Oncoplastic surgery combining partial mastectomy and immediate volume replacement using a thoracodorsal adipofascial cutaneous flap with a crescent-shaped dermis

Purpose

The treatment of early breast cancer using breast-conserving therapy commonly ensures local control and acceptable cosmetic results. We herein report a useful technique, including the use of a thoracodorsal adipofascial cutaneous flap for reconstructing defects in the outer quadrant area after partial mastectomy, which achieved excellent results.

Methods

We performed partial mastectomy followed by immediate volume replacement using a modified thoracodorsal adipofascial cutaneous flap with a crescent-shaped dermis in ten patients.

Results

The modified oncoplastic technique was performed without any complications in all patients. Sufficient blood flow to the cutaneous flap with the crescent-shaped dermis was visualized in two patients during the operation after the injection of indocyanine green. The oncological and cosmetic results were excellent to good in these patients.

Conclusions

Oncoplastic surgery using a modified thoracodorsal adipofascial flap with a crescent-shaped dermis was successfully performed in patients with early cancer lesions in the outer quadrant, and the cosmetic results obtained were excellent.     

The inferior pedicle flap used as “filler” in breast conservative therapy

Background

Oncoplastic techniques are capable of correcting or preventing morphological changes of the breast undergoing conservative surgery with the aim of improving the cosmetic outcome and therefore the quality of life. Literature reports several post-conservative surgical oncoplastic procedures using autologous or local glandular tissue.

Methods

Authors report their experience with 24 breast cancer patients (localized in upper and central quadrants). The flap used, described by Ribeiro, is a dermal–adiposal–glandular flap with an inferior pedicle prepared utilizing the lower breast pole. In the six cases, we have performed an immediate nipple reconstruction using C–V flap, sculpted with a skin island on the Ribeiro flap, and areola tattooing. The mean age was 56.3 years (range, 35 to 74 years), and mean follow-up was 26 months (12 to 40 months). The level of patient satisfaction was rated on a 1 (low) to 5 (high) scale, before and after radiotherapy (12 months).

Results

In all patients, no depression of the superior quadrants was noted, as well as no morphological change noted in the “oncological” breast contour and that of the “cosmetic” contralateral breast, with mean satisfaction score of 4.2. The degree of satisfaction symmetry, assessed at 1 year from radiotherapy, had a mean satisfaction score of 4.0.

Conclusions

The use of the Ribeiro flap as a filler in appropriate and selected indications can represent a good alternative to the many reconstructive methods available for partial breast resection. Level of Evidence: Level IV, therapeutic study.     

Results from the American Society of Breast Surgeons Oncoplastic Surgery Committee 2017 Survey: Current Practice and Future Directions

Introduction

Oncoplastic surgery is emerging as a validated, safe, patient-centric approach to breast cancer surgery in the United States. The American Society of Breast Surgeons Oncoplastic Surgery Committee (ASBrS-OSC) conducted a survey to assess the scope of practice and level of interest in oncoplastic surgery among its members. Furthermore, the group sought to identify barriers to incorporating oncoplastic skills in a surgeon’s practice.

Methods

A 10-question survey was administered in March 2017 to the entire ASBrS membership using an online format. Three solicitations were sent. Unique identifiers allowed a single response.

Results

Of the 2655 surveys sent out, 708 members responded. Nearly all (99%) respondents had at least some interest in oncoplastic surgery. The current rates of performing nipple-sparing mastectomy, adjacent tissue transfer, and breast reduction with lumpectomy were 80, 60, and 51%, respectively. A minority of respondents reported independently performing breast reductions/mammaplasties (19%) or contralateral symmetrization (10%). Barriers to learning oncoplastic surgery included surgeon’s time and access to oncoplastic educational material/courses. Most respondents felt that training courses and videos may allow them to better incorporate oncoplastic techniques in their practices.

Conclusions

The interest in oncoplastic surgery among U.S. surgeons is significant, yet there are barriers to incorporate these surgical techniques into a breast surgeon’s practice. As professional organizations provide access to effective training and enduring educational resources, breast surgeons will be enabled to develop their oncoplastic skill set and safely offer these techniques to their patients.

     

Outcome of oncoplastic breast surgery in 90 prospective patients

Background

Oncoplastic breast surgery refers to a wide range of techniques with a parallel goal of safely removing all malignant breast tissue while achieving the best possible esthetic outcome. We report the results of our oncoplastic breast operations from 2005 to 2007.

Methods

Ninety selected breast cancer patients were treated with a variety of oncoplastic operations. The patients were prospectively monitored. Radiotherapy and systemic adjuvant treatment were given according to national guidelines.

Results

Fifteen patients had an immediate surgical complication, of which 8 required a reoperation. Eleven patients had an inadequate surgical margin and required a completion mastectomy. During a median follow-up of 26 months no local or regional recurrences were noticed. Three patients developed distant metastases.

Conclusions

Oncoplastic breast surgery offers tools for breast conservation in patients otherwise destined for mastectomy or poor esthetic outcome. Despite the high proportion of patients in this series with large-volume ductal carcinoma in situ (DCIS) or extensive intraductal component, the use of oncoplastic techniques achieved negative margins with acceptable cosmetic results in the majority (84%) of patients.     

Clinical Series of Oncoplastic Mastopexy to Optimize Cosmesis of Large-Volume Resections for Breast Conservation

Background

Oncoplastic mastopexy has been popularized as a method to hide the cosmetic effects of central or large-volume resections associated with breast conservation surgery for breast cancer.

Materials and Methods

This review was undertaken to study the uses and limitations of these techniques in providing adequate breast conservation lumpectomy for breast cancer of any stage in a single surgeon’s practice. A review of breast cancer cases March 2004 through December 2009 were analyzed for the use of oncoplastic reconstruction in breast conservation surgery.

Results

A total of 167 patients had lumpectomies during this period associated with oncoplastic mastopexy reconstruction. The average age was 55.6 years with a range of 33–85 years. Stage 0 breast cancer accounted for 33 cases (19.8%), and 134 cases were invasive cancers stages 1–3 (stage 1, 34.1%; stage 2, 30.6%; and stage 3, 15.6%). The most common oncoplastic techniques used were, in order of frequency: batwing mastopexy, parallelogram mastopexy, and Modified Wise pattern mastopexy. Positive or close margins (≤2 mm) were present in 37 of 167 cases (22%). Positive margins were most associated with higher stage, positive nodes, positive lymphovascular invasion (LVI), use of neoadjuvant chemotherapy, and larger initial T stage, positive estrogen receptor (ER), and younger age. Of these higher stage, node positive, and use of neoadjuvant chemotherapy were statistically significant in this small series (P values = 0.034, 0.016, and 0.022, respectively). Ki-67 and HER2 status were not associated with positive margins. Positive margins were manageable by local re-excision of a solitary face of the prior resection wall in more than 2/3 of cases to achieve negative pathologic margins. Only 11 of 167 required mastectomy because of failure to achieve adequate margins for oncologic control.

Conclusions

Oncoplastic mastopexy allows the surgeon to address large tumors or tumors in cosmetically difficult sites adequately for breast conservation. Careful margin marking and re-excision of close or positive margins is still often feasible to achieve adequate negative margin with acceptable cosmesis in spite of the large initial volumes of resection.     

Thoracodorsal artery perforator (TDAP) flap in immediate breast reconstruction and the role of preoperative mapping: a clinical experience

Background

Oncoplastic approach to reconstruct partial breast resection is always challenging. Nowadays, pedicle perforator flaps have been described for partial breast mastectomy reconstruction

Methods

The study comprised all patients who received partial breast resection due to external quadrant breast cancers and who were reconstructed with thoracodorsal perforator flap between August 2010 and August 2011. Twenty-two patients received the thoracodorsal artery perforator (TDAP) for breast reconstruction. The mean surgical time (including oncology resection and reconstruction) was 160 min. Eleven patients (50 %) underwent Doppler and Computed tomographic angiography (AngioCT) presurgical planning, the rest Doppler alone.

Results

The mean stay was 3.27 days. Seroma formation in the donor site was found in five cases. No flap failures were detected. No breast size changes were observed after surgical and radiotherapy treatment.

Conclusions

We conclude that TDAP flap is suitable for partial breast reconstruction (quadrantectomy) in moderate breast cancer. Level of Evidence: Level IV, therapeutic study.     

Oncoplastic reduction mammaplasty,an effective and safe method of breast conservation

INTRODUCTION

Oncoplastic breast conserving surgery (BCS) can enhance both cosmetic and oncologic breast cancer outcomes. This study evaluates the outcomes and complications associated with oncoplastic reduction mammaplasty performed by surgical breast oncologists.

Neoareolar Wise Pattern Reduction in Patients Requiring Central Partial Mastectomy

Background

Oncoplastic surgery integrates breast cancer resection with tissue transfer techniques to preserve breast cosmesis. With the novel methods developed in the oncoplastic movement, we are capable of performing larger resections with clear margins while minimizing the cosmetic deformity caused by more traditional surgical techniques. Central and retroareolar breast cancers continue to be a cosmetic challenge because removal of the central portion of the breast can be particularly deforming.

Methods

An inferior pedicle Wise pattern reduction mammoplasty is performed. The inferior pedicle is de-epithelized except for a circular disc of skin superiorly, which will become the neoareola. The breast cancer is removed along with the nipple–areolar complex (NAC). Part of the NAC may be preserved if tumor resection can be performed with sufficient margins. A standard reduction is performed, removing more tissue as indicated by cosmetic need. The reduction is completed in standard fashion using the neoareola as a replacement for the previously removed NAC.

Results

The video demonstrates the feasibility of this technique, highlighting both preservation of breast shape and contour, and creation of a substitute for the NAC.

Discussion

Complex reduction techniques have been reported in the literature as feasible options for breast conservation surgery. The neoareolar Wise pattern reduction mammoplasty offers an option that allows for oncologically sound cancer surgery while simultaneously preserving cosmesis.     

Trends in Lumpectomy and Oncoplastic Breast-Conserving Surgery in the US, 2011–2016

Background

Oncoplastic breast surgery aims to optimize efficacy of surgical resection and cosmesis to maximize patient satisfaction; however, despite the benefits, oncoplastic techniques have not been widely adopted in the US. This study examined trends in the incidence of lumpectomy (partial mastectomy) with or without oncoplastic techniques from 2011 to 2016.

Methods

This was a retrospective analysis of claims from the Optum Clinformatics database (January 2010–March 2017). Female patients with no history of breast surgery in the prior year were categorized into three independent cohorts: isolated lumpectomy (Lx), lumpectomy with tissue transfer (LxTT), or lumpectomy with mammaplasty and/or mastopexy (LxMM). Oncoplastic techniques (in cohorts two and three) were performed at either time of the initial lumpectomy or during 90-day follow-up.

Results

Overall, 19,253 patients met the inclusion criteria (91.1% Lx, 5.2% LxTT, and 3.7% LxMM). Significantly fewer patients with Lx had a family history of breast cancer compared with patients with oncoplastic techniques (26.4% vs. 33.7% and 37.9%, respectively; p?<?0.001). The incidence of Lx declined significantly from 2011 (92.9%) to 2016 (88.1%), while LxTT and LxMM increased from 4.2 to 7.2% and 2.8 to 4.7%, respectively (both p?<?0.001). The greatest utilization of oncoplastic techniques was observed in the Pacific census division (19.2%), while lowest utilization was in the East South Central division (3.2%; p?<?0.001).

Conclusions

While increased adoption of oncoplastic techniques was observed, the compound annual growth rate remained below 10% and varied significantly by region. Further adoption of oncoplastic techniques is necessary to improve cosmetic outcomes and patient satisfaction following breast-conserving surgery.

     

Tumoradaptierte Reduktion der Brust

Background

Tumor-adapted breast reduction is an oncoplastic surgical procedure which allows large volume excision of malignant tumors of the breast while providing excellent aesthetic outcomes.

Aim and methods

This article describes the various techniques for tumor-adapted breast reduction and the associated complications. There are still concerns about oncological safety and limitations with respect to adjuvant therapy in the treatment concept of malignant neoplasms of the breast.

Discussion

In women with macromastia or ptotic breasts, the incorporation of tumor-adapted reduction techniques in the reconstruction of partial mastectomy defects allows reshaping of the remaining breast tissue and skin to maintain or improve aesthetic results. The breast-conserving therapy following whole breast irradiation is the standard of care in the treatment of malignant breast lesions. Breast radiotherapy can result in alterations to the skin and parenchyma and a further volume reduction in up to 10–20?%. To reduce complications oncoplastic breast reduction should be performed before breast irradiation. In most cases a contralateral breast reduction is required for symmetry which can be performed simultaneously or at a later time. More than 80?% of patients reported satisfactory or better outcomes.

Results

Selection of the tumor-adapted reduction technique used is based on breast volume and shape as well as tumor location. Furthermore, surgeon skills and individual preferences play a role in the choice of approach. For an assessment of oncological safety, long-term follow-up data are lacking. The aim of an oncoplastic R0 breast reduction should primarily be focused on the oncological and not on the aesthetic outcome.

     

Cosmesis Outcomes for Sector Resection for Ductal Carcinoma In Situ (DCIS)

Background

Oncoplastic surgery allows wide excision of pathology with greater margins in breast-conserving surgery (BCS) without compromising the shape of the breast. Oncoplastic techniques were used to remove a sector of tissue to fully excise ductal carcinoma in situ (DCIS) with a large margin, with relocation of the breast tissue to maintain normal shape. We assessed patient satisfaction with breast cosmesis after surgery as well as patients’ psychosocial well-being.

Methods

A retrospective study was conducted of patients who underwent BCS alone for pure DCIS between 1995 and 2009, performed by two surgeons. The BREAST-Q questionnaire was modified for partial mastectomy to gain patients’ perspectives on cosmetic outcomes and satisfaction after surgery. The questionnaire also assessed the emotional and sexual well-being of the patients.

Results

Overall, there was a high level of patient satisfaction, with 52 of 55 women (94 %) satisfied or very satisfied with their cosmetic outcome after partial mastectomy.

Conclusions

Oncoplastic techniques used for partial mastectomies to provide greater oncological clearance resulted in a high level of patient satisfaction after surgery.     

Oncoplastic Breast Surgery

Breast Surgery is now a recognized subspecialty of General Surgery abroad with structured training for designated ‘Oncoplastic Breast Surgeons’. Oncoplastic Breast surgery is probably one of the most interesting and challenging new developments over the past 20 years. The aims of Oncoplastic surgery are wide local excision of the cancer coupled with partial reconstruction of the defect to achieve a cosmetically acceptable result. Avoidance of mastectomy and consequent reduction of psychological morbidity are the principal goals in the development of various oncoplastic techniques. The use of plastic surgical techniques not only ensures good cosmetic outcome, but also allows the cancer surgeon to remove the tumour with greater volume of surrounding tissue, thus extending the boundaries of breast conserving surgery. Proper patient selection and careful planning after proper radiological and clinical assessment are the two essential prerequisites before undertaking oncoplastic breast surgery. Oncoplastic surgery involves both volume displacement and volume replacement techniques. Some commonly used volume displacement procedures are described in the article. The need for adjustment of contralateral breast should also be anticipated at the time of planning breast conserving surgery, which can be done either at the same time as breast cancer surgery or as a delayed setting.     

Basic Oncoplastic Surgery for Breast Conservation: Tips and Techniques

Background

The demand for oncoplastic breast surgery has increased significantly in recent years. However, these procedures are often not taught in standard training for breast surgeons, and a simple guide for surgeons to start performing basic oncoplastic breast surgery techniques is not available.

Methods

The basic concepts of oncoplastic breast surgery and the tools needed prior to starting these types of procedures are discussed, and the procedure, in a stepwise pattern, for the building blocks of oncoplastic techniques is outlined.

Results

The importance of oncoplastics from a quality of life and oncologic standpoint are described. Key concepts are defined and the decision on when it is necessary to consult reconstructive plastic surgery is delineated. The basic necessities for oncoplastic breast surgery, including patient photographs, important intraoperative tools, anatomic knowledge, and patient selection, are discussed. The building block procedures include aesthetic scar placement, parenchymal closure, deepithelialization, and donut therapeutic mastopexy, which are described in detail.

Conclusions

Oncoplastic breast surgery techniques and clinical reasoning build on one another, allowing a surgeon to move from level I to level II oncoplastic procedures. Even the most basic level I breast conservation oncoplastic skills can improve a patient’s cosmetic outcome and are easily learned by a general surgeon.

     

Level 2 Oncoplastic Surgery for Lower Inner Quadrant Breast Cancers: The LIQ-V Mammoplasty

Background

Oncoplastic surgical techniques offer an option of breast conserving surgery for larger tumors with the use of glandular reshaping to prevent postoperative deformity. A technique for the excision of lower inner quadrant tumors via a V incision is described, the lower-inner quadrant-V (LIQ-V) mammoplasty, and the results of a pilot study are reported.

Methods

Retrospective collection of pre- and postoperative data was collected from patients undergoing a LIQ-V mammoplasty for a LIQ tumor.

Results

Twenty-two patients were operated on between 2004 and 2011 at a mean age of 58 years. The mean follow-up was 55 months. The mean resection weight was 101 g for tumors ranging in size from 4 to 31 mm. The margins were clear in 95 % of cases. There was one case of local recurrence and metastatic disease. The cosmetic outcome was judged as excellent in 68 % of cases, and no patient required further ipsilateral or contralateral symmetrizing surgery.

Discussion

The deformity often associated with tumors of the LIQ is adequately addressed by this new technique. It has a complication rate comparable to other mammoplasty series and a high rate of clear resection margins. Many oncoplastic surgery techniques are based on inverted T mammoplasty, but these are not suited for all tumor locations. The LIQ-V mammoplasty is an adaptation of the standard techniques that best suit the LIQ. It is oncologically safe and provides disease-free margins, and although the resection volumes are large, the cosmetic outcome is not compromised.     

Breast Cancer Mastectomy Trends Between 2006 and 2010: Association with Magnetic Resonance Imaging, Immediate Breast Reconstruction, and Hospital Volume

Purpose

Analysis of mastectomy rates in breast cancer patients diagnosed between 2006 and 2010 in Germany with focus on impact of breast magnetic resonance imaging (MRI), immediate breast reconstruction (IBR) rates, and hospital volume as possible influencing factors of mastectomy rates.

Methods

Data of a voluntary monitored benchmarking project were used to evaluate mastectomy trends across time in an unselected cohort of breast cancer patients. We used univariate and multivariate logistic regression analysis to identify predictive factors of mastectomy.

Results

A total of 142.863 cases were included into the analysis. There was an overall decrease of 5.9 % (95 % confidence interval 5.1–6.7) in mastectomy trend from 36.5 % in 2006 to 30.6 % in 2010 (P < 0.0001). Known predictive factors were confirmed. Breast MRI (odds ratio 1.42, 95 % confidence interval 1.36–1.47) and small hospitals (<150 cases per year) seem to favor mastectomy. IBR was not associated with mastectomy rates.

Conclusions

Mastectomy rates in comparable health systems differ. Performance of preoperative breast MRI and hospital volume seem to be independent influencing factors for mastectomy rates.     

DIEAP flap selection for unilateral breast reconstruction: a comparison of flap side harvest

Background

For breast reconstruction, the deep inferior epigastric artery perforator (DIEAP) flap can be harvested at the same side as that in mastectomy (ipsilateral) or from the contralateral hemi-abdomen. This paper seeks to establish the benefits of either side of DIEAP flap harvest, on the basis of our experience and a literature review.

Methods

We analysed our experience with the DIEAP flap and compared the two different technical approaches to flap harvesting. Using the internal mammary vessels as the standard recipient, with comparable vessels on either side, we compared the differences between harvesting on the contralateral and ipsilateral hemi-abdomen and analysed any references to it in the literature.

Results

Seventy-three DIEAP flaps were harvested for breast reconstruction, over a 2-year period, by the two senior authors. Of the 44 cases where the ipsilateral hemi-abdomen was used, this was the routine primary choice of the operating surgeon in 42 cases. The contralateral hemi-abdomen was the preferred choice in 29 cases. We accessed 302 papers related to the topic of breast reconstruction using a DIEAP flap, of which 63 papers were reviewed, based on the abstracts. Only six of these papers mentioned their routine or preferred choice of the hemi-abdomen.

Conclusions

There appears to be no consensus in the literature as to the preferred side of DIEAP flap harvest, if the perforators are of similar calibre and ease of dissection. Modern DIEAP flap harvest is based on the preoperative selection of the most reliable perforator. In relation to mastectomy defect, this may be on the ipsilateral or contralateral. Level of Evidence: Level IV, prognostic/risk study     

Breast Cancer Surgery Trend Changes Since the Introduction of BRCA1/2 Mutation Screening: A Retrospective Cohort Analysis of 158 Mutation Carriers Treated at a Single Institution

Background

Bilateral mastectomy in women diagnosed with unilateral breast cancer is on the rise in the USA. One contributing factor is increased awareness of contralateral breast cancer risk. Positive testing for deleterious mutation in BRCA1/2 is a concrete measure of this contributing factor. We hypothesize that breast cancer surgery trend change is temporally associated with the introduction of BRCA1/2 genetic testing around 1996.

Methods

Our study cohort included 158 BRCA1 or BRCA2 mutation carriers diagnosed with unilateral breast cancer between 1963 and 2009. Mutation carriers with ovarian cancer or bilateral breast cancer were excluded. Breast surgery and breast reconstruction surgery trends were analyzed according to year of breast cancer diagnosis or when bilateral mastectomy was performed, respectively.

Results

Surgery trends changed significantly over time. We observed a significant drop in the rate of unilateral mastectomy (P < 0.001) after the period 1996–2000, and the rate of bilateral mastectomy appears to be on the rise, up to 30.3% between 2006 and 2009. Breast reconstruction trends also changed significantly over time, with a significant rise in the rate of free flap reconstruction to 58.8% between 2006 and 2009.

Conclusions

Our results demonstrated a significant decrease in unilateral mastectomy with a rise in bilateral mastectomy after the period 1996–2000, a period which encompassed the year when genetic testing of the two BRCA1/2 genes became commercially available, hence supporting our hypothesis.     

The Role of Oncoplastic Surgery in Breast Cancer

The authors discuss the objectives of oncoplastic surgery in breast cancer management. Indications and advantages are summarised. Some surgical techniques are described.

The authors report their own experience with oncoplastic surgery (26 patients who had immediate breast reconstruction after tumorectomy, and 126 patients who had lumpectomy alone. Oncoplastic surgery was characterised by a wider excision, with negative margins in all cases. In isolated breast conservative tumorectomy, 20% of the margins were positive, requiring re-excision or radical mastectomy.

Oncoplastic surgery is preferred especially in younger patients with smaller breasts, since it is less cosmetically mutulating and allows complete tumor resection with save margins.     

Surgical,oncologic, and cosmetic differences between oncoplastic and nononcoplastic breast conserving surgery in breast cancer patients

Background

There is a lack of information regarding the safety, complication rate, and cosmetic outcome of oncoplastic breast conserving surgery. The purpose of this study is to evaluate and compare oncoplastic and nononcoplastic procedures.

Methods

A retrospective review was conducted of patients treated with oncoplastic or nononcoplastic lumpectomies. Immediate and long-term complication rates and cosmetic satisfaction were compared.

Results

Of the 142 surgeries, 58 were oncoplastic lumpectomies (40.8%). Oncoplastic patients were younger than nononcoplastic patients (60.9 vs 65.2 years, P = .043). Immediate complications were similar with the exception of nonhealing wounds (oncoplastic = 8.6% vs nononcoplastic = 1.2%, P = .042). Cosmetic complaints were similar, but fat necrosis was more common in the oncoplastic group (25.9% vs 9.5%, P = .009). Time to radiation and number of future biopsies were similar between the groups.

Conclusion

Oncoplastic lumpectomy is a safe alternative to standard lumpectomy for selected breast cancer patients.