Preoperative breast marking to correct asymmetrical mammary hypertrophy

Summary The preoperative marking based on standard patterns may mislead the surgeon when the breasts are asymmetrical, necessitating intraoperative readjustments to obtain a good result. A new method for preoperative breast marking in reduction mammaplasty that is particularly suitable for breast asymmetry correction, is presented. The design is not predetermined but varies with the shape of each breast and allows the excision of different amounts of skin, leaving skin flaps of equal shape in both breasts.     

Auto-circler device (Tercan device) for marking a vertical scar mammaplasty

It is known that the desired shape and position of the nipple–areola complex may be difficult to achieve in vertical-scar reduction mammaplasty. The marking of a mosque-shaped areolar pattern varies from one surgeon to another, and therefore, periareolar trimming or resection may be inevitable with the use of such technique. We have developed a device to standardize the periareolar marking, and reduce the irregularity of the periareolar region. This device mimics the elasticity of normal breast tissue, and has the flexibility to be applicable to all breast types. We believe that this device improves the results of vertical-scar reduction mammaplasty and can eliminate the necessity of “last-minute” modifications intraoperatively.     

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??Surgical management of breast cancer in guidelines of Chinese Society of Clinical Oncology YAO Fan, JIN Feng. Department of Breast Surgery, the First Hospital of China Medical University, Shenyang 110001, China
Corresponding author:JIN Feng, E-mail:jinfeng66cn@hotmail.com
Abstract Neoadjuvant chemotherapy is standard treatment for locally advanced breast cancer or inflammatory breast cancer to downstage tumor and make the inoperable breast cancer operable. it is recommended to deliver all planned treatment (the standard 4 to 8 cycles) to achieve better prognosis. There were no significant differences in the local recurrence when breast conserving surgery (BCS) is given after neoadjuvant chemotherapy(NACT) or primarily for early breast cancer. Multiple factors such as primary tumor, molecular subtypes, tumor response should be considered to the extent of BCS after NACT. A negative margin is a standard for BCS following neoadjuvant therapy.There was some controversy regarding sentinel lymph node biopsy(SLNB) after NACT. SLNB can be carried out before or after NACT in case of the clinically negative axilla(cN0) initially. For a patient who downstaged to negative(cN1-cN0) undergo SLNB, the false negative rate can be improved by using dual tracer and IHC staining, removing more sentinel nodes, marking axillary node with clip.The impact of primary tumor resection (PTR) on survival is still controversial in stage ?? breast cancer. Generally, the primary treatment approach for metastatic breast cancer is systemic therapy, with the consideration of surgery after effective systemic treatment. Surgery of distant sites of recurrence may be indicated as needed for improving quality of life.     

Benefits and pitfalls of vertical scar breast reduction.

A quality assurance study was undertaken three years after beginning the vertical scar breast reduction technique. We examined the rate of early and late complications (major and minor) and compared these to the formerly used inverted-T scar and L scar breast reduction techniques. Inverted-T scar breast reductions have an early complication rate of up to 20% and a late complication rate of 20-30%.Our vertical scar breast reduction is a modified Lassus technique, incorporating a geometrically based and measurable preoperative marking of the breast, a superior pedicle, a central breast resection, an intraoperative positioning of the nipple-areola complex, and occasionally a periareolar skin resection.In the time span examined (September 1998-December 2001) 153 patients could be included in the study. The resection weight per breast ranged from 60 to 1262 g (mean 390+/-210 g, median 380 g).The early complication rate (hematoma, seroma, wound dehiscence, wound infection and necrosis) was 21.6%. Of these cases, 19.6% were minor complications. The late complication or imperfection rate was evaluated very strictly using the standardized, extended scheme of Ferreira (problems of volume, shape, symmetry, areola, scars and position of the breast on the thorax) and was 26%. Major late complications necessitating a reoperation occurred in 11.1% of cases.These complication rates compare well to those of other vertical breast reduction techniques and T scar reductions in our own clinic and in the literature. Given that the vertical scar breast reduction method also results in shorter scars and a significantly better, long-lasting breast projection, this technique is clearly justified to remain the standard method at our clinic.     

《中国临床肿瘤学会乳腺癌诊疗指南2018.V1》外科问题解读

新辅助化疗是局部晚期乳腺癌或炎性乳腺癌的规范疗法,可以使肿瘤降期以利于手术或将不可能手术转变为可以手术,一般应按照既定化疗方案周期数（6～8个周期）内最大疗效的原则进行。新辅助化疗后的保乳与常规保乳术后局部复发率间差异无统计学意义,新辅助化疗后保乳切除范围应根据肿瘤初始状况、分子亚型、肿瘤化疗后退缩模式等综合考虑,切缘阴性是基本原则。新辅助化疗后的前哨淋巴结活检（SLNB）争议较多,对cN0病人新辅助化疗前后均可行SLNB,对于cN1-cN0病人可以考虑在双示踪剂、增加淋巴结检出数目、免疫组化病理学检查、应用标记夹等方法有效降低假阴性率（FNR）后行SLNB。Ⅳ期乳腺癌原发灶切除是否改善生存尚存争议,手术应在全身治疗有效的基础上进行,现阶段转移灶手术的主要目的是改善病人生存质量。     

Evolutive French regulation and materiovigilance specific to the breast implants

Too much a long time the manufacture of the breast implants does not have the object of a specific regulation. This lack led partly to the prohibition of the implants filled with silicone in 1995. It took 10 years for the European Union to create and to set up a standard EC specific to the breast prosthesis. It's the history of these steps as well on the level of Europe as has the French scale as we report you. Initially classified as implantable devices of IIb level, the breast implants were reclassified on level III in 1993, the highest level of requirement of CE marking. In accordance with the recommendations of the group of experts named by the Afssaps, the technical standard IN ISO 14630:1997, fixing the mechanical properties of the prosthesis, is in the course of revaluation since 2004. According to Council Directive 93/42/EEC of the June 14th 1993, the French government instituted a materiovigilance specific to the breast implants. All these evolutions allow, now a serene use of the breast implants.     

Keyhole pattern for preoperative marking for reduction mammaplasty

BACKGROUND

There are many techniques used for reduction mammaplasty; however, the most frequently performed procedures result in an inverted T scar. Preoperative marking is an important step for the success of the procedure, especially for surgeons at the initial learning stage. However, there is no consensus regarding the best method. In 1981, Strömbeck designed a pattern for preoperative marking for reduction mammaplasty. This pattern provides stable parameters that promotes an acceptable symmetry marking.

OBJECTIVE

To evaluate the use of the Strömbeck pattern for preoperative marking for reduction mammaplasty.

METHODS

Fifty-seven patients who underwent reduction mammaplasty between April 2006 and April 2007 were prospectively evaluated. Patient ages ranged from 17 to 61 years; the mean body mass index was 22.2 kg/m². After defining the standard landmarks of the breast, preoperative markings were made using the Strömbeck pattern. Breast reduction surgery was performed under local anesthesia with sedation. Postoperative results were evaluated according to a numerical visual analogue scale, at the seven-, 15- and 30-day follow-up periods. The Student’s t test and the Kruskal-Wallis test were used for statistical analysis (P<0.05).

RESULTS

The mean weight of resected breast tissue was 317.5 g for the right breast and 305.8 g for the left breast (P=0.17). Scores obtained using a visual analogue scale showed a progressive increase in the scores during the postoperative follow-up period (P<0.0001).

CONCLUSION

The use of the Strömbeck pattern enabled surgeons to perform reduction mammaplasty with good postoperative results as seen in the follow-up periods.     

Simulation of microcalcifications on specimen radiographs of breast biopsies by inks used in marking the surgical resection margins

In routine practice, the evaluation of breast excisional biopsy specimens is assisted by the use of various tissue marking inks to delineate surgical margins and preserve tissue orientation. These inks may simulate microcalcifications in specimen and tissue block radiographs. The magnitude of this problem is studied by systematically identifying the factors leading to the creation of this artifact. Samples of fresh tissue from breast reduction mammaplasties were painted separately with fresh wet ink and ink mixed with dried powdery residue. Black India ink and commercial colored tissue inks (the Davidson Marking System) were tested. The painted tissues were radiographed before and after routine paraffin embedding. Routine histologic sections were obtained from each tissue block for microscopic examination. Compared with unmarked controls, samples inked with blue, green, and red inks containing powdery residues showed radiopaque artifacts on radiographs prior to tissue processing. Only the sample marked with red ink showed residual radiopaque artifacts after processing. Microscopically the dried red ink particles were readily distinguishable from microcalcifications on the tissue sections. On the tissue radiographs, the dried ink artifacts were indistinguishable from true microcalcifications. This study demonstrates that some tissue marking inks used in the pathology laboratory are radiopaque. Inks contaminated with particles of dried residue, often present on ink container lids, may appear as artifacts mimicking microcalcifications on specimen and tissue block radiographs, occasionally complicating the histologic localization of mammographically demonstrated microcalcifications. Tissue marking inks should be tested for radiopacity prior to use on breast biopsies. Ink containers should be checked frequently for buildup of dried residue.     

Treatment of the axilla by tangential breast radiotherapy in women with invasive breast cancer

BACKGROUND: The objective of this study was to determine if standard tangential breast radiation covered the sentinel lymph node in women with invasive breast cancer. METHODS: Women with invasive breast cancer treated by lumpectomy, radiotherapy and sentinel node biopsy at our institution were included in this study if the sentinel lymph node site had been marked with a clip. Plain films were used to determine if the clip fell within the tangential fields. RESULTS: Between April 1999 and May 2001, 36 women with invasive breast cancer treated by lumpectomy, sentinel lymph node biopsy and breast radiation were identified. Median age was 56 years (range 34 to 80) with a median tumor size of 1.1 cm (range 0.3 to 2.9 cm). The clip marking the sentinel lymph node fell within the tangential fields in 34 of 36 (94%) of the patients. The radiation dose to the clip area was greater than 4,400 cGy in 50% of those calculated by three-dimensional techniques. CONCLUSIONS: The sentinel lymph node is located within classic tangential fields in the overwhelming majority of women with invasive breast cancer. The extent of the radiation fields, and ultimately the final dose, may need to be modified if the intent is for prophylactic treatment.     

Reduction of mammaplasty scars: from a short inframammary scar to a vertical scar]

A better understanding of the vascular anatomy of the breast has drastically reduced the risk of postoperative necrosis in breast reduction. Scars however remain a major concern, and techniques to reduce these have often been considered to be less satisfactory in terms of the shape and stability of the result. Our experience with more than 1,000 breasts operated on between 1984 and 1989 with a short inframammary scar technique has proved the contrary. The next step was to eliminate the inframammary scar, as proposed by Lassus, and to leave just a periareolar scar and a lower vertical scar which does not cross the inframammary fold. One hundred and four breasts, in sixty four patients--17 to 60 years old--have been operated on according to this vertical technique between April and September 1989. Twenty seven cases of ptosis correction in seventeen patients, and seventy seven reductions in forty seven patients, with a median excision weight of 460g, have been performed. By means of an individualized preoperative drawing and several technical devices, the results have proved that vertical mammaplasty is an excellent technique particularly indicated for women with elastic skin and a firm gland. Recent experience with liposuction at the beginning of the operation, has given new possibilities for breast modelling. In fatty juvenile hypertrophies, liposuction alone may even be adequate to reduce the volume, retaining a satisfactory shape for the breast with minimal scarring.     

Modified vertical reduction mammaplasty: ten years of experience

Background

Over the years, vertical scar breast reduction has gained more and more importance. This is due to the fact that this technique is associated with smaller scars and absence of scars in the inframammary fold. However, this technique also has some disadvantages, such as the pleating of the vertical scar during the first 6–12 months and final shape of the breast is achieved only after a year. It also cannot be applied to very large mammary hypertrophies. Herein, we present some modifications to the vertical scar breast reduction that allow long lasting results and reduced complications.

Methods

The modified vertical reduction was executed in 280 patients. Depending on the breast type and position of the nipple–areola complex (NAC) three different types of pedicles were used: superior, supero-medial and supero-lateral. Follow-up was carried out for at least 18 months and complications were recorded.

Results

Neither major complications nor bottoming out deformity were detected during follow-up. Maximum volume of tissue reduced was 1,600 g per breast.

Conclusion

By adding some modifications to the vertical scar breast reduction, the technique can be indicated in large mammary hypertrophies. A meticulous preoperative marking, minimum detachment of the breast, the suturing of mammary pillars, and a thin but large NAC pedicle are essential for obtaining a long lasting mammary shape and better results. Level of Evidence: Level IV, therapeutic study.     

Peri-areolar marking in Lejour's mammoplasty��a simple device to aid trainee learning: the flexible curve

We propose the use of a simple device—the flexible curve—to aid trainees with the peri-areolar markings of Lejour's mammoplasty. This cheap and simple, commercially available, wipe clean device can be purchased in any art store and easily adapted for purpose. It assists beginners in the marking of the areola site in vertical mammoplasty and speeds the learning curve needed to make the marks accurately despite great variation in pre-operative breast size and contour. Both authors have found the device incredibly useful in the peri-areolar marking of Lejour's mammoplasty technique. We hope that publication and awareness of the device may assist others to achieve accurate peri-areolar markings with ease.     

Aesthetic Breast Augmentation: The Double Implant

The objectives of the augmentation prostheses are to increase the volume, enhance the shape, and improve the projection of the breast. Since 1962, plastic surgeons have used the silicone gel-filled breast implant created by Cronin and Gerow [6]. The contents of the standard implant have been modified: silicone gel-filled, PVP, dextran, oil, saline hydrogel, etc. The shell of the prostheses had been made with a smooth surface, textured silicone, and polyurethane-covered silicone. The shape has been modified: In 1993, A. Miller patented the stacked breast implant used in breast reconstruction [7]. This contribution tends to improve the projection of the breast. In 1994, the authors [1,3,4] described a new surgical procedure for locating the standard implants named the double pocket technique. Simultaneously, the authors [2–5] modified the shape of the prosthesis creating the double implant prostheses.     

钼靶摄片立体穿刺定位乳腺活检术

目的 探讨X线立体穿刺钢丝标记定位活检术用于无体征的早期乳腺癌诊断的可行性。方法 对18例钼靶X片上有可疑病灶而无任何临床体征的患者,在X线立体定位下穿刺病灶并用金属导丝标记,标记后根据导丝位置切除病灶,并进行快速冰冻活检,明确诊断。结果 18例中,7例恶性,11例良性。与术后病检报告一致。对无体征的早期乳腺癌诊断准确率为100％。结论 X线立体穿刺钢丝标记定位活检技术解决了只有影像学改变的乳腺病灶切除活检术中精确定位的难题,是诊断无体征的早期乳腺癌的理想诊断技术。     

Modifications in vertical scar breast reduction.

The use of vertical-scar breast reduction techniques is only slowly increasing, even though they have been advocated by Lassus and Lejour and are requested by patients. Possible reasons why surgeons are reluctant to use these techniques are that they are said to be more difficult to learn, they require considerable experience and intuition, and their applicability is confined to small breasts. Several surgeons have developed modifications, combining vertical-scar breast reduction techniques with details of the familiar inverted-T-scar technique. We present a procedure involving two further modifications of the vertical-scar breast reduction technique: first, a standardised, geometrical preoperative drawing from our superior-pedicle T technique, with the aim of establishing a reproducible method of reduction requiring no particular intuitive touch, and, second, the addition of a periareolar skin resection, to give the breast the desired round shape. Between September 1998 and December 1999 we used this technique in a prospective series of 52 patients. The median resection weight was 450 g. The maximal postoperative follow-up was 15 months. There were no acute postoperative complications necessitating reoperation. The late complication rate was within the expected range for such procedures (seven patients, 13.5%) and included vertical-scar widening, areolar distortion, residual wrinkles due to incomplete shrinkage of the undermined skin in the inferior pole and asymmetry of the breast. This procedure enables us to offer patients with moderate to marked hypertrophy a reproducible versatile vertical breast reduction technique. The technique is easy to teach and easy to learn, especially for those who are familiar with the superior pedicle inverted-T-scar technique.     

How to improve breast implant reconstructions?

Prosthetic breast reconstruction is a simple procedure that has become a standard of care for breast reconstruction. The technique generally provides satisfactory results, although minor defaults requiring further correction may sometimes be detected. The present study is a systematic review of prosthetic breast reconstruction defaults, which we have classified in different categories: shape too round, disruption of inframammary fold, excessive firmness, wrinkling and rippling, and localized imperfections. Based on this analysis of physical signs, we propose surgical solutions adapted to the needs of each patient. Reconstruction with abdominal advancement flap an intrapectoral fat graft (lipomodeling) appear to be among the most significant current advances of prosthetic breast surgery. The skillful analysis of prosthetic reconstruction defaults will make it possible to contribute to enhancing the quality of prosthesis reconstruction, whereas improving both aesthetic outcome and patient satisfaction.     

改良双环法乳房缩小整形术

目的：探讨双环法乳房缩小整形术的一些技术改进。方法：在双环法乳房缩小整形术的基础上,从设计、操作上加以技术改良。结果：本组17例33侧,术后乳房外形满意,手术切口瘢痕不显;乳头、乳晕血运良好,感觉正常。结论：本方法设计合理、操作便捷,切除乳腺量大,术后效果理想,不仅适用于轻中度乳房肥大症,也适用于较重度乳房肥大症。     

Refinements of Vertical Scar Mammaplasty: Circumvertical Skin Excision Design With Limited Inferior Pole Subdermal Undermining and Liposculpture of the Inframammary Crease

Vertical scar mammaplasty, first described by Lötsch in 1923 and Dartigues in 1924 for mastopexy, was extended later to breast reduction by Arié in 1957. It was otherwise lost to surgical history until Lassus began experimenting with it in 1964. It then was extended by Marchac and de Olarte, finally to be popularized by Lejour. Despite initial skepticism, vertical reduction mammaplasty is becoming increasingly popular in recent years because it best incorporates the two concepts of minimal scarring and a satisfactory breast shape. At the moment, vertical scar techniques seem to be more popular in Europe than in the United States. A recent survey, however, has demonstrated that even in the United States, it has surpassed the rate of inverted T-scar breast reductions. The technique, however, is not without major drawbacks, such as long vertical scars extending below the inframammary crease and excessive skin gathering and “dog-ear” at the lower end of the scar that may require long periods for resolution, causing extreme distress to patients and surgeons alike. Efforts are being made to minimize these complications and make the procedure more user-friendly either by modifying it or by replacing it with an alternative that retains the same advantages. Although conceptually opposed to the standard vertical design, the circumvertical modification probably is the most important maneuver for shortening vertical scars. Residual dog-ears often are excised, resulting in a short transverse scar (inverted T- or L-scar). The authors describe limited subdermal undermining of the skin at the inferior edge of the vertical incisions with liposculpture of the inframammary crease, avoiding scar extension altogether. Simplified circumvertical drawing that uses the familiar Wise pattern also is described.     

The Asplund-Davies vertical scar breast reduction technique preserves the sub-areolar skin thickness in the long term: a matched comparative study with the inverted T technique.

BACKGROUND AND AIM: The inverted T technique, a popular method of breast reduction, relies on stretching the skin over glandular breast tissue to create the breast shape. The Asplund-Davies vertical scar method of breast reduction by contrast uses glanduloplasty to create the desired breast shape, achieving tension-free skin closure. Indeed the skin at the end of the vertical scar technique is wrinkled. It is known from tissue expansion literature that when skin is placed under tension the dermis becomes thinner. In this pilot cross-sectional study we compared breast skin thickness between two matched groups of patients undergoing breast reduction either with the inverted T or the vertical scar techniques, to determine whether the method of breast reduction impacts on breast skin thickness in the long term. MATERIALS AND METHOD: With a high frequency ultrasound machine the breast skin thickness of 24 breasts, 12 in each group, was measured by an independent consultant radiologist. Patients were matched in terms of age, time since operation, Fitzpatrick skin type, preoperative cup size and the amount of tissue resected. RESULTS: The breast skin in the inverted T group was significantly thinner than the vertical scar group (P<0.001). The inverted T group also had thinner skin in comparison to its control point (P<0.05). The vertical scar group had comparable skin thickness compared to its control point (P>0.05). CONCLUSION: This pilot study suggests that tension-free closure of skin with the vertical scar technique maintains breast skin thickness. Maintenance of breast skin thickness in this group may in turn contribute to the long term preservation of breast shape and form.