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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1054_Библиотеки_им_академика_М_И_Перельмана
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20 Chest Wall Perforator Flaps forPartial Breast Reconstruction
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Fig. 20.6 Demonstration of partial breast reconstruction with AICAP and MICAP
143
Fig. 20.7 A 54-year-old with partial breast recon with AICAP, 120gm specimen, 45mm invasive carcinoma. Pre-op,
10months post-op, and 3months post-radiotherapy
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G. Shetty
20.5 Complications
andManagement
The pedicled chest wall perforator aps generally
have low morbidity [20, 21]. The specic complica-
tions in the chest wall perforator aps reconstruction are ap necrosis and fat necrosis. The literature
on ap failure for CWPF is sparse. The fat necrosis
is variable depending on the patient’s comorbidities
and post-operative adjuvant treatment for carci-
noma (Fig.20.8). The comorbidities such as diabetes, smoking, and vasculopathy may increase the
incidence of fat necrosis. Often it is very well tolerated by patients and easily identied on surveillance
mammogram. In rare cases, this can lead to further
biopsies. If it is troublesome, especially after adjuvant radiotherapy, it can be managed with liposuction and lipografting. The other signicant
complications include haematoma, wound dehiscence, seroma, and chronic pain.
Fig. 20.8 The early results of fat necrosis and suboptimal aesthetic results following partial breast reconstruction with
anterior intercostal artery perforator ap
20 Chest Wall Perforator Flaps forPartial Breast Reconstruction
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145
20.6 Conclusion
Chest wall perforator ap for partial breast reconstruction is an innovative approach which is an
effective and safe procedure for the outer quadrant
and the lower quadrant breast tumours, especially
in women with small to moderate breast size and
high tumour to breast ratio. It is associated with
low morbidity alongside good aesthetic outcome
and avoids contralateral symmetrisation.
References
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volume. J Surg Oncol. 2019;121(2):216–23.
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9. Agrawal SK, etal. Chest wall perforator aps in partial breast reconstruction after breast conservation
surgery: an additional oncoplastic surgical option.
Ecancermedicalscience. 2020;14:1073.
10. Youssif S, etal. Pedicled local aps: a reliable reconstructive tool for partial breast defects. Gland Surg.
2019;8(5):527–36.
11. Munhoz AM, et al. Immediate conservative breast
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13. Meybodi F, et al. The modied lateral intercostal
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14. Petit J-Y, et al. Update on breast reconstruction techniques and indications. World J Surg.
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15. Hamdi M, et al. Pedicled perforator aps in breast
reconstruction: a new concept. Br J Plast Surg.
2004;57(6):531–9.
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aps in breast reconstruction. Semin Plast Surg.
2006;20:73–8.
17. Hamdi M, Spano A, Van Landuyt K, etal. The lateral
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clinical application in breast surgery. Plast Reconstr
Surg. 2008;121:389–96.
18. McCulley SJ, etal. Lateral thoracic artery perforator
(LTAP) ap in partial breast reconstruction. J Plast
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19. Yang JD, et al. Usefulness of a lateral thoracodorsal ap after breast conserving surgery in
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with breast cancer. Gland Surg. 2017;6(4):336–42.
Oncoplastic Reduction
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Mammoplasty andContralateral
Symmetrisation
ShivangiSaha andManeeshSinghal
21
21.1 Oncoplastic Reduction
Mammoplasty
It is an approach that combines the concept of
oncological clearance with bilateral reduction
mammoplasty to achieve the best possible aes-
thetic result. Up to 40% of women treated with
Breast Conservation Therapy (BCT) have been
reported to have macromastia. Lumpectomy
alone may not provide the best aesthetic results
for these women. Moreover, BCT in a largebreasted woman can result in a heterogeneous
radiation dose distribution, thus affecting oncological outcomes. This is suitable for women
who have preoperative macromastia or ptosis, as
well as those who have a high tumour-to-breast
ratio and such that excision alone would be disguring. This approach allows for the removal of
a considerable portion of the tumour while still
offering high levels of patient satisfaction and
outstanding aesthetic results.
S. Saha · M. Singhal (*)
Department of Plastic Reconstructive and Burns
Surgery, All India Institute of Medical Sciences,
New Delhi, India
21.1.1 Patient Selection
andPreoperative Assessment
andPlanning
Before considering a patient for oncoplastic
reduction mammoplasty, the clinician should
obtain an accurate history and perform a physical
examination. It is important to document the history of smoking, diabetes, use of steroids, prior
breast surgery, prior radiation to the chest area or
connective tissue disorders as they can impact the
wound healing process. The surgeon should also
record the symptoms and severity of macromastia. The presence of any of these factors increases
the risk of fat/nipple necrosis and delays wound
healing.
The physical examination should record the
body mass index, breast size and shape, scars of
previous surgery, location of tumour, size of
expected defect should be assessed and degree of
ptosis should be noted. Any asymmetries
between both the breasts should be brought to
the patient’s notice as they may persist after the
surgery.
The Breast width, Nipple Areola Complex
(NAC) width, Sternal notch to nipple (SN-N)
distance, and nipple to inframammary distance should be measured (Fig. 21.1). A SN-N
distance change of more than 10 cm has poor
results with vertical scar breast reductions. A
SN-N distance of more than 35cm has the risk of
jeopardising the circulation to the nipple through
© 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_21
147
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Fig. 21.1 Standard measurements to be performed in the preoperative assessment
S. Saha and M. Singhal
the pedicle. Thus, the patient should be apprised
of the risk of nipple necrosis and the possibility
of a free nipple graft.
A suitable candidate for oncoplastic reduction
mammoplasty is:
• Someone who needs a large volume resection
and has symptomatic macromastia (chronic
headaches, back pain, neck pain, shoulder
grooving, or intertriginous rashes) is a suitable
candidate.
• A woman who desires smaller breasts.
• The extent to which the cancer surgeon is
concerned about aesthetic abnormalities
while resecting a sufcient specimen size is
also a consideration in this procedure’s
selection.
• According to Clough etal.’s [1] bi-level classication, if 20–50% breast volume excision
is anticipated, it is classied as a level II resection and requires reshaping of the breast using
mammoplasty techniques.
• All women with moderate-to-large breasts are
still eligible for consideration.
• It can also be used in patients undergoing primary cancer resection or in patients with prior
lumpectomy with positive margins.
21.1.2 Timing oftheSurgery
• A single stage immediate reconstruction is
expected to produce a better psychological
and aesthetic outcome and is thus preferred.
• A delayed reconstruction after conrmation
of negative margins is favoured in patients
with extensive ductal carcinoma in situ
(DCIS), especially in young patients, as it carries a higher risk of positive margins.
21.1.3 Choice ofIncision andPedicle
Pre-operatively, a skin pattern and NAC pedicle
are planned and established based on tumour
location to allow for tumour excision within the
typical resection pattern for the specic reduction
technique chosen, as well as lling of the anticipated tumour defect with leftover breast tissue
(Fig.21.2).
Once resection is performed on the side of the
tumour, a symmetrisation procedure can be performed on the contralateral breast simultaneously. The incisions most commonly used for
mammoplasty are the wise or inverted T pattern
or the vertical scar pattern.
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149
Fig. 21.2 Various options for reconstruction (Reduction mammoplasty technique and its variations) for each tumour
location
21.1.3.1 Choice ofIncision
The most common oncoplastic approach is Wise
pattern skin design with inferior pedicle reduc-
tion mammoplasty. This procedure combines
upper pole or centrally located tumour removal
Several other incisions have been described,
such as peri-areolar incision or batwing inci-
sion for tumours located in the vicinity of the
NAC, the lateral or medial incisions for tumours
located in the respective positions.
with gland resection, resulting in a more pleasing
appearance of a ptotic breast. The incision pattern preserves the skin aps’ viability while
allowing sufcient access and exposure for the
partial mastectomy.
The vertical scar approach was rst described
by Lassus, and popularised by Lejour for cosmetic breast surgery. Since inferior pole and central subareolar tumours can be excised widely
within the margins of the typical marks, the vertical scar technique is ideal for them. Smaller skin
incisions, easier glandular excision, and a shorter
pedicle providing consistent blood supply to the
NAC are some of the advantages of this approach.
During contralateral symmetrisation, the vertical
scar technique additionally enables the elevation
of the inframammary crease, which is unachievable with the wise pattern incision technique.
21.1.3.2 Choice ofPedicle
Superior, inferior, and medial pedicles are the
most widely used pedicles.
The superior and supero-medial pedicle is
chosen because it is more reliable, and capable of
preserving nipple sensation. The inability to
manipulate the nipple over long distances is a
limitation of this pedicle, particularly in individuals with glandular and hypertrophic breast.
Superior pedicles are best for tumours in the
lower quadrants, especially in moderately sized
breasts. With substantial reductions, where shaping may only result in superior fullness, using
this pedicle may be challenging.
For tumours in any location, inferior pedicles
are versatile and dependable. Larger breasts with
longer sternal notch to nipple distances, as well
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Fig. 21.3 Superior
versus inferior Pedicle
technique, and the
location of tissue
resection
S. Saha and M. Singhal
as tumours in the upper quadrants of the breast,
are suitable candidates for this method. However,
because it lacks parenchymal support, the breasts
may sag or “bottom out,” leading to redundant
skin and breast tissue between the nipple and the
IMF (Fig.21.3).
For medial tumours that extend into the upper
or lower quadrants, the lateral pedicle is an option.
This pedicle is not frequently used for cosmetic
breast reductions, because if the pedicle is too
thick, the breast will be too full laterally. It is normally reserved for women with
small-to-moderate- sized breasts and who require a
blood supply and nerves to the nipple is limited
by the length of the pedicle needed to carry the
NAC into its new position and by the ability to
reduce the breast with a large pedicle. The nipple
areola complex is removed as a skin graft, the
breasts are reduced, and the NAC is then sutured
in the appropriate position on the breasts. This
surgery causes the loss of nipple sensitivity as
well as hypopigmentation, which takes at least a
year to restore. When oncologic margins necessitate the excision of the nipple areola complex, it
can be done without compromising breast shape
as long as sufcient skin is maintained.
mastopexy or a minor reduction.
In patients with gigantomastia (excessive
breast tissue that contributes 3% or more of the
patient’s total body weight are the best candidates for free nipple grafting during reduction
mammaplasty [2]. In such cases, preservation of
is a viable treatment. Wide tumour excision is
combined with supero-medial NAC repositioning
on a dermo-glandular pedicle, preventing lateral
axial scar contraction and breast ptosis. The
majority of reconstructions undertaken with this
For lateral pole cancers, lateral mammoplasty
21 Oncoplastic Reduction Mammoplasty andContralateral Symmetrisation
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approach have yielded good or exceptional
results.
21.1.4 Steps ofSurgery
The markings are performed in the standing position (Figs.21.4, 21.5, 21.6, 21.7, 21.8, 21.9 and
21.10). The markings of wise pattern inferior
pedicle mammoplasty are being demonstrated
Fig. 21.6 Or by the marking of the inframammary crease
onto the breast surface by the nger method, this is point A.
151
Fig. 21.4 A straight vertical line joining the suprasternal
point to the xiphoid is marked. The breast meridian is
marked, which may/may not go through the nipple
Fig. 21.5 The proposed site of neo-nipple is marked by
the Hall Findlay method
Fig. 21.7 The angle of the vertical limbs are marked, by
placing the thumb and index nger of one hand and pinching the breast about 6.5- 7 cms from point A. The other
hand is used to mark the angle points. These are B (lateral)
and C (medial) which are equidistant from the breast
meridian. The angle decides the amount of resection and
tightness of closure
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S. Saha and M. Singhal
Fig. 21.8 The medial limit of resection (point E) is
marked by gently displacing the gland laterally
Fig. 21.9 The lateral limit of resection (point D) is
marked on the breast gland by gently displacing the gland
medially. The breast is elevated and the inframammary
crease is marked, the point where the inframammary
crease joins the breast meridian is also marked
Fig. 21.10 Straight lines are drawn to join points C to E
and also from B to D. They should be adjusted so that they
equal the line from the skin resection pattern is marked as
described. The inferior pedicle is marked with a base
width of 6 to 8 cms and is centered on the breast meridian,
it extends for about 2 cms above the nipple areola
complex.
here, as it is the most commonly performed procedure especially for tumours located in the
superior half and central location.
21.1.4.1 Reduction Mammoplasty
Using Wise Pattern Scar
(Inferior Pedicle Technique)
From the nipple areola complex to the inframammary fold, the inferior pedicle is marked and
de- epithelialized. The tissue along the medial
and lateral borders of the pedicle is sharply
divided, and the tumour is resected. The inferior
pedicle is advanced to ll the space created by
tumour resection, the gland is then re-approximated with absorbable sutures, the inverted T
scar is closed.
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153
21.1.4.2 Reduction Mammoplasty
Using Lejour Vertical Scar
(Superior Pedicle Technique)
The cuff of tissue all around the nipple areola
complex is deepithelised. An inferior vertical
incision is made, and tumour at the inferior pole
with adequate margins are excised. The breast
tissue medially and laterally is undermined in the
retro-glandular plane, anterior to the pectoralis
major and serratus anterior muscle. The medial
and lateral breast pillars are re-approximated in
layers and the overlying vertical skin incision is
closed (Fig.21.11).
21.1.5 Margin Assessment
Similar to other oncoplastic techniques, reduction mammoplasty techniques allow resection of
wider margins, or resection of larger tumours.
The margin assessment in a reduction mammoplasty oncoplastic technique is performed similar
to the other oncoplastic resections. The margins
can be assessed by specimen sonography, mammography or using a frozen section.
Once all the margins are adequately resected,
generally hemoclips are installed (2 per site) on
each resection cavity to mark the limits of excision. Re-excision if needed is performed at least
1month after the previous surgery to allow for
some consolidation of the seroma cavity. Another
advantage of marking the cavity is to target the
delivery of radiotherapy boost.
21.1.6 Post-Operative Radiation
Therapy
Following the healing of incisions, the second
part of BCT is radiation therapy, which com-
mences 3 to 6weeks after the reduction procedure. Whole-breast irradiation, as well as other
treatments, are used. A boost is delivered to the
tumour bed in order to eliminate any remaining
microscopic cancer cells. Surgeons should avoid
extensive skin-gland dissection and exceedingly
Fig. 21.11 Vertical scar
reduction mammoplasty
technique of Lejour
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