Reduction mammoplasty improves breast conservation therapy in patients with macromastia

BACKGROUND: Macromastia has been considered a contraindication to breast conservation therapy because of difficulties with radiation therapy. This study evaluates the feasibility of bilateral reduction mammoplasty as a component of breast conservation therapy for breast cancer patients with pendulous breasts. METHODS: Of 153 patients undergoing reduction mammoplasty at the University of Texas M. D. Anderson Cancer Center, 28 were identified as breast cancer patients with macromastia receiving breast conservation therapy. Median follow-up was 23.8 months. RESULTS: Median patient age was 55 years. Nearly all patients were described as obese. Median weight of the reduction mammoplasty specimen on the cancerous side was 766 g. One patient (4%) required completion mastectomy for inadequate margin control. Major postoperative complications occurred in 2 patients (7%). There were no major postradiation complications. Patient survey revealed a satisfaction rate of 86%. CONCLUSION: Bilateral reduction mammoplasty is a reasonable and safe option for breast cancer patients with macromastia who desire breast conservation therapy.     

缩小整形与保乳术相结合在乳腺癌伴巨乳症病人中的临床应用

目的：评估对乳腺癌伴巨乳症病人行双侧乳房缩小整形术与保乳手术的可行性。方法：我院对105例巨乳症病人作了缩小整形术，对其中9例同时患乳腺癌病人在保乳基础上同时行双侧乳房缩小整形术，中位随访时间为14．2个月。结果：平均年龄45岁，平均切下含肿瘤一侧乳房标本重量为561g，肿瘤大小0．5～3cm。其中1例因切缘阳性行乳房全切除。本组术后没有出现明显的并发症，病人随访显示满意率达87％。结论：对于希望行保乳术的乳腺癌伴巨乳症病人，双侧乳房缩小整形术是可行且安全的一种方法，将是对乳腺肿瘤外科的一种挑战。     

Breast reduction in the irradiated breast: evidence for the role of breast reduction at the time of lumpectomy

Given the high incidence of breast cancer in our society, it is common to encounter patients with macromastia who desire breast reduction after breast-conserving therapy by lumpectomy and radiation. We hypothesize that radiation leads to a significant increase in postoperative complications after breast reduction. All patients with a history of unilateral breast lumpectomy and radiation who subsequently underwent bilateral breast reduction by a single surgeon from 2004 to 2008 were retrospectively reviewed. Outcomes including cellulitis, wound breakdown, seroma, and need for repeat operations were compared between the radiated and nonradiated breast. The Fisher's exact test was used for statistical analysis. Twelve patients (mean age, 57 years) underwent bilateral breast reduction a mean of 86 months after unilateral lumpectomy and radiation. The nonradiated breasts had no complications postoperatively. The radiated breasts had a significant increase in complications with a total of five breasts (42%, p<0.04) having postoperative complications including cellulitis in two breasts, seroma requiring drainage in five breasts, two cases of fat necrosis, and one case of wound dehiscence. This resulted in two admissions for intravenous antibiotics and two repeat operative procedures. Additionally, three patients had significant breast asymmetry or contour deformities after reduction requiring operative revisions. Breast reduction after radiation leads to a significant increase in complications. Given this data, patients with macromastia undergoing breast conservation therapy for cancer should be considered for reduction at the time of lumpectomy and prior to radiation.     

Reduction mammaplasty in the previously radiated breast: is it safe and does it interfere oncologically?

Lumpectomy with axillary dissection followed by irradiation for early breast cancer, also known as breast conservation therapy, offers less radical surgery with similar rates of survival and recurrences. However, following radiation therapy, temporary and permanent, early and late changes of the breast soft tissue can occur. Thus, any subsequent elective surgery can potentially end in disappointment and disaster. The safety of reduction mammaplasty following irradiation and its effect on oncological follow-up are not well known. In this case report, a 39-year-old female patient is presented. Her breast carcinoma was treated with breast conservation therapy plus irradiation, followed by breast reduction using the inferior pedicle technique 2.5 years later. Postoperative healing was uneventful with no postoperative complications and the aesthetic result was satisfactory. We strongly believe that surgery should be delayed until resolution of the early signs of radiotherapy. Regardless of the technique, if surgical steps are performed delicately on appropriately selected patients, reduction mammaplasty can be accomplished safely. Of course, pathological evaluation of the resected material, as well as postoperative mammograms are essential in order to detect any recurrence.     

A Modified Excision for Combined Reduction Mammoplasty and Breast Conservation Therapy in the Treatment of Breast Cancer

Wide local excision combined with postoperative radiotherapy is a useful technique for patients with breast cancer. For patients with macromastia whose tumor is situated in the lower pole of the breast, a breast reduction (keyhole\inverted T pattern ) can be used to achieve wide local excision. However, for patients whose tumor is not in the inferior portion of the breast, and in whom this cancer also is situated close to the skin (requiring excision of skin with a 1-cm margin for oncologic safety), the traditional keyhole pattern cannot be used. A modification of the keyhole pattern\inverted T is described. The pedicle used depends on the site of the tumor. Although the breast scars are in different positions, a similar breast shape as well as symmetry still can be achieved. This is a useful technique for a select subgroup of patients. The outcomes for three patients are presented.     

Therapeutic mammoplasty is an appropriate option in a patient with breast cancer and macromastia

Bilateral reduction mammaplasty in women with breast cancer and macromastia allows appropriate oncological surgical treatment with functional and cosmetic benefits and facilitates postoperative radiation therapy. The surgical approach carried out in three patients with breast cancer and macromastia is discussed.     

下蒂瓣法乳房缩小整形术的效果

目的:探讨下蒂瓣法乳房缩小整形术治疗中重度乳房肥大症的方法及效果。方法:2010年1月至2019年12月,南京医科大学附属妇产医院整形外科对19例女性患者(年龄18~54岁,平均36.2岁)38侧肥大乳房,以Robbins的垂直下蒂瓣术式为基础,结合乳房血供、神经等解剖学进展,进行乳晕设计、下蒂瓣位置等改进。结果:19...     

复合组织下蒂法乳房缩小整形术25例

目的：回顾性总结复合组织下蒂法乳房缩小整形术25例病例资料,探讨复合组织下蒂法乳房缩小整形术手术注意事项及其并发症防治。方法：从2003～2008年5年间,对25例女性乳房肥大患者分别进行手术治疗,方法采用复合组织下蒂法。通过对术中复合组织下蒂的修整及术后乳房外形、乳头乳晕复合体血运、术后瘢痕及乳房感觉等方面观察,分析复合组织下蒂法乳房缩小整形术的术中注意事项及术后并发症的防治策略。结果：25例患者均取得了较好的效果,无乳头乳晕复合体血运障碍发生。结论：复合组织下蒂法乳房缩小整形术是较好的乳房缩小术式,良好的术前设计及术中调整是确保手术成功的关键。     

Effects of radiation therapy on pedicled transverse rectus abdominis myocutaneous flap breast reconstruction

Radiotherapy is being increasingly used in the treatment of breast cancer after breast conservation as well as after total mastectomy. The effect of radiation on pedicled transverse rectus abdominis myocutaneous (TRAM) flap reconstruction is examined. A retrospective review of 199 patients undergoing 232 pedicled TRAM flap reconstructions was performed to identify patients who received radiotherapy. Patients were stratified into 5 groups by the use and timing of radiation as well as the timing of the reconstruction. The overall esthetic appearances were assessed by blinded reviewers. The incidence of flap complications was 34.2% in the immediate nonirradiated group, 10.7% in the delayed nonirradiated group, 44% in the post-TRAM radiation group, 60% in the immediate pre-TRAM radiation group, and 33% in the delayed pre-TRAM radiation group (P = 0.010). Patients who had immediate TRAM flap reconstruction and did not receive radiation had a better global esthetic outcome (P < 0.001) than the other 4 groups. The esthetic outcome was similar whether radiation was administered pre- or post-TRAM flap reconstruction. Radiation therapy has a deleterious effect on the esthetic outcome of pedicled TRAM flap reconstruction whether administered before or after reconstruction. There was no difference in TRAM flap complications in any of the groups that received radiation therapy.     

Breast conservation surgery using nipple-areolar resection for central breast cancers

HYPOTHESIS: Resection of the nipple-areolar complex (NAC) for central breast cancers that involve the nipple or areola, with postoperative radiation therapy, adheres to the oncologic principles established for breast conservation surgery of other breast cancers. Good or excellent cosmetic results can be achieved. The rate of ipsilateral breast recurrence will be similar to that seen with peripheral breast cancers. The indications for breast conservation surgery can be safely extended to include patients with breast cancers that involve the NAC. DESIGN: Retrospective medical record review; follow-up patient questionnaire. SETTING: Community teaching hospital. PATIENTS: Fifteen patients, aged 46 to 88 years, whose central breast cancers involved the NAC precluding preservation of the NAC. INTERVENTIONS: Nipple-areolar complex resection, postoperative radiation therapy. MAIN OUTCOME MEASURES: Ipsilateral breast recurrence, survival, cosmesis. RESULTS: Ten patients had subareolar cancers that directly involved the nipple or areola; 5 patients had Paget disease of the nipple. Average tumor size was 1.6 cm (range, 0.2-3.5 cm). With a mean follow-up of 32 months (range, 4-109 months), there has been only 1 recurrence (7%), which was treated successfully by modified radical mastectomy. All 15 patients are alive and free of disease. Cosmetic results are satisfactory to excellent, as judged by both the patients and the surgeons. CONCLUSIONS: Nipple-areolar complex resection for central subareolar cancers that directly involve the NAC, as well as for Paget disease of the nipple, extends the indications for breast conservation in other areas of the breast, and with acceptable cosmesis.     

Maximizing breast projection with combined free nipple graft reduction mammaplasty and back-folded dermaglandular inferior pedicle

Standard technique for free nipple reduction mammoplasty was described by Thorek in 1922. In contrast to its effectiveness, late postoperative results included insufficient projection of the breast and the nipple-areola region. We describe a modification of this well recognized technique in order to increase central mound projection and improve nipple-areola projection by suturing the dermaglandular flap to the pectoralis major muscle by back-folding the pedicle. Twenty macromastia patients were subjected to free-nipple-graft reduction mammoplasty in combination with inferior pedicled dermaglandular reduction mammaplasty of a total of 40 breasts with this technique between years 2000 and 2004. Preoperative planning for inferior pedicled dermaglandular flap was made using the "Wise" pattern for large breasts. The variation of the technique comes from using the back-folded deepithelialized inferior pedicled dermaglandular flap for increasing the breast mound projection by fixating the demaglandular flap with absorbable sutures to the underlying pectoralis major muscle fascia and the costal cartilage pericondrium. By applying this technique, increased projection during the early preoperative and late postoperative periods are achieved, compared with patients who only underwent free-nipple- graft reduction mammoplasty.     

环乳晕切口下蒂瓣法矫治巨大乳房

目的:探讨环乳晕切口下蒂瓣矫正特别巨大乳房的临床效果。方法:采取环乳晕切口,以部分去表皮的下蒂瓣为基础,切除乳头乳晕上方、外侧大部分腺体皮肤及内侧部分腺体皮肤组织,上提下蒂瓣,固定重塑乳房腺体形态,再将下蒂两侧的皮肤均匀拉拢,覆盖下蒂瓣,切除多余皮肤,使之形成不超过乳房下皱襞的斜形短切口,乳晕及周围的皮肤真皮层辐射状环缩缝合,缝合皮肤。结果:10例20只乳房,单侧乳房组织平均切除量为1 050g,最大2 200g。随访6~12个月,无乳头坏死、感觉良好,外形饱满。患者对乳房形态、对称性、乳晕大小形状、乳头乳晕感觉及切口瘢痕的满意率分别为100%。结论:环乳晕切口下蒂瓣的巨大乳房缩小整形术,组织切除量大,瘢痕短,并发症少,是一种较好的巨大乳房缩小术式。     

A comparison of the LeJour and Wise pattern methods of breast reduction

Supporters of the vertical mammoplasty state the resultant breast shape and scar are superior to the Wise pattern breast reduction. This study contains a comparison of the LeJour vertical reduction with the Wise pattern reduction by analysis of pre- and postoperative photographs, as well as a retrospective review comparing operative times, blood loss, complications, and a postoperative patient questionnaire. Of the 112 women who had moderate to large reductions (>500 g/breast) between 1999 and 2002, 65 subjects had adequate standard perioperative photographs. Esthetic appearance, symmetry, nipple quality, and scarring were assessed using a Likert scale (10 = superior, 1 = poor) by 30 evaluators. Based on the photographic analysis, there is no difference in the esthetic outcome between the vertical reduction mammaplasty and the inferior pedicle Wise pattern mammaplasty. Additionally, this study indicates that vertical patients with moderate to large reductions have a significantly higher rate of complications when their body mass index is greater than 30 kg/m.     

No-vertical-scar inferior pedicle breast reduction using the dermal suspension sling

Background

The authors previously presented favorable outcomes with the use of the horizontal dermal suspension sling and plication of the inferior pedicle in reduction mammaplasty surgical cases. We propose a modification to this technique tailored to patients with moderate to severe ptosis. The modification avoids the vertical scar inherent to the inverted T pattern.

Methods

The surgical technique utilizes portions of the dermal suspension and plication technique previously described by the authors. Minor modifications were made to take advantage of the vertical excess of skin found in patients with moderate to severe macromastia and ptotic breasts. The modification leads to a superior skin flap that drapes the inferior pedicle and newly constructed breast mound, resulting in a single inframammary scar.

Results

Thirty-eight women have undergone breast reduction using the vertical scarless inferior pedicle with horizontal dermal suspension and plication surgical technique. Breast projection and shape were sustained during follow-up with positive aesthetic results; the median follow–up time was 7 months.

Conclusions

The modifications to our surgical technique allowed for an improved appearance in the postoperative breast scar and in the overall cosmetic outcome in patients who underwent large-volume breast reductions. Level of Evidence: IV, therapeutic study     

Avoiding free nipple grafting with the inferior pedicle technique

In cases of severe macromastia, the free nipple graft technique has been the traditional alternative to pedicle transposition. Distress over nipple survival in large reduction mammaplasty and long pedicle transposition is largely responsible for this.A retrospective investigation of the records of 142 reduction mammaplasty patients was carried out to determine whether nipple survival or overall complication rates were significantly different in patients undergoing larger (>1500 g per side) as compared with smaller reductions (< 1500 g per side). The 2 patient groups were compared with respect to mild or severe complications. Data were analyzed using Fisher exact test and 2-sample t tests. A P value of < 0.05 was considered statistically significant. No patient in either group had total nipple loss. There were no statistically significant differences in major or minor complications between the 2 groups.In our experience, the inferior pedicle, Wise pattern reduction is a reliable and predictable method of reduction, appropriate for all breast sizes and pedicle lengths.     

Latissimus dorsi reconstruction: a good option for patients with failed breast conservation therapy

The majority of patients with breast carcinoma are being treated with breast conservation therapy (BCT): lumpectomy and postoperative radiation. Local recurrence reported at 8% to 11% is often treated with salvage mastectomy. This has led to a growing group of patients requiring breast reconstruction after failed BCT. Reluctance to use the latissimus dorsi flap (LDF) has resulted from reports of high implant capsular contracture rates. We present a series of 12 patients who underwent LDF reconstruction after the development of recurrent breast cancer after BCT. All 12 patients had a satisfactory esthetic result. Despite previous radiation, the capsular contracture rate was 12.5% (median follow up, 50 months; range, 20-93 months). The most common complication was donor site seroma in 25% (3 of 12) of cases. The LDF yielded satisfactory esthetic results with a low capsular contracture rate. Despite prior radiation, LDF remains a good option for breast reconstruction after failure of BCT.     

Bilateral Reduction Mammaplasty for Immediate Breast Conservation Surgery Reconstruction and Intraoperative Radiotherapy: A Preliminary Report

Background Breast conservation surgery and postoperative radiotherapy are widely accepted as the treatment of choice for patients with early breast cancer. Despite its oncologic benefits, the radiotherapy may cause unpredictable outcomes in soft tissues, especially in patients undergoing breast reconstruction. Described recently, intraoperative irradiation (IORT) has been indicated for selected patients as an alternative to radiotherapy with fewer adverse local effects. Clinical use of reduction mammaplasty (RM) techniques in oncologic breast surgery has been described previously. However, no previous studies have mentioned its application after breast conservation surgery and IORT. Methods The authors used RM to reconstruct a partial breast tissue defect secondary to breast conservation surgery followed by IORT treatment in a 46-year-old patient with an 11-mm invasive ductal carcinoma between the superior internal quadrants of the right breast. Results Satisfactory breast volume and shape were achieved, and no immediate or late complications were observed. After 2 postoperative years, no evidence of fat necrosis, tumor recurrence, or tissue volume loss was observed. Conclusion The initial data indicate that RM in the setting of breast conservation surgery reconstruction and IORT is feasible. With appropriate patient selection, respecting indications and limitations, RM has its place among the various reconstructive techniques. Additional studies with larger clinical series and longer follow-up periods are necessary to analyze the precise IORT effects in patients submitted to immediate breast conservation surgery reconstruction.     

Oncoplastic surgery and cancer relapses: Cosmetic and oncological results in 489 patients

During the past 20 years, breast conservation has become the preferred treatment modality for breast carcinoma, and in recent times there is an increased expectation from breast cancer patients to retain their “normal breast appearance”. For large tumor-to-breast ratio excision, the subspecialty of oncoplastic surgery is born, helping to achieve a good oncologic and esthetic result. In our study we have considered 767 patients undergone a mastectomy or quadrantectomy, and especially 489 undergone quadrantectomy. We have used our protocol for breast reshaping and analyzed our data in terms of oncologic safety and esthetic results. Considering the lesions, they were placed like this: 214 (44%) in the SEQ, 58 lesions (12%) in the SIQ, 54 lesions (11%) in the IEQ, 24 lesions (5%) in the IIQ, 45 lesions (9%) respectively in the CQ and between the SQ, 39 lesions (8%) between the EQ, 5 lesions (1%) respectively between the internal quadrants and between the inferior quadrants. We have chosen simple breast reshapings in case of operations on the superior quadrants, while, in case of operations on the inferior quadrants, we have chosen complex techniques, like reshapings according to a “key hole” reductive mammaplasty, which requires also a contralateral reshaping. We have done simple and monolateral reshapings respectively in 372 (76%) and 296 (60.5%) cases. We have had early complications in 98 (20%) cases: 12 infections (2.4%), 10 hematomas (2%), 11 seromas (2.2%), 65 liponecrosis. As late complications, we have found scar retractions and minus areas in 20 cases (4.08%), while we have found asymmetries and bigger deformities in 34 cases (6.95%). We have not found any cancer relapse after one year of follow up, while we have had 3 cases of relapse (0.6%) after 5 years of follow up, respectively after 5, 4 and 2 years. This result has to be attributed to our preoperatory project of surgery derived from many factors, among which stands out the MRI done in all the cases. We think that an immediate breast reshaping following quadrantectomy is the best esthetic and psychologic option for breast cancer patients.     

Superior-medial dermoglandular pedicle reduction mammaplasty for immediate conservative breast surgery reconstruction: technical aspects and outcome

BACKGROUND: Reduction mammaplasty procedures and especially the superior-medial dermoglandular pedicle (SMDP) technique are frequently used for esthetic objectives; however, few reports have been available regarding its application following conservative breast surgery reconstruction. The purpose of this study is to analyze the feasibility of the technique and describe the surgical planning and its outcome following oncologic surgery. METHODS: Thirty-nine patients underwent immediate bilateral SMDP breast reconstructions. Mean time of follow-up was 20 months. SMDP was indicated to reconstruct inferior breast defects in patients with enough remaining breast tissue. Reconstructed (RB) and opposite (OB) breast complications were evaluated and information on esthetic result and patient satisfaction was collected. RESULTS: Tumors (51.2%) measured 2 cm or less (T1) and 66.6% were located in the lower outer quadrants. Mean change in nipple position was 12.5 cm. Immediate RB complications occurred in 8 patients (20.5%), with skin necrosis in 3 (7.6%), infection in 2 (5.1%), dehiscence in 2 (5.1%), and partial areola necrosis in 1 (2.5%) patient. Late complications were observed in 7.6%. All late complications were observed after adjuvant radiotherapy. The cosmetic result was considered to be good or very good in 84.6%, and the majority of patients were either very satisfied or satisfied. All complications were treated by conservative approach. CONCLUSION: SMDP is a reliable technique and should be given primary consideration in cases of lower quadrant reconstruction. The success of the procedure depends on patient selection, coordinated planning, and careful intraoperative management.     

修复韧带和保留T4肋间神经的巨乳缩小术

目的 探讨一种能保留T4肋间神经和血管韧带的重塑锥体形乳房的巨乳缩小术.方法 对18例轻、中、重度巨乳者,乳腺组织切除选择在乳房中线上、下极部形成中央蒂,蒂部保留了内外侧深浅韧带、T4肋间神经外侧皮支深浅支.蒂部旋转移位固定,缩小乳房基底,增强韧带张力.二瓣法旋转皮瓣从内到外缩小乳房.保留T4肋间神经走行区真皮层以保护其浅支,旋转固定后起到纤维隔的作用.结果 术后乳头乳晕血供和感觉良好,乳房外形挺拔.随访3个月至2年,平均7个月.随访达1年者,瘢痕已不明显,外观无明显改变,患者满意.结论 修复韧带和保留T4肋间神经的巨乳缩小术设计简单,手术时间缩短,术后乳房外形挺拔稳定.