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15 General Principles ofTherapeutic Mammoplasty
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outer segment is minimal, then a secondary
15.14 UI Tumours
pedicle using the de- epithelialised inferior pedicle can be rotated laterally into the defect
(Fig.15.4b). It is important to ensure that minimal tension is maintained at the T junction.
Sentinel node biopsy can usually be done
through the same incision.
These areas are always difcult to reconstruct. If
an inferior pedicle is planned, then the deepithelialised lower medial segment can be
moved up to ll the space. Usually, the amount of
breast tissue in this area is limited and may be
inadequate (Fig.15.5a) It may be useful to design
Fig. 15.5 (a)—Inferior pedicle Mammoplasty for UI
Tumors, (b)—Lateral pedicle Mammoplasty with pillar
extension as secondary pedicle for UI Tumours,
(c)—Lateral pedicle Mammoplasty with inferior pedicle
extension as secondary pedicle for UI Tumours, (d)—
superomedial pedicle for Lower, LO and LI Tumors
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S. Soumian
the nipple on a lateral pedicle and an extension of
the lateral pedicle pillar can be done and rotated
into the defect (Fig.15.5b). Alternatively with the
nipple on the lateral pedicle, the de-epithelialised
inferior pedicle can be used as a secondary pedicle for lling the medial defect (Fig.15.5c).
15.15 Lower, LO andLI Tumours
Tumours in these three areas are easier to manage
with minimal morbidity as they fall into the zone
of the standard excision pattern. Wise pattern
design with the nipple on the superior or the
superomedial pedicle with excision can be done
with good cosmetic outcomes (Fig.15.5d).
15.16 Complications
Postoperative recovery from therapeutic mammoplasty is similar to breast reduction surgery
and has relatively less complications when compared to mastectomy and reconstructions. Type II
oncoplastic procedures take longer operating
times and have an impact on theatre resources.
Based on the extent and magnitude of the incisions and glandular mobilisation, there are risks
with skin necrosis especially at the upper and
lower T junctions, partial or total nipple necrosis,
fat necrosis, altered sensation and sensitivity of
nipple, nipple malposition and breast asymmetry.
Reoperation for margins can sometimes be difcult due to glandular rotation and rearrangement,
therefore clear descriptive operation notes with
illustrations are essential and paramount in terms
of these procedures.
This can also potentially impact or delay the
starting of adjuvant chemotherapy or radiotherapy if complications arise. In the long term, inferior pedicle-based procedures with a wise pattern
design have a problem with bottoming out with
impact on cosmetic outcomes.
15.17 Summary
TM has now been accepted as the standard procedure for the appropriate indications and has
improved the standard of care in a holistic way
for breast cancer patients. Case selection is the
most important factor, along with patient counselling and meticulous surgical planning, in
dening the success of TM.
References
1. Van Maaren M, de Munck L, de Bock H, etal. 10 year
survival after breast-conserving surgery plus radiotherapy compared with mastectomy in early breast
cancer in The Netherlands: a population-based study.
Lancet Oncol. 2016 Aug;17(8):1158–70. https://doi.
org/10.1016/S1470- 2045(16)30067- 5.
2. Boniface J, Szulkin R, Johansson A.Survival after
breast conservation vs mastectomy adjusted for
comorbidity and socioeconomic status: a Swedish
national 6-year follow-up of 48 986 women. JAMA
Surg. 2021 May 5:e211438. https://doi.org/10.1001/
jamasurg.2021.1438.
3. Wang HT, Barone CM, Steigelman MB, et al.
Aesthetic outcomes in breast conservation therapy.
Aesthet Surg J. 2008;28:165.
4. Bajaj AK, Kon PS, Oberg KC, Miles DA.Aesthetic
outcomes in patients undergoing breast conservation
therapy for the treatment of localized breast cancer.
Plast Reconstr Surg. 2004;114:1442–9.
5. Choong WL, Andrew RE, Hogg FJ, et al. Age and
cancer treatment factors inuence patient-reported
outcomes following therapeutic mammoplasty and
contralateral symmetrisation for the treatment of
breast cancer. J Plast Reconstr Aesthet Surg. 2021
Mar 28;74(10):2557–64. https://doi.org/10.1016/j.
bjps.2021.03.031.
6. van la Parra RFD, Clough KB, Thygesen HH, etal.
Oncological safety of Oncoplastic level II mammoplasties after neoadjuvant chemotherapy for large
breast cancers: a matched-cohort analysis. Ann Surg
Oncol. 2021 Mar 28;28(11):5920–8. https://doi.
org/10.1245/s10434- 021- 09829- 8.
7. Kosasih S, Tayeh S, Mokbel K, Kasem A.Is oncoplastic breast conserving surgery oncologically safe?
A meta-analysis of 18,103 patients. Am J Surg.
2020 Aug;220(2):385–92. https://doi.org/10.1016/j.
amjsurg.2019.12.019.
15 General Principles ofTherapeutic Mammoplasty
https://t.me/medicina_free
113
8. Potter S, Trickey A, Rattay T, et al. Therapeutic
mammaplasty is a safe and effective alternative to
mastectomy with or without immediate breast reconstruction. Br J Surg. 2020 Jun;107(7):832–44. https://
doi.org/10.1002/bjs.11468.
9. Mansell J, Weiler-Mithoff E, Stallard S, et al.
Oncoplastic breast conservation surgery is oncologically safe when compared to wide local excision and
mastectomy. Breast. 2017 Apr;32:179–85. https://doi.
org/10.1016/j.breast.2017.02.006.
10. Kelemen P, Pukancsik D, Újhelyi M, etal. Comparison
of clinicopathologic, cosmetic and quality of life outcomes in 700 oncoplastic and conventional breastconserving surgery cases: a single-Centre retrospective
study. Eur J Surg Oncol. 2019 Feb;45(2):118–24.
https://doi.org/10.1016/j.ejso.2018.09.006.
11. Soumian S, Parmeshwar R, Chandarana M, et al.
Chest wall perforator aps for partial breast reconstruction: surgical outcomes from a multicenter study.
Arch Plast Surg. 2020 Mar;47(2):153–9. https://doi.
org/10.5999/aps.2019.01186.
12. McCulley SJ, Schaverien MV, Tan VK, etal. Lateral
thoracic artery perforator (LTAP) ap in partial
breast reconstruction. J Plast Reconstr Aesthet Surg.
2015 May;68(5):686–91. https://doi.org/10.1016/j.
bjps.2015.01.008.
13. Chatterjee A, Gass J, Patel K, et al. A consensus
denition and classication system of Oncoplastic
surgery developed by the American society of breast
surgeons. Ann Surg Oncol. 2019;26:3436–44.
14. Chu CK, Hanson SE, Hwang RF, etal. Oncoplastic
partial breast reconstruction: concepts and techniques. Gland Surg. 2021 Jan;10(1):398–410. https://
doi.org/10.21037/gs- 20- 380.
15. McCulley SJ, Macmillan RD. Planning and use of
therapeutic mammoplasty -Nottingham approach. Br
J Plast Surg. 2005;58:889–901.
16. Dixon M. Breast surgery. A companion to specialist surgical practice Fifth edition © 2014 Elsevier
Limited.
Therapeutic Mammoplasty
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Surgical Techniques
NitaS.Nair, JessickaShah, GarvitChitkara,
andVaniParmar
16
16.1 Evolution ofTherapeutic
Mammoplasty
The latter part of the last millennium has seen
advances in science and medicine, with a new
understanding of the cause and treatment of cancer in general. Over the years, there has been a
paradigm shift toward more conservative surgery
in the treatment for breast cancer. The oncological safety of breast-conserving surgery (BCS) in
early stage disease has been conclusively evaluated across numerous studies [1]. As systemic
therapy has advanced, with better outcome, quality of life has now come to the forefront. We have
thus started expanding the indications of BCS
using various oncoplastic techniques.
Larger excisions are more likely with larger
tumours, smaller breast sizes and surgical preference or protocol for quadrantectomy. As the proportion of breast removed increases, risk of
cosmetic deformity increases. This can be associated with poor psychological adjustment after
breast cancer treatment [2]. Additionally, in cases
with larger breasts there is a risk of receiving
non-homogenous radiation dosage and an
increased risk of post-operative [3] and long-term
cosmetic [4] complications. The evolution of
N. S. Nair (*) · J. Shah · G. Chitkara · V. Parmar
Department of Surgical Oncology, Tata Memorial
Centre, Homi Bhabha National Institute,
Mumbai, India
oncoplastic breast surgery, particularly therapeutic mammoplasty (TM) procedures, has grown
over the years due to the demand for more aesthetically acceptable results [5, 6].
Therapeutic mammoplasty is the use of breast
reduction techniques to perform breast cancer
resection, wherein oncoplastic techniques are
used to extend the role of breast-conserving surgery in ptotic or large-breasted women to facilitate wider resection margins, immediate
symmetry and perhaps less radiation toxicity. In
addition, it is likely to positively affect the quality of life as seen with breast conservation [7].
Breast cancer in a large sized breast has always
been a challenge for radiation oncologists as the
breast- tumour ratio may allow for ease of conservation, but the technical challenge of delivering therapeutic radiation and a boost would
possibly result in higher morbidity to the affected
breast with higher incidence of late onset radiation brosis and poor cosmesis. At the same
time, mastectomy would be physically challenging to the surgeon and would result in gross
imbalance of posture for the patient with longterm consequences, asymmetry and difculty in
procuring an appropriate sized prosthesis.
Bilateral wise pattern reduction mammoplasty
is a standard plastic procedure being offered in
women with oversized and physically disabling
macromastia since early last century [8]. In breast
cancer, it was more towards the end of last century that these procedures were offered to reduce
© 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_16
115
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N. S. Nair et al.
Table 16.1 Therapeutic mammoplasty has three main
components
1. Resect excessive breast tissue if needed
2. Excise excessive skin
3. Maintain viability and repositioning of the
nipple-areolar complex
the breast size along with oncological wide resection of the malignant lesion, thus offering breast
conservation to these women as well. None of
this has escaped the trepidations of radiation
oncologists and surgeons concerning the high
risk of fat necrosis and possibly also higher rate
of local recurrence. The earliest reports of low
recurrence rates after breast conservation with
reduction mammoplasty were in 2001 by
Newman LA etal. [9], reporting no recurrences
at nearly 2years, albeit a relatively short follow
up. Subsequently Clough etal. [10] has described
a series of 101 patients over 15 years and their
ndings support clinical and oncological safety.
16.2 Patient Selection
andSurgical Planning
To obtain a good cosmetic outcome in patients
who have TM, contralateral symmetrisation procedures are most often needed. There are several
key steps when planning a TM (Table 16.1). At
the time of surgery, careful consideration should
be given to the type of dermoglandular pedicle
(primary or secondary) used to ll any defect to
ensure proper remodelling of the breast.
Preoperative localization of the tumours and
intraoperative marking of the tumour bed are
critical steps to ascertain effective treatment.
Patients planned for TM have large breasts and/or
ptosis that benet with the reduction and/or mastopexy that is achieved with a therapeutic
mammoplasty.
There are different techniques of TM.These
techniques are fashioned according to the different tumour locations (Table16.2). The most commonly used techniques are the superior-medial
and the inferior pedicle mammoplasties. Vertical
reduction mammoplasty was described by
Elizabeth J Hall-Findlay [11, 12]. Additionally,
Table 16.2 Choice of technique
There are two common scenarios one encounters when
planning TM [13]
Scenario A—tumour lies within a routine reduction
mammoplasty excision
Classically, this could be an inferior pole tumour that
can be excised with a wise or vertical pattern reduction
using a superior pedicle for the nipple. The options
can be extended for other tumours by employing
different pedicles, such as an inferior pedicle for
tumours above the nipple and so on for medial/lateral
tumours (Fig.16.1).
Scenario B—the tumour lies outside of a standard
mammoplasty method.
This refers to very superior, medial or lateral
tumours or those that occur in the area that would
form either the medial or lateral pillar of the
mammoplasty. In these cases a modication to the
mammoplasty technique must be planned
(Fig.16.2).
the lateral and horizontal TM are also described.
Losken also described using different recognized
pedicles for the nipple depending upon the
tumour position [3], and the use of alternate pedicles to help ll the tumour excision site to
improve contour. This enables many tumours to
be excised by adapting a known method and
highlights the advantage of understanding a range
of recognized mammaplasty techniques.
The skin pattern chosen will be mostly inuenced by the amount of breast skin and tumour
position. The wise pattern and vertical mammmoplasty are the two most commonly used
therapeutic mammoplasty skin patterns. Many
factors inuence the skin incision, like surgeon’s
choice and the presence of previous scars. The
nipple is repositioned using vascularized pedicles, the most commonly used are superomedial
and inferior. Other options include, central pedicle, vertical pedicle (McKissock) and horizontal
bipedicle (Strombeck). Vascularity of the pedicles should be ensured as much as possible to
avoid fat necrosis. The pedicle should be dissected only to the amount to allow the required
movement. A slightly shorter safer pedicle may
be accepted if needed. The most common factors
inuencing the choice of pedicle is the site of
tumour or transverse scars across one of the skin
pillars. All other components of the mammo-
ab
c
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Supero-medial pedicle
Inferior pedicle
Fig. 16.1 Scenario A. (a) Wise pattern Incision Superomedial pedicle (b) Wise pattern Incision Inferior pedicle, (c)
Vertical mammoplasty (superomedial pedicle)
Fig. 16.2 Scenario B
(secondary pedicle)
NAC moved on
Superomedial pedicle and
Inferior pedicle used to ll
lumpectomy cavity.
117
plasty procedures are the same. Both breasts can
be operated on at the same time.
16.3 Types ofTherapeutic
Mammoplasty
Preoperative evaluation must include, not just
the tumour site, scars, breast density, skin quality,
grade of ptosis, but good counselling to avoid any
unreasonable expectations. The risk of breast
asymmetry, altered sensation, nipple-areolar
necrosis and abnormal scarring must be explained
to the patient. Preoperative photography is a crucial and may be helpful in addressing any future
concerns. Three views documenting the appearance of the breast from the front and both sides
with additional views including a hands-overthe-head view are recommended. It is critical that
the patient’s face is not included in any
photographs.
The surgical marking and planning for a therapeutic mammoplasty includes planning of the
skin marking (verticle, wise pattern, lateral or
periareolar) and the movement of the nipple areola complex on a dermoglandular pedicle (which
can be planned using either, inferior pedicle, lateral pedicle, superomedial pedicle, central pedicle, vertical pedicle (McKissock) and horizontal
bipedicle (Strombeck). A review of plastic surgeons in the USA reported that 56% preferentially use an inferior pedicle and an inverted-T
skin pattern [14]. We describe some of the commonly used procedures below.
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16.3.1 Wise Pattern Reduction
The wise pattern is very versatile in allowing
good access for tumour excision and removing
excess tissue in case with marked ptosis.
16.3.1.1 Skin Marking
The preoperative assessment includes a good
documentation by photographs in standing position. Prior to marking any pattern of resection of
therapeutic mammoplasty, the breast landmarks
are marked (Fig.16.3).
a
1. With the patient standing, mark the midline
from the sternal notch to the umbilicus.
2. The breast meridian is marked with a use of a
measuring tape by putting it around the
patient’s neck and letting it hang loosely from
both mid-clavicular points to the abdomen.
Often the breast meridian does not transect
the nipple areola complex.
3. The inframammary fold (IMF) is then marked
and the new nipple site is marked.
To mark the new nipple (Point A): The index
nger in placed at the centre of the IMF to mark
Midline
Breast meridian
Point A (Pitanguy’s point)
b
Point B
Fig. 16.3 Skin markings (a) Landmarks (b) Medial and lateral extent of resection
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its projection on the breast on the breast meridian, this is Pitanguy’s point [15]. Which is a
usually 18–22cm from the supra sternal notch
4. The medial limit of resection is then marked
by displacing the breast with the palm of the
hand, and marking the projection of the
meridian on this side (Point B). Then the same
manoeuvre is performed laterally to mark the
lateral limit of excision. (Point C).
5. Points B and C are then connected to the IMF.
6. Point A is connected to point B and C (8–9cm
distance).
7. The NAC can be marked as a mosque dome
around ABC or during surgery using nipple
stencils of 4.5–5cm diameter.
16.3.1.2 The Pedicle
While technique of inferior pedicle reduction was
earlier more popular and technically easier, it was
associated with higher chances of bottoming out of
a
the lower pole which can make the breast ptotic
again [16]. The superior and superomedial pediclebased reduction is cosmetically more popular as it
maintains the cleavage and allows for better contouring in the upper inner quadrant. Eventually, the
feasibility of one over the other is based on site of
the primary tumour and excision area in relation to
the respective pedicles.
(A). Superior and superomedial pedicle
(Figs.16.1a, 16.4).
The superomedial pedicle is based on
anterior perforator branches arising from
the second and third space from internal
mammary artery. It is a major perforator
and supplies the NAC and accounts for 60%
of the blood supply. Remaining 30% of
blood supply of NAC is from the lateral thoracic artery and perforators from 3 to 5th
intercostals arteries [17].
b
Fig. 16.4 Superomedial wise pattern therapeutic mammoplasty (a) Preoperative marking (b) Post-operative images
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a
b
c
Fig. 16.5 Inferior pedicle wise pattern therapeutic mammoplasty (a) Per operative marking (b) Post-operative image
(c) Horizontal bipedicle
In majority of cases, a superomedial pedicle is suitable for a primary located anywhere between 5 o’clock and 11 o’clock
(clockwise) in right breast and 1 o’clock
and 7o’clock (clockwise) in left breast.
There may be a need to tailor the wise pattern based on exact site of primary and size
and thickness of the lateral pillars to create
a well contoured lower pole without bottoming out or indenting at the vertical scar.
(B). Inferior pedicle (Figs.16.1b and 16.5).
For upper region tumours, the lower
breast tissue may be moved into the defect
as a glandular ap and an inferior pedicle
can be utilized. This was introduced originally by Ribeiro [18] in the 1970s and
subsequently modied by Courtiss and
Goldwyn [19], the technique describes the
transposition of the NAC on an inferiorly
based dermoglandular ap. The inferior
pedicle receives its blood supply directly
from the fourth, fth and sixth intercostal
perforating and intercostal branches of the
internal mammary artery and the external
mammary branches of the lateral thoracic
artery [19]. The Inferior pedicle provides a
breast that is easily shaped, without neurovascular changes to NAC[20]. The preferred
pedicle length in no more than 15cm and
minimum pedicle base of 6cm is preferred,
to avoid nipple areola complex necrosis.
The inferior pedicle is bent over itself to
provide extra glandular tissue so that it does
not become depressed post-operatively [21]
and care is taken to ensure the inferior pedicle lies comfortably within the defect and
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there is no undue pressure on the pedicle
from the medial and lateral pillars that close
over it.
The horizontal bipedicle, described by
Strombeck [22], uses both a medial and a lateral
pedicle to supply the nipple-areolar complex and
can be done in cases with up to 1000gm resections. It was popular in the 1960s, until it began
to be largely replaced by other techniques. The
Strombeck reduction was criticized on the basis
of an awkward nipple inset, difcult manoeuvring of the pedicle intraoperatively and a high
rate of loss of nipple sensation [23].
16.3.1.3 Surgical Procedure
(i) The preoperative markings are reinforced at
the time of surgery and landmarks (Points
ABC) are marked with clips or sutures. The
Nipple areola complex is marked (if needed
a
reduced in size to 4.5–5cm diameter) and
the pedicle is de-epithelized saving the nipple and areola (Fig.16.6a).
(ii) The tumour is then excised with a wide
margin and oriented with sutures (short
superior, long lateral, skin anterior) for
pathological evaluation. The axillary surgery is also performed as appropriate. In
cases of scenario A, wherein the tumour is
within the TM excision, the skin, parenchyma and fat within the TM markings are
excised along with the tumour, while in scenario B, the wide excision is done separate
from the TM excision.
(iii) The base of the tumour cavity is marked
with clips.
(iv) The pedicle that has been previously dened
is then moved into place. The pedicle may
be thinned to not less than 2–3cm thickness
to improve its reach (Fig.16.6b).
b
c
Fig. 16.6 Surgical steps (a) De-epithelised pedicle (b) Inferior pedicle dened and thinned out as needed (c) Final
closure, after NAC brought into position
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