Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1054_Библиотеки_им_академика_М_И_Перельмана
.pdf
General Principles ofTherapeutic
https://t.me/medicina_free
Mammoplasty
SoniSoumian
15
15.1 Introduction
Over the last few decades with the increased
understanding of the oncological parity between
mastectomy and breast conserving surgery in the
management of breast cancer, the rate of breast
conserving surgery (BCS) has gradually
increased worldwide and is currently about 60%
in most UK centres. In addition, there is published data supporting survival benet in patients
with BCS when compared to mastectomy [1, 2].
However, this increase in BCS had resulted in
signicant cosmetic sequelae based on the relative volume of tissue excised and there is clear
evidence showing that up to 35 percent of patients
report dissatisfaction with the aesthetic results of
BCS [3, 4]. The recognition of the holistic
approach to patient care taking into consideration
the psychosocial aspects, self-image issues and
patient satisfaction did bring about signicant
changes in the approach to BCS procedures. In
the last couple of decades, the concept of therapeutic mammoplasty (TM) incorporating cancer
excision along with aesthetic maintenance or
enhancement was introduced and is being
adopted universally.
TM incorporates the principles of breast reduc-
tion plastic surgery techniques and oncologic
S. Soumian (*)
Oncoplastic Breast Surgeon, University Hospital of
North Midlands, Staffordshire, UK
resection to achieve good cosmetic results. It has
been demonstrated from multiple centres that TM
has comparable results with conventional BCS
techniques and mastectomy in terms of oncological outcomes, reoperation rates, complication
rates and quality of life in reasonably longer follow-up as well [5–10]. The added advantages
include the removal of larger tumours in turn
potentially reducing mastectomy rates, larger
excision margins with reduced re-excision rates
and the superior cosmesis achieved using these
techniques. Targeted and supervised training in
oncoplastic techniques is currently undertaken in
specialised centres treating breast cancers internationally where either the plastic and breast surgeons work together, or the procedures entirely
undertaken by trained oncoplastic breast surgeons. Both the models have been remarkably
successful in achieving the desired outcomes.
BCS broadly is classied into volume dis-
placement and volume replacement techniques.
In the displacement technique, following the
wide local excision (WLE) large volume excision, the remaining breast tissue is utilised to ll
the defect by rotation or advancement of tissue
based on its anatomy and blood supply. TM is the
common terminology used to describe volume
displacement techniques. In the replacement
technique, the resulting defect following a WLE
is reconstructed using autologous tissue from
local areas or elsewhere. These procedures can be
done either as one stage or two stage procedures
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
S. V. S. Deo (ed.), Breast Oncoplasty and Reconstruction,
https://doi.org/10.1007/978-981-99-5536-7_15
101
102
https://t.me/medicina_free
S. Soumian
but generally one stage procedures are preferred.
The two stage procedures have an advantage of
the knowledge of margin status so that any potential additional margin resection can be done dur-
a
b
ing the second stage. The details of options for
BCS had been described in Fig.15.1a. Currently
volume replacement oncoplastic techniques are
considered as rst choice for small and moderate
Fig. 15.1 (a) Various Oncoplastic options for Breast Conserving Surgery (BCS), (b) Zones of the breast. Central:
Upper, UI-Uper inner, UO-Upper outer. Lower, LI-Lower inner, LO-Lower outer
15 General Principles ofTherapeutic Mammoplasty
https://t.me/medicina_free
103
sized breasts up to a C cup especially with the
recent trend towards using chest wall perforator
based aps [11, 12]. These has been detailed elsewhere in the book.
Traditionally, types of oncoplastic volume displacement procedures are classied into type I
(less than 20%) and II (20–50%) based on percentage of excision volumes planned [13, 14].
These have been described in detail elsewhere in
the book.
Generally, with volume displacement techniques for larger breasts, there is a high likelihood for the need for contralateral symmetrisation
procedures either at the same time or in the
future. Usually, the preference would be to undertake the contralateral symmetrisation reduction
concurrently.
This chapter will focus on the essential techniques used across the two levels of volume displacement techniques.
15.2 Assessments
The intention of TM should be primarily to
achieve oncological clearance and simultaneously achieve an aesthetic functional breast with
regard to all parameters including symmetry,
shape, nipple areola complex (NAC) position and
inframammary fold (IMF) position.
For planning purposes, the breast can be
divided into subunits or zones. The published
data in literature gives account of different systems in use which are helpful [15]. In terms of
simplicity, the breast can be divided into seven
zones– one central and three each in the upper
and lower (Fig.15.1b).
Central
Upper
Upper outer (UO)
Upper inner (UI)
Lower
Lower outer (LO)
Lower inner (LI)
In general, based on the location of cancer,
breast size and ptosis, the surgical approach can
be planned. However, on practical grounds,
understanding the tumour location and the potential cosmetic impact of excision on overall cosmesis is important and therefore a comprehensive
assessment needs to be done.
Parameters to assess include:
Breast factors
Tumour factors
Other factors
15.2.1 Breast Factors
Size
Shape
Ptosis
Position of IMF
Nipple position
Areolar diameter
Skin quality
Skin to gland ratio
Breast density on Mammogram
Scars
Symmetry
Synmastia
Chest wall deformities
Previous Radiotherapy
15.2.2 Tumour Factors
Size / relative size ratio to breast
Quadrant
Proximity to skin
Proximity to chest wall
Proximity to nipple
Multifocality
Multicentricity
15.2.3 Other Factors
Connective tissue diseases
Co-morbidities- Diabetes
Smoking
BMI
Psychosocial factors
104
https://t.me/medicina_free
S. Soumian
15.2.3.1 Breast Factors
In general, excision of more than 20% of breast
tissue can potentially result in poor cosmetic outcomes. Even as much as more than 10% excision
can have a signicant impact on cosmetic outcomes as reported from patient feedback in an
Edinburgh Study [16]. The tumour size to breast
size ratio is the essential decision maker in terms
of choice of TM.Imaging should be assessed and
especially MRI can be used selectively to assess
actual size of cancers and proximity to the nipple.
The ratio of the skin to gland is helpful in assessing how much of glandular excision is needed
and, in some cases, the procedure would be a
therapeutic mastopexy mainly with the excision
of more skin than glandular tissue. Documentation
of synmastia and chest wall deformities are paramount as they inuence the nal cosmetic outcome signicantly and the patient should be
counselled appropriately regarding the outcomes
and expectations.
Previous radiotherapy to the breast or previous
mantle radiotherapy would be a relative contraindication for surgery especially considering the
mobilisation of glands and skin vascularity
issues. The risk associated with glandular mobilisation is fat necrosis and this is much higher in
fatty breasts. Therefore, assessment of mammograms for glandular density is paramount in any
oncoplastic procedure. Dual plane mobilisation
both simultaneously in the mastectomy plane and
the prepectoral plane should be completely
avoided in case of fatty breasts owing to the high
risk of devascularisation and fat necrosis. Any
previous scar and surgery should be considered
for planning especially for incisions around the
NAC or any incision that could affect skin viability if a wise pattern incision is planned. Very
large breasts can be associated with increased
complication rates.
15.2.3.2 Tumour Factors
The relative tumour to breast size would be the
deciding factor in planning any BCS oncoplastic
procedure. In smaller breasts even a T1 sized
lesion may need volume replacement.
Considering the distribution of glandular tissue
in the breast, the upper outer quadrant usually is
forgiving in terms of the impact of excision from
this area. Signicant cosmetic deformities can be
caused by surgery in the central, lower, medial
and the upper inner quadrants and therefore any
surgery in these areas involving more than 10%
of tissue will need planning and use of TM techniques to ensure optimum cosmetic outcomes.
En-bloc excision of multicentric tumours can
be facilitated with any localisation technique most
commonly using bracketing wires and decision of
BCS for multicentric and multifocal cancers
should be based on the quadrants involved and
availability of adequate breast tissue for volume
displacement. If tumour involves the skin or close
to the skin, then incision planning should be done
based on excision of skin with the area either
closed primarily or replaced by skin based on the
secondary pedicle. Similarly for lesions closer to
the nipple, if there are doubts about compromise to
nipple vascularity based on oncological resection
margins, then a full thickness nipple graft can be
planned. If tumour is very close to the nipple, then
in terms of oncological safety, it should be excised,
and a nipple reconstruction can be performed at
the same time but preferably at a later stage.
15.2.3.3 Other Factors
The main risk factors are smoking, high body
mass index, connective tissue disorders, poorly
controlled diabetes, cardiorespiratory diseases
and renal failure. These factors have a direct
inuence on both general and local complications specically the risks of skin necrosis, fat
necrosis, nipple necrosis and wound breakdown.
In signicant connective tissue conditions like
scleroderma, radiotherapy would be high risk to
the skin and therefore BCS is generally not
recommended.
Although the relative tumour size is a main
criterion for offer of these procedures, patient
15 General Principles ofTherapeutic Mammoplasty
https://t.me/medicina_free
105
choice should be the priority in the decisionmaking process for the procedures. Psychosocial
factors should be assessed as a part of this process for surgery. Even in smaller tumours,
patients have a choice of therapeutic mammoplasty if they prefer a breast reduction at the same
time, provided they understand the magnitude
and morbidity of the procedure.
15.3 Moderate Sized Breasts
The selected procedure will need to take into
account, the amount of skin reduction needed,
NAC centralisation, skin ap undermining and
avoiding dual plane dissection in case of fatty
breasts. These mammoplasty procedures are likely
to result in volume discrepancy and asymmetry
and patient may need symmetrisation procedures
but, majority of patients are reasonably satised
with the cosmetic outcome despite the resulting
asymmetry. In any procedure, it would be prudent
to document in the notes, the pedicle on which the
nipple vascularity is based, on so that any future
surgery can be planned appropriately if needed.
15.4 Central Tumours
A simple central segmentectomy through a circumareolar incision and a purse string closure
can give good results. Alternatively, a straightfor-
ward central segmentectomy followed by nipple
reconstruction on the skin can also be done. For
smaller tumours of the NAC, Grisotti’s procedure
can be used which is a modied J mammoplasty
with rotation of a circular skin island from the
inferior segment to ll the gap. This has been
detailed elsewhere in the book. A nipple reconstruction on the skin island usually can be done at
a later stage.
15.5 Upper Tumours
Round block (doughnut) mammoplasty can be
used in smaller and moderate sized breasts for
tumours in the Upper, UO and UI zones.
Usually, a round block mammoplasty incision
can be used for minimal skin reduction with
NAC repositioning, wide undermining, full
glandular wide local excision and then closing
the glandular defect (This has been detailed
elsewhere in the book). If skin excision anterior
to the tumour needed, a Batwing incision can
be used to facilitate this (explained elsewhere
in the book). In larger breasts with an increased
IMF to nipple distance, a modied doughnut
mammoplasty can be used with lateral wedge
extensions of de-epithelialised area, and the
nipple based on the inferior pedicle can be used
(Fig. 15.2a) This can successfully reposition
the nipple and avoid a high riding nipple or a
bottomed-out appearance.
106
ab
cd
https://t.me/medicina_free
S. Soumian
Fig. 15.2 (a) Modied Doughnut Mammoplasty, (b) Racquet Mammoplasty, (c) J-Mammoplasty, (d) Racquet
Mammoplasty with Medial glandular rotation
15.6 UO Tumours
tumour, then a racquet mammoplasty incision
(incorporating the circumareolar aspect of the
Excision can be done again using a roundblock
mammoplasty incision as explained previously.
If there is a need for skin excision anterior to the
skin and anterior skin for excision) extending
along to the axilla can be used and the axillary
procedure either a sentinel node biopsy (SLNB)
15 General Principles ofTherapeutic Mammoplasty
https://t.me/medicina_free
107
or axillary node clearance (ANC) can be done
through the same incision (Fig.15.2b). In these
procedures, single plane skin undermining and
closure of the gland to close the defect along with
repositioning of the nipple (more deepithelialisation towards opposite side) should be
done to avoid retraction of the nipple laterally
and superiorly. Racquet mammoplasty can also
be used in much larger breasts in patients who are
not suitable for extensive level II oncoplastic
procedures.
15.7 UI Tumours
Excision can be done again using a roundblock
mammoplasty incision as explained previously.
The difcult area to reconstruct is the upper
inner quadrant where glandular rotations can be
done to ll the defect but become quite difcult
in fatty breasts. If skin excision is needed, then a
racquet mammoplasty incision can be used with
the discussion of medial scar placement. If a volume replacement procedure is feasible using
local perforator aps, then this should be
recommended.
15.9 LO Tumours
A J mammoplasty incision with nipple repositioning and medial glandular rotation is an effective way to maintain reasonable cosmesis in LO
zone tumours along with excision of the anterior
skin if needed (Fig.15.2c). It would be important
to emphasise that in this area, for T2 tumours in
moderate sized breasts, a chest wall perforator
ap with volume replacement may be a better
option.
15.10 LI Tumours
A racquet mammoplasty incision with excision
of skin over the tumour and then extending laterally along the IMF with medial glandular rotation
would be the choice in LI tumours and this can be
used quite effectively in fatty breasts as well as
there is minimal skin undermining thus reducing
risk of fat necrosis and wound problems.
(Fig.15.2d).
15.10.1 Larger Breasts
15.8 Lower Tumours
These zones are very well known to cause signicant cosmetic defects (bird beak deformity) if
operative procedures are not planned properly. It
is paramount to assess the volume of breast tissue
present in the lower quadrants and the distance
between the NAC and IMF to plan surgery. If feasible, for Lower, LI and LO zone tumours, volume replacement techniques using chest wall
perforator aps would be the current choice.
Usually for the lower segment, a vertical mastopexy pattern with repositioning of the NAC
higher and closure of the glandular pillars in the
lower half of the breast would be a reasonable
option. It is paramount to avoid transverse incisions in the lower segment.
It is paramount to assess suitability for level II
oncoplastic procedures as these procedures are
complex with associated morbidity. Therefore,
less extensive procedures such as round block
mammoplasty, melon slice excision (Fig.15.3a),
racquet mammoplasty can be used in larger
breasts as well if patients have risk factors and
not suitable. Melon slice excision are simple
elliptical incisions (with skin excision) for cancers on the upper aspect in a ptotic breast in
patients who may not be suitable for major procedures. There is no skin undermining needed and
therefore very little morbidity is seen with these
procedures.
If suitable, usually either a wise pattern or a
vertical mammoplasty design would be necessary along with the selection of the appropriate
pedicle for the nipple based on the tumour loca-
108
ab
https://t.me/medicina_free
c
S. Soumian
Fig. 15.3 (a)—Melon slice excision, (b)—Central Zone—Skin Island Inferior pedicle Mammoplasty, (c)—Upper
Zone Inferior pedicle Mammoplasty
tion. In general, wise pattern incisions are relatively easier to plan. It would be good option to
undertake the contralateral symmetrisation
reduction at the same time and to ensure that the
same type of pedicle is used for the nipples bilat-
erally unless there are specic indications to
change it for, e.g., bilateral cancers. The vertical
pattern, however, has lower incidence of skin
necrosis, gives better projection and slightly
raises the IMF as well. Vertical design can be dif-
15 General Principles ofTherapeutic Mammoplasty
https://t.me/medicina_free
109
cult to undertake on very large breasts but feasible in experienced hands. If skin excision
anterior to the tumour is required, then the incision design would need to be adjusted accordingly or altogether new novel designs need to be
planned.
Standard measurements of the breasts are
done for the breasts which are detailed elsewhere
in the book. It is important to spend adequate
time in planning and doing the marking properly.
Following the marking of the midline, the breast
meridian is an important landmark along with the
marking of the new nipple position.
Certain useful points regarding the preop
workup and marking, intraoperative techniques and post op care are detailed below.
1. The intent of therapeutic mammoplasty is to
reshape the breast with resection of cancer
and therefore cosmetic aspect should be an
adjunct rather than the primary aim and there
should be no compromise on this principle.
A clear surgical plan should be made for
each case about the incision pattern to be
used, access for the WLE and SLNB, nipple
pedicle and if a secondary pedicle is needed
and feasible.
2. SLNB can be done through the same inci-
sion, but it would be difcult to carry out an
ANC through the access available and therefore a separate axillary incision should be
planned and can be placed slightly higher up
in the axilla in the transverse skin creases to
avoid compromised vascularity of the skin
and T junctions.
3. Any one risk factor (High BMI, smoking,
etc.) can signicantly increase morbidity.
Therefore, case selection and patient counselling are paramount and please ensure that
patient is seen at least twice in outpatient
clinic before surgery. During counselling, it
would be important to not only show postoperative photographs of expected results but
also of complications like skin necrosis,
wound dehiscence, nipple malposition, fat
necrosis, asymmetry and skin puckering. A
full understanding of the procedure along
with management of expectations should be
a part of the informed consent process.
4. The neo-nipple position on the breast meridian is generally marked at least a cm below
the level of the IMF.This is done anticipating
the skin elasticity and the reduction pattern.
In the vertical pattern design, it may be useful to place the neo-nipple position at least
2cm below the planned level considering the
potential ascent of the IMF position as well.
5. Measurements should be part of the marking
process but should not be the strict guide in
the process.
6. Assessment of the volume of glandular components on the lower segments clinically and
on radiology is necessary as this would inuence the decision regarding the need for secondary pedicles.
7. Based on the tumour position and the incision used, a plan should be made for access
for the WLE and the SLNB.It may be useful
to take extra margins in case of larger
tumours to reduce re-excision rates.
Reoperations for margins can be difcult
sometimes due to rearrangement of tissues.
8. It may be better to avoid secondary pedicles
in very fatty breasts because of the high risk
of fat necrosis. Secondary pedicles should
generally be broad based and used with deepithelised skin rather than glandular tissue
alone. It may be useful to de-epithelialise the
areas of excision in the wise pattern (lateral
area below the wings of the wise pattern
mainly) as these de-epithelialsed areas can
be used for planning secondary pedicles.
9. For superomedial and lateral pedicles, it is
important to keep the pedicles less thick as
the blood vessels are in the supercial layers.
In addition, it is only necessary to release the
pedicle just enough for the nipple to sit in the
neo-nipple position without any tension or
kinking.
10. Avoid excising too much breast tissue on the
medial aspect as a part of reduction as this
could impact on cosmetic outcomes.
11. When using the superior, superomedial or
lateral pedicles and excising the lower seg-
110
ab
https://t.me/medicina_free
S. Soumian
ment, it would be useful to leave a broad
based de-epithelialised skin island at the T
junction area so that the sutured T junction
lies on this. In case of T junction healing
issues, there will be de-epithelialised skin
underneath which could aid healing.
12. It is important to avoid tight dermal sutures
at the T junction. Instead, deep dermal
sutures are placed about 5–7mm away from
the junctions on the three sides and a 3 point
suture is done at the T junction only during
placement of the subcuticular sutures. This
reduces the tension at the T junction.
Negative pressure wound dressings could be
considered for selected high risk cases if
available locally as they could potentially
reduce morbidity.
15.11 Central Tumours
If a larger central segmentectomy is planned in
a ptotic Breast, then a wise pattern design can
be done with excision of the NAC along with
the tumour and a circular paddle of skin island
on the inferior pedicle below the original NAC
can be moved up to create the neo-NAC
(Fig. 15.3b). A nipple reconstruction can be
done at the same time or at later stage on the
skin paddle.
15.12 Upper Tumours
A wise or vertical pattern design with inferior
pedicle for the nipple can be used (Fig.15.3c). If
the defect is above the level of the neo-nipple
position, then it can be either be closed with glandular mobilisation or a secondary pedicle as an
extension of the inferior pedicle pillar can be
used to ll the defect superiorly.
15.13 UO Tumours
A wise pattern reduction design or a vertical
pattern with the nipple based on either the superior, superomedial or the inferior pedicle can be
used. If there is adequate amount of tissue in
the lower outer quadrant, then that de-epithelialised area can be moved up to ll the defect
(Fig. 15.4a). However, if tissue on the lower
Fig. 15.4 – for UO tumours, (a)—Inferior pedicle Mammoplasty with advancement of depithelialised lower segment
tissue upwards, (b)—Superomedial pedicle for nipple with inferior pedicle used as secondary pedicle
Соседние файлы в папке Библиотека им академика М.И. Перельмана