smaller breast size.
During consultation, the history and physical should note the patient’s age and
medical comorbidities, particularly any that could affect wound healing or skin ap
viability such as diabetes, steroid use, smoking, prior breast surgery, or prior chest
radiation [3]. Patients should be encouraged to mitigate modiable risk factors such
as smoking cessation and weight control. Patients should also be asked about their
satisfaction with their current breast size and shape, their desire for reduction and/
or mastopexy, and any symptoms of macromastia including neck, back, or shoulder
pain, headaches, or intertriginous rashes [13].
Physical exam should include height and weight measurements and corresponding body mass index (BMI). Breast size and volume should be documented, as well
as the shape and degree of excess skin or ptosis. If the lesion is palpable, its location
and size should be noted. The contralateral breast should be similarly examined and
any asymmetry noted. [3, 13].
It is important to obtain preoperative photographs and record breast measurements. Breast width, sternal notch-to-nipple (SN-N) distance, nipple-toinframammary fold distance, and width of the nipple areolar complex (NAC) should
be recorded for each breast, as this will affect the surgical approach [3, 14].
While the purpose of performing reduction mammoplasty after partial mastectomy is to improve aesthetic outcomes in large-breasted women undergoing BCT,
ultimately oncologic safety is of the utmost importance and needs to be considered
above all else. A multidisciplinary approach is crucial and the plastic surgeon, breast
surgical oncologist, and breast radiologist must work together and communicate to
determine the optimal surgical approach and ensure the integration of oncologic
principles with aesthetic goals [3]. The patient’s imaging, including mammograms,
MRI, and ultrasounds, should be reviewed by both surgeons as well as a radiologist
prior to surgery to determine the tumor’s extent as well as the relationship to surrounding breast tissue, overlying skin, NAC, inframammary fold, and the chest wall
[13, 15]. With input from the breast surgeon, the surgical incision should be selected
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based on the tumor’s location and the patient’s breast anatomy. The breast surgeon
will also decide if axillary staging or dissection is needed and the surgery team will
decide if a separate axillary incision will be needed [10]. Preoperative localization
of the tumor should also be discussed with the breast surgeon and radiologist prior
to surgery [15].
The patient’s insurance provider’s policy towards oncoplastic approaches and or
breast reduction should be reviewed to ensure the patient will have medical coverage for the planned procedure. The Women’s Health and Cancer Rights Act of 1998
(WHCRA) is a federal law that mandates insurance coverage by group health plans,
health insurance companies, and HMOs for patients with breast cancer undergoing
reconstruction of the breast after mastectomy, including surgery on the contralateral
breast to achieve symmetry [16]. However, this law specically focuses on reconstruction after mastectomy only. In the 25years since the enactment of WHCRA,
signicant advances have been made in oncoplastic surgery that enable surgeons to
perform reconstructive techniques on patients undergoing only partial mastectomy.
This presents a potential conict with insurance coverage under the WHCRA [17].
To improve likelihood of coverage, the surgeon must document that the procedure
is medically necessary in relation to their cancer care. The patient should be sure to
review their insurance plan to conrm that their surgical team is in-network, and
should be prepared to pay any deductibles or co-pays mandated by their insurance
plan. It is important for the patient to communicate with their insurance company so
that obtaining insurance authorization does not delay surgery. It is not uncommon
for insurance providers to provide coverage for oncoplastic reduction only if the
patient meets medical necessity criteria for a breast reduction. These criteria vary by
states and subsequent insurance providers. It is common for insurance providers to
require that a patient document symptoms of macromastia (neck pain, upper back
pain, breast fold intertrigo) and that the plastic surgeon document certainty in
removing more than a certain amount of breast tissue. This amount varies by insurance providers but common criteria include removing more than 500g/breast or a
weight based upon the Schnur scale which is extrapolated based upon a patient’s
body surface area. Insurance providers set these criteria to differentiate a medically
necessary breast reduction to alleviate symptoms, versus a mastopexy which is a
purely cosmetic breast lift.
P. Rudnicki et al.
4 DCIS
Special consideration should be given to patients with ductal carcinoma in situ
(DCIS), which often presents as a mammographic abnormality rather than a palpable mass. It can be difcult to appreciate the full extent of disease preoperatively,
therefore often challenging to obtain clear margins [18]. In one series of 28 patients
with DCIS who underwent lumpectomy and reduction mammoplasty, 36% underwent a second operation for positive margins or residual calcications, and 25%
required completion mastectomy. Young age (<45years old) and more aggressive
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DCIS with intermediate to high grade lesions or comedo necrosis were associated
with positive margin status, suggesting that these patients should be considered for
a delayed oncoplastic procedure so that margin status can be determined before tissue is rearranged [19]. Another study of 68 patients demonstrated that patients with
lesions greater than 5cm were signicantly more likely to have positive margins
and undergo mastectomy [20]. Though multiple studies have demonstrated the
oncologic safety of reduction mammoplasty in the setting of DCIS, careful patient
selection is needed to avoid reoperation for positive margins and conversion to mastectomy [19–21].
Another consideration for patients with DCIS is the role of sentinel lymph node
biopsy (SLNB) at the time of oncoplastic reduction. The NCCN recommends
against SLNB for DCIS unless the lymphatic drainage of the breast is disrupted
during the procedure, as it is with a mastectomy, because it compromises future
SLNB if invasive cancer is found on nal pathology [22]. It is unclear if reduction
mammoplasty alters the lymphatic drainage and interferes with future lymph node
mapping in patients with DCIS.One study of nine patients with initial diagnosis of
DCIS undergoing SLNB within 4months of oncoplastic reduction found that at
least one node was identied in all patients, suggesting that SLNB during reduction
mammoplasty is not needed [23]. However, more research is needed on this subject
and the choice to perform a SLNB is ultimately left up to the surgeon.
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5 Preoperative Counseling
Prior to surgery the patient should understand the risks, benets, and alternatives to
the procedure as well as the expected postoperative course. For most patients with
macromastia and operable breast cancer, these options include BCT alone, BCT
with reduction mammoplasty (oncoplastic reduction), or mastectomy with or without reconstruction.
While the benets of reduction mammoplasty have already been discussed, there
are also risks to the procedure. Risks include hematoma or seroma formation, surgical site infection, wound dehiscence, nipple or skin necrosis, and loss of sensation.
While some studies have found a higher complication rate after reduction mammoplasty compared to traditional lumpectomy, the rate of complications is similar to
that of reduction mammoplasty performed for benign disease and does not lead to
delays in time to adjuvant radiation therapy [24–26].
The risk of positive margin also needs to be discussed with the patient. Due to the
large volume of breast tissue resected, patients undergoing reduction mammoplasty
have a lower incidence of positive margins and lower rates of completion mastectomy compared to patients undergoing standard lumpectomy [26–29]. However, a
positive margin after reduction mammoplasty presents a unique challenge as the
tissues have been rearranged and the location of the lumpectomy cavity signicantly altered, making it difcult to identify margins for re-excision. For this reason,
many surgeons recommend a completion mastectomy following positive margins
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after oncoplastic reduction mammoplasty [3, 30, 31]. However, some breast surgeons consider placing radioopaque markers or biabsorbable markers within the
lumpectomy cavity to allow future identication of the cavity due to the possibly of
positive margins. Therefore allowing a return to the operating room and proper cavity identication for re-excision should the margins show positivity.
Another important discussion point is the role of postoperative radiation. The
need for radiation after partial mastectomy needs to be explained to the patient, as
well as the risks associated with radiation. Radiation may affect the cosmetic result
as the treated breast may become involuted and edematous, causing it to become
rm and to retract up on the chest wall [3]. This may cause asymmetry and lead to
dissatisfaction with the appearance of the breast. For this reason, a minority of plastic surgeons prefer to perform a contralateral symmetry procedure after completion
of radiation therapy, though this subjects the patient to another operation and induction of general anesthesia.[32]. Approaches to radiation are discussed more in depth
later in the chapter. It is important to note that performing reduction mammoplasty
on the treated breast after radiation is not recommended due to the high risk of
delayed wound healing and other complications [33].
P. Rudnicki et al.
6 Operative Approach
6.1 Pre-operative Markings
Patients should be marked in the pre-operative area. Certain anatomic landmarks
shift when supine, therefore patients should be marked in a standing position.
Standard breast markings are placed, which include the following landmarks: inframammary fold (IMF), upper breast border, midline with sternal borders, and lateral
extent of the breast footprint. Both breasts should be marked regardless of the laterality of the procedure for the purpose of achieving symmetry.
6.2 Breast Landmarks
The breast footprint, or the surface on the anterior chest wall covered by the breast,
is variable in every patient. In some patients, the breast sits lower on the chest and
in others, higher. There are four landmarks that delineate the borders of the breast
footprint, as mentioned above.
We start by marking the sternal notch, and then drawing a straight line caudad,
which delineates the midline overlying the sternum. It is also helpful to mark the
edges of the sternum; these lines are helpful as guides to prevent overly aggressive
dissection and resection at the midline. The IMF by denition follows the inferior
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Fig. 1 Traditional breast
landmarks
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curve of the breast, hence the inframammary border is marked at that location under
each breast. The breast meridian is marked in the superior chest and upper abdomen. The breast meridian is the center of the breast mound; the nipple-areolar complex (NAC) position should be ignored during this process as it is not always
positioned at the center of the breast. Finally, in order to mark the superior breast
border, each breast is pushed gently cephalad, and the outline of the breast is delineated from midline toward the axillary fold. See Fig.1 which demonstrates the
preoperative marks identifying the breast landmarks.
6.3 Incision Marking
The incisions are those which are typically used for a standard mastopexy or reduction mammaplasty, depending on breast size and ptosis grade. For a typical C cup
breast, the new nipple position is marked 10cm inferior from the superior breast
border. The preference of the senior author is to then mark the superior height of the
areola 1.5 to 2cm above the planned nipple position. Another guideline is the new
NAC position should be located on the most projected part of the breast. The breast
is then distracted laterally and the position of the medial pillar is marked. In a similar fashion, the breast is then distracted medially and the position of the lateral pillar
is marked. The distraction is such that the new ideal planned shape of the breast is
created with the distraction and the medial and lateral pillars marked in alignment
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Fig. 2 Pre-operative
markings for breast
reduction
P. Rudnicki et al.
with the meridian. The length of the pillars should be 5–6cm down from the inferior
border of the areola. The inferior extent of both pillars is then connected with a
curved line, 2cm above the IMF.The “mosque dome” is then drawn to complete the
borders of the new NAC.In larger breasted patients, inferior wedge resections may
be necessary, which would result in the typical Wise pattern skin resection.
In cases in which the patient desires a balancing procedure, the same markings
are replicated on the contralateral side. If the patient does not desire a balancing
procedure, nal measurements are compared to the unaffected breast.
Once markings are complete, symmetry should be conrmed. The breast meridian should be the same distance from the midline beneath each breast. The distance
from the sternal notch to the new nipple position on one side should be compared to
the contralateral. The pillar lengths should be conrmed as equal on each side.
Finally, the distances between the pillars is measured; this represents the parenchymal resection. It is expected that the larger breast will have a larger distance between
the pillars. See Fig.2 which demonstrates the traditional marks for a breast reduction.
6.4 Pedicle Selection
Knowledge of the blood supply to the breast and specically to the nipple-areola
complex (NAC) will ensure the best possible result for the patient. The location of
the tumor should be marked on the breast as a reference point. The location of the
tumor will determine the pedicle choice, therefore the plastic surgeon and the breast
surgeon should plan the operative approach as a team. The following is a description
of the possible pedicle choices and their advantages and disadvantages.
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6.5 Superior Pedicle
The superior pedicle has a robust blood supply from the internal mammary system
at the level of the second interspace. This blood supply enters the pedicle supercially, approximately 1cm deep to the skin, just medial to the breast meridian. This
pedicle is an excellent choice for inferiorly located tumors, with the caveat that the
distance to the new location of the NAC is less than or equal to 5cm from its original location. The superior pedicle provides excellent aesthetic results, as the upper
pole of the breast is preserved therefore preserving the cleavage area of the breast.
Its major disadvantage is it is challenging in the setting of large volume breast
reductions. The superior pedicle is the senior author’s pedicle of choice in the setting of small to moderate volume breast reductions.
6.6 Medial Pedicle
The medial pedicle is a great alternative to the superior pedicle in patients with
larger or more ptotic breasts who also have an inferiorly or laterally located tumor.
The blood supply to this pedicle is from the internal mammary system from the
third to fourth interspaces. When dissected as a full-thickness pedicle, sensation is
well preserved. This pedicle is also often referred to as the superior medial pedicle.
The medial pedicle also provides excellent aesthetic results in the same manner as
the superior pedicle. Unlike the superior pedicle, it is well suited for large volume
breast reductions. As a result, the medial pedicle is the senior author’s preferred
pedicle in the setting of large volume breast reductions.
6.7 Inferior Pedicle
The inferior pedicle is known as a safe and reliable pedicle and for many plastic
surgeons remains the standard pedicle for breast reductions. Maintenance of blood
supply, sensation, and breast-feeding potential are benets. This pedicle is supplied
by a perforator from the internal mammary system via the fourth interspace, just
medial to the breast meridian and about 5cm above the IMF.This pedicle may be
selected in cases of superior, medial, or lateral tumors. The major disadvantage of
the inferior pedicle is that its aesthetic results over time are comprised as it is prone
to “bottoming out.” This refers to lack of upper pole fullness and less cleavage with
the bulk of the volume of the breast in the lower pole.
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6.8 Central Pedicle
The central pedicle has a similar blood supply to the inferior pedicle; however, it is
less reliable because some of the perforators are cut at the time of resection when
the resection involves the inferior-most tissue of the breast. A central pedicle may
be considered in the cases of tumors at the peripheral-most aspects of the breast.
The senior author rarely uses this as the pedicle of choice.
6.9 Lateral Pedicle
The lateral pedicle is a reliable option for superiorly, medially, or inferiorly based
tumors. Its blood supply is from the lateral thoracic artery via the supercial thoracic branch. Care must be taken when resecting tissue, as part of the tissue to be
removed is also the base of the pedicle. The senior author rarely uses this as the
pedicle of choice.
6.10 Operative Technique
The breast surgeon starts the operation by performing the lumpectomy. Again, the
incision for lumpectomy is determined jointly by the plastic and breast surgeon. The
incision commonly incorporates the marks for the breast reduction which is marked
in the preoperative area. Upon completion of the lumpectomy, the plastic surgeon
starts by selecting an appropriately sized areola marker and the NAC is scored. The
marked incisions and selected pedicle are also scored. Local anesthetic preferences
vary; typically, either 1% lidocaine with 1:100,000 epinephrine is injected into dissection planes, or Kleins solution is inltrated into the breast gland. In either case,
the base of the selected pedicle is avoided.
The scored peri-areolar area of pedicle is then de-epithelialized with a scalpel. A
full-thickness skin incision is then made at the remaining markings, with the exception of the pedicle base. See Fig.3 which demonstrates a medial pedicle, the outline
of the new NAC dimensions, and the planned area of de-epithelization of the pedicle
and areas for parenchymal resection.
Once dissection is fully complete and hemostasis is achieved, the deeper tissues
are brought together and the NAC is inset in its new location. The skin is loosely
approximated with staples and the patient placed upright and examined for equivalent NAC position and symmetry. Determination is made as far as whether a horizontal skin resection is required. Skin closure is nally preformed with absorbable
sutures.
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Fig. 3 Medial pedicle
outline and lines of
incision
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7 Post-operative Course
7.1 Postoperative Expectations
The post-operative care is similar to those undergoing breast reduction surgery.
While varying among different surgeons, most include 4 to 6weeks of no heaving
lifting, no strenuous exercise, and a non-wired bra during this time period. Breast
reduction scar patterns will vary depending on the amount of breast tissue resected.
The two main scar patterns are the vertical (lollipop shaped) and the inverted (anchor
shaped) incision. Minor degree of wound dehiscence is common at the T-junction of
the suture lines. Postoperative swelling can last for 6months up to a year.
7.2 Radiation
For patients that require adjuvant radiation therapy, most begin radiation therapy
approximately 4–6 weeks after surgery [34]. Possible post radiation changes
include breast edema/swelling, shrinkage/retraction, discoloration, subcutaneous
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