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23.6.6 Case 6: EO withDual Flap forMulticentric Disease

C. Koppiker et al.

(a) Pre-operative Markings (b) Excision Planning for LICAP Flap and MICAP ap (c-d) Intraoperative LICAP and MICAP ap respectively (Excision size: 5×5×3cm

b c

h i

and 8.8×8×4.1cm; 75cc and 288.64cc) (e) The Larger Specimen (f-g) Post-operative (Immediate) (h-i) Postoperative (after 2years)

A 44-year-old female patient presented two irregular spiculated masses in right breast at 3 o’clock 2B position (2.37 × 1.76 cm)and 9 o’clock 2B position (2.76 × 1.6 cm) – multicentric disease also with suspicious right axillary lymph node. Trucut Biopsy of both the lesions revealed IDC Grade II.ER: 95%, PR: 95%, HER2: Negative. Post-NAHT tumour sizes reduced to –

1.66×0.92cm and 1.98×1.14cm. Patient then

underwent excision of both lumps and reconstruction with LICAP and MICAP with Sentinel

node biopsy HPE revealed IDC Grade II+DCIS, 9 o’clock had multiple foci of invasive carcinoma the largest one being 3.7× 3.3 ×1.9cm in size and satellite focus was 0.2cm in size (DCIS was 20% of the volume) (closest margin 0.4cm). 3 o’ clock lesion showed 5% DCIS (closest margin

0.5cm) with tumour size 1.9×1.8×0.9cm. SLN status: 2/8, clinical staging pT2N1M0. Patient received RT and hormonal therapy and is alive and well at 2years.

Medial Pillar

23 Extreme Oncoplasty inBreast Reconstruction

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23.6.7 Case 7: Benign Pseudoangiomatous Stromal Hyperplasia

177

Lateral pillar with

Latero central

pedicle

bii

Inferior pedicle having some

PA SH - pseudo angiomatous stromal hyperplasia

breast tissue

(a) Large Left breast presented with Pseudo- angiomatous Stromal Hyperplasia (PASH). (bi) and (bii) MRI showing the benign PASH in the breast. (c) Post-op image after the

A 28-year-old female presented with a complaint of huge left breast enlargement. Trucut biopsy of the lesion of the left breast showed a benign Pseudo-angiomatous Stromal Hyperplasia (PASH). The size of the lesion reported on MRI was 17.0 × 15.5 × 17.1 cm (4505.85 cc). The patient underwent breast conservation using an extreme therapeutic mammoplasty of the left breast. Histopathological analysis conrmed the presence of a benign Pseudo-angiomatous Stromal Hyperplasia. After 10years she remains

extreme oncoplastic procedure. (d) 3-year follow-up after the surgery

well. She lactated from the right breast with minimal lactation from the left side.

Acknowledgement The author would like to thank all participants who consented to participate in this Chapter. I, acknowledge Bajaj Auto Ltd. for providing support to research activities at Prashanti Cancer Care Mission, Pune.

I am thankful to, Dr. Sneha Joshi, Dr. Sanket Nagarkar, Dr. Santosh Dixit, Dr. Rupa Mishra, Ms. Smeeta Nare, Dr. Nutan Gangurde Ms. Shaheen Shaikh and Ms. Laleh Busheri for their support in the preparation of this book chapter.

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References

1. Rose M, Svensson H, Handler J, Hoyer U, Ringberg A, Manjer J. Patient-reported outcome after oncoplastic breast surgery compared with conventional breast-conserving surgery in breast cancer. Breast Cancer Res Treat [Internet]. 2020/01/27. 2020 Feb;180(1):247–256. Available from: https://pubmed.

ncbi.nlm.nih.gov/31989380

2. Bazzarelli A, Baker L, Petrcich W, Zhang J, Arnaout A. Patient satisfaction following level II Oncoplastic breast surgery: a comparison with mastectomy Utililizing the breast-Q questionnaire will be published in surgical oncology. Surg Oncol. 2020 Dec;35:556–9.

3. Silverstein MJ.Radical mastectomy to radical conservation (extreme Oncoplasty): a revolutionary change. J Am Coll Surg. 2016 Jan;222(1):1–9.

4. Silverstein MJ, Savalia N, Khan S, Ryan J.Extreme oncoplasty: breast conservation for patients who need mastectomy. Breast J. 2015;21(1):52–9.

5. Weber WP, Soysal SD, El-Tamer M, Sacchini V, Knauer M, Tausch C, et al. First international consensus conference on standardization of oncoplastic breast conserving surgery. Breast Cancer Res Treat. 2017 Aug;165(1):139–49.

6. Franceschini G, Terribile D, Magno S, Fabbri C, Accetta C, Di Leone A, etal. Update on oncoplastic breast surgery. Eur Rev Med Pharmacol Sci. 2012 Oct;16(11):1530–40.

7. Franceschini G, Magno S, Fabbri C, Chiesa F, Di Leone A, Moschella F, et al. Conservative and radical oncoplastic approches in the surgical treatment of breast cancer. Eur Rev Med Pharmacol Sci. 2008;12(6):387–96.

8. Mock V.Body image in women treated for breast cancer. Nurs Res. 1993;42(3):153–7.

9. Türk KE, Yılmaz M.The effect on quality of life and body image of mastectomy among breast cancer survivors. Eur J breast Heal. 2018 Oct;14(4):205–10.

10. Yerushalmi R, Tyldesley S, Woods R, Kennecke HF, Speers C, Gelmon KA.Is breast-conserving therapy a safe option for patients with tumor multicentricity and multifocality? Ann Oncol. 2012 Apr;23(4):876–81.

11. Behranwala KA, Dua RS, Ross GM, Ward A, A’hern R, Gui GPH. The inuence of radiotherapy on capsule formation and aesthetic outcome after immediate breast reconstruction using biodimensional anatomical expander implants. J Plast Reconstr Aesthet Surg. 2006;59(10):1043–51.

12. Boughey JC, Hoskin TL, Hartmann LC, Johnson JL, Jacobson SR, Degnim AC, etal. Impact of reconstruction and reoperation on long-term patient-reported

satisfaction after contralateral prophylactic mastectomy. Ann Surg Oncol. 2015;22(2):401–8.

13. Rocco N, Catanuto G, Cinquini M, Audretsch W, Benson J, Criscitiello C, et al. Should oncoplastic breast conserving surgery be used for the treatment of early stage breast cancer? Using the GRADE approach for development of clinical recommendations. Breast. 2021 Jun;57:25–35.

14. Franceschini G, Di Leone A, Masetti R. Comment on “extreme Oncoplastic surgery for multifocal/multicentric and locally advanced breast cancer”. Int J Breast Cancer. 2019;2019:4693794.

15. Koppiker CB, Noor AU, Dixit S, Busheri L, Sharan G, Dhar U, etal. Extreme Oncoplastic surgery for multifocal/multicentric and locally advanced breast cancer. Int J Breast Cancer. 2019;2019:4262589.

16. Crown A, Laskin R, Rocha FG, Grumley J.Extreme oncoplasty: expanding indications for breast conservation. Am J Surg. 2019 May;217(5):851–6.

17. Acea Nebril B, García Novoa A, Polidorio N, Cereijo Garea C, Bouzón Alejandro A, Mosquera OJ. Extreme oncoplasty: the last opportunity for breast conservation- analysis of its impact on survival and quality of life. Breast J. 2019 May;25(3):535–6.

18. Savioli F, Seth S, Morrow E, Doughty J, Stallard S, Malyon A, etal. Extreme oncoplasty: breast conservation in patients with large, multifocal, and multicentric breast cancer. Breast Cancer (Dove Med Press). 2021;13:353–9.

19. IARC Inc. Globocon India Fact Sheet 2020. In 2020. p.2.

20. Thakur KK, Bordoloi D, Kunnumakkara AB.Alarming burden of triple-negative breast cancer in India. Clin Breast Cancer. 2018 Jun;18(3):e393–9.

21. Bhattacharyya GS, Doval DC, Desai CJ, Chaturvedi H, Sharma S, Somashekhar SP. Overview of breast cancer and implications of overtreatment of earlystage breast cancer: an Indian perspective. JCO Glob Oncol. 2020 Jun;6:789–98.

22. Mishra V, Kelkar R, Agrawal A, Matcheswalla S.A survey on oncoplastic breast surgery awareness and practice patterns among indian surgeons: a crosssectional study. Int J Med Sci Diagnosis Res. 2021 Feb;5(2 SE-Articles)

23. Koppiker CB, Chintamani DS. Oncoplastic breast surgery in India: thinking globally, acting locally. Indian J Surg. 2019;81(2):103–10.

24. Winters ZE, Benson JR.Can patients with multiple breast cancers in the same breast avoid mastectomy by having multiple lumpectomies to achieve equivalent rates of local breast cancer recurrence? response to the preliminary alliance 11102 trial report. Ann Surg Oncol. 2019;26:700–1.

Overview ofBreast Reconstruction

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S.V.S.Deo, JyotiSharma, ChitreshKumar, andV.Seenu

24.1 Background

Breast conservation and oncoplasty may not be possible in all the women with breast cancer when the oncological safety is at compromise or due to patient related factors. Such women are likely to have large, multicentric or hereditary breast cancers. Breast aesthetics can still be maintained in these women with breast reconstruction. Breast reconstruction has evolved over last 3 decades and involves various types of autologous ap reconstruction methods and implant based breast reconstruction

24.2 Denition

Breast reconstruction is a surgical procedure that restores shape to breast after mastectomy done to treat or prevent breast cancer [1].

S. V. S. Deo (*) · J. Sharma DR BRAIRCH, All India Institute of Medical Sciences, New Delhi, India

C. Kumar Department of Surgical Oncology, DR BRA-IRCH, AIIMS, New Delhi, India

V. Seenu Department of Surgery, AIIMS, New Delhi, India

24.3 Classication

1. Based on composition: The breast can be reconstructed using alloplastic or autologous tissue. Sometimes combined reconstruction may be needed. Alloplastic reconstruction involves placement of saline or silicone gel lled implants. Autologous reconstruction uses the patient’s own skin, fat, and muscle to reconstruct the breast mound. Broadly, it is divided into pedicled versus free ap [2].

2. Based on indications: Mostly breast recon- struction is therapeutic but sometimes in hereditary cases, prophylactic contralateral or bilateral reconstruction is being performed

3. Based on timing: It can be immediate recon- struction following mastectomy or delayed reconstruction afterwards. There is little evidence available from randomized studies to favor immediate or delayed reconstruction

Immediate reconstruction is associated with low cost, lesser anesthesia related complications, improved psychological benet and better cosmetic outcome. Mostly implants are used in immediate reconstruction. Delayed reconstruction might be offered to patients with advanced disease, with uncertainties about disease control, or patients not able to decide for reconstruction at the time of their oncologic procedure. Commonly delayed autologous reconstruction is preferred when adjuvant radiation therapy is expected, to

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avoid complication related to tissue expander or implant. Breast implants may have capsular rupture or contracture (tightening or hardening of the scar tissue around the implant) and need revision surgeries. Therefore we should wait for 6months to a year to decrease the risk of complications. Delayed breast reconstruction is, however, considered more challenging than immediate reconstruction due to post-radiation skin and soft tissue changes

There is another two-stage approach, “delayed-immediate breast reconstruction,” for patients who are at an increased risk for factors necessitating post mastectomy radiotherapy. It allows patients who do not require radiotherapy to receive the benets of skin-sparing mastectomy with aesthetic outcomes similar to those of immediate reconstruction. Patients who do require radiation receive a skin-preserving delayed reconstruction, while avoiding the problems that can be associated with radiation delivery after an immediate breast reconstruction [3].

24.4 Components

1. Mound: Shape and volume

2. Nipple-areola complex

3. Symmetry

24.5 Techniques

There are many ways for breast reconstruction but following are the most commonly used

1. Tissue Expander– Breast implants: This is

the most common two-stage technique used worldwide. The mastectomy prior to TEbreast reconstruction can be either a simple skin-sparing or skin reducing or NAC-sparing mastectomy. A tissue expander, a temporary silastic implant, is inserted in to a partial or complete pocket created beneath the pectoralis major muscle. For submuscular pocket creation, the pectoralis major is dissected from its insertion on the rib cage, starting with the

lateral edge. The acellular human or animal dermal onlay grafts or polyester mesh have been used as “pectoralis extender,” covering the inferolateral portion of the TE.The saline solution is injected into a tube inside of the expander, which allows for the expansion of the tissue until the tissue is stretched to the appropriate size. Tissue expansion is normally started from the 10th to the 14th postoperative day as outpatient expansion, and is usually repeated every 1–4 weeks according to the patient will. The desired expansion is usually achieved by 2months. However, second stage reconstruction with exchange to nal implant usually takes place after 6months [4].

2. Direct to implant– This involves placement of nal implant at the time of mastectomy. It mandates healthy native skin during surgery and is suitable for small to medium breast with minimal ptosis. Patient might need second surgery (for contouring, symmetry, or nipple reconstruction)

3. Flap reconstruction: The second most com- mon procedure uses tissue from other parts of the patient’s body, such as the back, buttocks, thigh or abdomen. This procedure may be performed by leaving the donor tissue connected to the original site to retain its blood supply (the vessels are tunneled beneath the skin surface to the new site: pedicled aps) or it may be cut off and new blood supply may be connected (free aps). Few commonly performed aps are described in subsequent chapters of this book

4. Nipple and areola reconstruction: Aim is to create a nipple and areola that mimics the native papule in size, position, projection, color, and texture. Nipple reconstruction is the nal step and usually delayed for 3–5months until after the breast mound reconstruction is completed so that the positioning can be planned precisely. Procedure includes reconstruction of the projecting nipple and pigmentation. Pigmentation of the NAC can be obtained via tattoo or skin graft. There are several methods of reconstructing the nippleareolar complex [5].

24 Overview ofBreast Reconstruction

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181

(a) Nipple-areolar composite graft/ nipple

sharing–It is feasible when the patient

has sufciently large nipples. Partial dome of contralateral nipple-areolar tissue is harvested and sutured to the deepithelialized recipient site [6]. Distant site composite grafts like toe pulp, and labial tissue were employed before. They gave satisfactory results but donor site morbidity made these techniques obsolete

(b) Local tissue aps– Nipple may be cre-

ated by raising a small ap in the target area and producing a raised mound of skin. To create an areola, a circular incision may be made around the new nipple and sutured back again. Among the various aps designed, C-V, S, star, skate, and arrow aps are by far the most commonly employed

autologous, alloplastic, and allogenic grafts have been used in combination with aps to maintain nipple projection. None of them is ideal and has different complications including loss of projection [7].

Different techniques and modications of breast and NAC reconstruction are described in literature. Few commonly performed procedures will be described in detail in the subsequent chapters

24.6 Key Points

The reader should be able to decide the ideal candidates for breast reconstruction and the technique of mound reconstruction suitable for an individual patient. Nipple areolar complex reconstruction is an important nal component

References

1. Platt J, Baxter NN, McLaughlin J, Semple JL. Does breast reconstruction after mastectomy for breast cancer affect overall survival? Long-term follow-up of a retrospective population-based cohort. Plast Reconstr Surg. 2015;135:468e–76e.

2. Somogyi RB, Ziolkowski N, Osman F, Ginty A, Brown M. Breast reconstruction: updated overview for primary care physicians. Can Fam Physician. 2018;64(6):424–32.

3. Kronowitz SJ. Delayed-immediate breast reconstruction: technical and timing considerations. Plast Reconstr Surg. 2010 Feb;125(2):463–74.

4. Bertozzi N, Pesce M, Santi PL, Raposio E. Tissue expansion for breast reconstruction: methods and techniques. Ann Med Surg. 2017;21:34–44.

5. Gougoutas AJ, Said HK, Um G, Chapin APA-C, Mathes DW. Nipple-areola complex reconstruction. Plast Reconstr Surg. 2018 March;141(3):404e–16e.

6. Lee TJ, Noh HJ, Kim EK, Eom JS. Reducing donor site morbidity when reconstructing the nipple using a composite nipple graft. Arch Plast Surg. 2012;39(4):384–9.

7. Bertozzi N, Simonacci F, Pesce M, Santi PL, Raposio E.Nipple reconstruction techniques: which is the best choice? Open Med J. 2018;5(1):62–75.

Skin Sparing Mastectomy

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andNipple Areola Sparing Mastectomy

S.V.S.Deo andS.ManojGowda

25.1 Introduction

The eld of breast surgery has signicantly evolved over the last few decades paralleling our improved understanding of the anatomy of the breast and disease biology. Conservative mastectomies followed by immediate breast reconstruction have emerged as oncologically safe options yielding excellent cosmetic outcomes [1]. In addition, the introduction of genetic testing and risk reducing surgeries has expanded this eld further in the recent past.

Conservative mastectomies incorporate the advantage of complete excision of tumour and breast tissue, as in traditional total mastectomy, with improvement in aesthetic outcome through conservation of skin and nipple areola complex (NAC). Conventional modied radical mastectomy is usually performed with an elliptical incision incorporating NAC and liberal amount of skin. In patients undergoing mastectomy without reconstruction the aim is to remove all redundant skin and leave chest wall as at as possible. By contrast in patients planned for conservative mastectomy with immediate recon-

S. V. S. Deo (*) Department of Surgical Oncology, AIIMS and NCI, New Delhi, India

S. ManojGowda Department of Surgical Oncology, AIIMS, New Delhi, India

struction, NAC and as much skin as possible should be preserved with natural anatomical boundaries to improve aesthetic outcomes following primary implant or autologous breast reconstruction.

25.2 Oncological Concepts ofConservative Mastectomy

(i) Rationale for removing Skin and NAC

during standard Mastectomy:

(a) The rationale for removing the NAC as

part of therapeutic mastectomy is due to concern that the cancer may be present in the NAC or the cancer may form de novo in breast tissue retained with in the NAC.

(b) Rationale for removing the skin over the

tumour is to prevent any chance of leaving behind the breast tissue harbouring tumour cells.

(ii) Oncological considerations in Conserva-

tive Mastectomies:

It should be noted that a well conducted conservative mastectomy (CM), will remove all the breast tissue including the tissue present behind the NAC complex. In a properly selected case, the local recurrence rate of conservative mastectomy equals to that of the modied radical mastectomy [1]. However, cases with extension of tumour

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into the skin and NAC should be carefully excluded from conservative mastectomy group.

25.3 Conservative Mastectomy

CM incorporates removal of entire breast parenchyma, sparing skin or in selected cases NAC.Three techniques of CM are described:

1. Skin sparing mastectomy (SSM),

2. Nipple sparing mastectomy (NSM), and

3. Skin reducing mastectomy (SRM)

25.4 Surgical Anatomy Pertaining toConservative Mastectomy

Mammary gland is located in between the anterior lamina (premammary layer) and posterior lamina (retromammary layer) of supercial facia. External to anterior lamina, there is celluloadipose layer, which varies in thickness from person to person. Below the lamina there are large axial vessels from where vertical branches branch off towards the subdermal plexus. Cooper’s ligament pass from anterior surface of mammary gland to the supercial lamina. Anatomical borders of mammary gland are:

25.5 Patient Selection forConservative Mastectomy

1. SSM Indications Contraindications

1. Extensive ductal carcinoma in situ (DCIS) with nipple discharge/DCIS close to nipple

2. Multifocal/multicentric early breast cancer

3. Positive retro areolar frozen section during NSM

2. NSM

Indications Contraindications

1. Tumour related factors:

(a) Extensive DCIS (b) Multifocal/

Multicenteric early breast cancer

surgery (BCS) leading to predicted bad cosmesis

2. Patient related factors:

(a) Risk reducing

mastectomy

(BRCA1/2 carriers) (b) Patient refuses BCS (c) Contraindication to

radiotherapy

1. Locally advanced breast cancer/ inammatory carcinoma

2. Smoking (relative contraindication)

1. Absolute:

(a) Locally advanced

breast cancer/ inammatory

carcinoma (b) NAC involvement (c) Paget’s disease of

nipple (d) Tumour<2cm

from nipple

2. Relative: (a) Previous RT,

smoking, DM (b) Large Ptotic

breast

1. Superior: Large infraclavicular muscle bundle

2. Medial: Mid sternal line

3. Lateral: Front edge of latissimus dorsi

4. Inferior: Lower edge of pectoralis major on 6th rib. This border is important due to the presence of inframammary fold, an area where supercial facia joins the deep pectoralis fascia.

Arterial supply of NAC is by the subareolar plexus formed by perforating branches of four arteries: Internal mammary artery, external mammary artery, anterior medial intercostal perforators, and anterior lateral intercostal perforators. Venous outow is through perforating veins of internal mammary, intercostal veins and axillary veins. Detailed anatomy is described elsewhere in the book.

25.6 Skin Sparing Mastectomy (SSM)

SSM was rst described by Toth, Lappert, and Kroll in 1991 [2]. SSM involves the removal of entire breast tissue, saving the breast skin and removal of the NAC and any area with previous surgical biopsy incisions.

Classication of SSM Carlson classied SSM in 1997 based on surgical approach and previous biopsy scar if any (Fig.25.1) [3]:

1. Type 1 SSM: Only NAC removed. Peri-

areolar incision is used. Commonly indicated in prophylactic mastectomy and for nonpalpable cancers. In patients with small diameter areola, a lateral extension or tennis

Type IType II

25 Skin Sparing Mastectomy andNipple Areola Sparing Mastectomy

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racquet incision is used to improve exposure (Fig.25.2).

2. Type 2 SSM: Used when a supercial tumour

or previous surgery scar is in proximity to areola. NAC, skin overlying supercial tumours and previous biopsy incision are removed in continuity with NAC.

3. Type 3 SSM: Used when a supercial tumour

or previous incision is remote from the areola.

Type III Type IV

NAC, skin overlying supercial tumours and previous biopsy incision removed without intervening skin. Care must be taken to ensure the viability of intervening skin.

4. Type 4 SSM: NAC removed with an inverted

or reduction pattern skin incision. Used in large ptotic breasts when a reduction is planned on opposite breast.

Fig. 25.1 Carlson classication of types of SSM

185

Fig. 25.2 (a) Preoperative image of a patient with multicentric DCIS in left breast (b) Skin sparing mastectomy with tennis racquet incision (c) marking for extended LD ap recon (d) Final outcome after LD ap reconstruction

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25.7 Nipple Sparing Mastectomy (NSM)

NSM involves removal of all breast tissue while preserving the skin of breast, NAC, and inframammary fold.

Incisions: Seven basic types of incisions are

used for NSM (Fig.25.3).

(a) Skin sparing dissection of nipple skin as a

free graft with dissection and removal of nipple duct tissue.

Fig. 25.3 Various incisions for NSM (Left breast). (a) Peri-areolar incision, (b) Upper peri-areolar, (c) Upper peri-areolar with lateral extension, (d) Lower peri-areolar

with inferior extension, (e) Trans nipple, (f) Trans areolar, (g) Inframammary, (h) Batwing incision

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