Periareolar subcutaneous quadrantectomy: a new approach in breast cancer surgery

Plastic and oncological breast surgery are becoming more and more closer as one surgical treatment. The term "oncoplastic surgery" refers to the use of plastic surgery techniques in breast cancer surgery, in order to avoid and to correct the adverse aesthetic findings. The care of cosmetic sequelae of breast cancer surgery has reached an important therapeutic role for psychological consequences of disease and because of the higher patients expectations of a good aesthetic result. Considering the concept of oncoplastic surgery, since 1999 the Authors began to use a periareloar approach in the breast conserving therapy (BCT), associated to axillary dissection performed through the same periareolar incision. This technique, original from the oncological point of view, is not different from the traditional quadrantectomy in the extension of the glandular resection, while the skin may be preserved in according to the conventional protocols of BCT. Oncological and aesthetic results have proved to be safe and satisfactory.     

Breast ptosis. Classification and summary of surgical indications]

A general classification of ptotic breasts is proposed by the author in four main groups. 1) Precocious ptotic breasts including ptosis because of anomalies of skin elasticity and primary morphological ptotic aspects of the breast. 2) Ptotic breast as a result of excess of volume due to early hyperplasia, because of excess weight (around puberty, around pregnancy, around menopause). 3) Acquired ptotic small or long breast by fibrous retraction, or after weight loss. 4) Asymmetric ptotic breast, either primary, presenting at puberty or secondary presenting around pregnancy or after weight variations, or iatrogenic. An approach to the morphological analysis of each type of ptosis includes evaluation of skin quality, glandular density, relation between both. The role of weight stability is also discussed before a brief summary of the author's choice of techniques.     

Our own experience in the treatment of hypotrophy and ptosis of the breast]

The outcome of surgical of small, ptotic breasts is reported in a retrospective series of fifteen patients operated between 1983 and 1989. Seven patients underwent breast augmentation by insertion of breast implant supplemented in one case by a dermopexy while eight patients underwent cutaneous and glandular remodeling alone. Simple breast augmentation with breast implant gave good results with mild to moderate ptosis (i.e. when the distance between the inferior margin of the clavicle and the upper margin of the areola was equal to or less than 17 cm) provided that: the subareolar segment III did not exceed 5 cm, the skin had good static qualities for breast suspension, the amount of glandular, adipose and cutaneous tissue present allowed the prothesis to be covered by a sufficiently thick layer. With breast ptosis greater than 17 cm or when segment III exceeded 5 cm, cutaneous remodeling by dermopexy was associated with insertion of breast implant. In this group of patients treated, either by breast implant alone, or associated with dermopexy, results were good in 33%, and satisfactory in 50% of cases. Better results were obtained in patients with marked ptosis and breasts which, although hypotrophic, conserved a amount of adipose and glandular tissue sufficient to allow breast reconstruction by soft tissue remodeling alone (without the insertion of an implant). Patients in this group were treated by glandular and cutaneous remodeling with good to excellent results in 80% of cases.     

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.     

Tuberous breast: clinical and therapeutic considerations. Report of 20 cases]

Tuberous breast is a so-called mammary deformity which associates: deficient and contracted base, enlarged nipple-areolar complex, glandular herniation through the areola. The parenchyma is reduced, cylindrical, asymmetric, and frequently posted. Surgery reveals a basic glandular ring. The gland passes through this ring like a "glove's finger", revealing the herniation. All the cases are very different, but the surgical correction is common: concentric skin excision for areolar reduction. "V" vertical excision, allowing gland dissection. Via the skin wedge of the "V", extended dissection is carried out and half of the breast is denuded. The inferior mammary sulcus is released. The basal ring is cut and the posterior breast tissue is radially incised to expanding base, the parenchyma is stretched out. Correction of volume abnormalities: augmentation (implant), posterior reduction of symmetry. Correction of ptosis by skin redraping over the new mammary shape.     

Augmentation in ptotic and densely glandular breasts: prevention, treatment, and classification of double-bubble deformity

After breast augmentation, separation of breast tissue from the implant is common, especially in patients with well-formed preoperative breasts. This problem is enhanced to a marked deformity in cases of scar contracture with firm, fixed implants. This paper addresses this problem preoperatively and therapeutically in secondary correction of double-bubble and waterfall deformity. The author classifies and explains double-bubble deformity in patients in whom the implant is below the normal crease, with glandular breast tissue superior and anterior to the implant. In "waterfall" deformity (a term suggested by the author), the glandular breast tissue droops over the implant and is inferior and anterior to the implant. Treatment used consists of opening the breast tissue from its posterior surface using radial incisions to accommodate the implant. This allows the two structures--the breast tissue and the implant-to blend as one unit with satisfactory results. The technique is easy to perform and teach. Complications are similar to those of regular breast augmentation. Strangely, radial incisions have not increased complications, and there have been no cases of seroma or hematoma to date.     

Esthetic outcome of immediate reconstruction with latissimus dorsi myocutaneous flap after breast-conservative surgery and skin-sparing mastectomy

With the recent advances in oncologic breast surgery, breast reconstruction with the latissimus dorsi myocutaneous (LDM) flap without an implant has become a good option among other autologous tissue reconstructions available. However, only a few large-scale studies have so far evaluated the critical factors affecting its esthetic outcomes. We retrospectively reviewed 97 consecutive patients who underwent breast reconstruction with the LDM flap between 2001 and 2005 at our institution. The esthetic outcome in comparison with the normal breast was evaluated by means of observer assessment consisting of 7 criteria. A stratified analysis was performed to determine the factors affecting the esthetic outcomes after the breast-conservative surgery and skin-sparing mastectomy. We found that reconstruction of the lower half of the breast and exposure of the skin paddle resulted in poor esthetic outcomes after breast-conservative surgery. Large preoperative brassiere cup size, radiation history, axillary node dissection, and exposure of the skin paddle were the factors which negatively affected the overall outcomes after skin-sparing mastectomy. Age, body mass index, presence of nipple areola-complex defect, or design of skin paddle did not affect the esthetic outcomes. On the basis of these critical factors, we could determine the indications and limitations of breast reconstruction with LDM flap. In some cases, further technical modifications are still warranted, and we believe that these modifications will optimize the use of this flap in breast reconstruction.     

A new level 1 oncoplastic technique for breast conserving surgery: Rotation glandular flap

BackgroundWhen performing conservative surgery for breast cancer, breast reshaping can be a challenging procedure. Level 1 oncoplastic surgery (OPS) techniques, i.e. advancement or rotation of glandular flaps, should be performed when less than 20 per cent breast volume is excised.ObjectiveA new Level 1 OPS technique is described. A wide centro-lateral glandular flap is created after extensive undermining of the skin and nipple-areolar complex, and rotated into the cavity.DiscussionThis rotation glandular flap is a new technique for use following a wide excision, in glandular, not fatty, breasts, and when standard closure of the cavity would not leave a satisfactory cosmetic result.     

Breast Implants as a Preventive Factor

After a large number of patients with silicone breast implants worldwide had been evaluated [2, 9], it was concluded that such implants were not carcinogenic. This allowed for experimentation with rats to determine the benefits and potential risks associated with implants. By means of a high-precision monitor, temperature measurements were obtained from 100 silicone-implanted rats. These measurements then were divided into various groups to compare the reaction of their implanted and nonimplanted mammary glands at different hormone levels. The temperature measurements were analyzed and compared. Dysthermia was detected in the skin area immediately overlying the implant. The results also demonstrated that at high hormone levels, implants act as neutralizing agents. By contrast, glandular alterations with severe signs of anisocytosis and anisokoryosis were observed in nonimplanted glands.     

Oncoplastic surgery: the evolution of breast cancer treatment

Oncoplastic surgery is an establish approach that combines conserving treatment for breast cancer and plastic surgery techniques. It allows wide excisions and prevents breast deformities by immediate reconstruction of large resection defects. The procedures are mostly useful for resection of 20-40% of the breast - a group of patients normally treated by mastectomy in the past. Four features are integral to oncoplastic breast surgery: (i) Appropriate surgery for cancer excision. (ii) Partial reconstruction to correct wide excision defects. (iii) Immediate reconstruction with the full range of available techniques. (iv) Correction of volume and shape asymmetries relative to the contra-lateral healthy breast. There are two fundamentally different approaches: (i) volume-replacement procedures, which combine resection with immediate reconstruction by using local flaps (glandular, fasciocutaneous, and latissimus dorsi mini-flaps), and (ii) volume-displacement procedures, which combine resection with a variety of different breast reduction and reshaping techniques, according to the location of the tumor. Oncoplastic surgery increases the oncological safety of breast-conserving treatment because a much larger breast volume can be excised and wider surgical margins can be achieved. Moreover, a "surgical screening" of the contra-lateral breast allows the diagnosis of occult cancers. Among oncoplastic approaches, a very unique technique is the possibility of implant use (augmentation mammaplasty) in case of quadrantectomy and simultaneous delivery of intraoperative radiotherapy to the tumor bed.     

Fluoroscopy cannot recognize intraoperative fracture in patients receiving 2-incision total hip arthroplasty

Intraoperative fluoroscopy is suggested as a standard procedure in 2-incision total hip arthroplasty. Between September 2003 and July 2004, 2-incision total hip arthroplasties were done in 18 hips with and another 18 hips without the use of fluoroscopy. In group 1, the anterior skin incision was initially limited to 5 cm. Fracture or instability was checked by fluoroscopy first and then the incision was enlarged to 8 cm for visualization. In group 2, incisions were made long enough to expose the surgical field. There were 2 femoral neck fractures in the fluoroscopy group. The fractures were linear in the anteromedial femoral neck and could not be detected by fluoroscopy. Such linear fractures if overlooked could result in serious complications such as fracture displacement or implant instability. Surgeons should not rely on intraoperative fluoroscopy to check implant stability, and visualization of the surgical field should not be compromised when doing minimally invasive approach for total hip arthroplasty.     

Evaluation of the effectiveness of the prepectoral breast reconstruction with Braxon dermal matrix: First multicenter European report on 100 cases

We report the outcomes of the European prospective study on prepectoral breast reconstruction using preshaped acellular dermal matrix for complete breast implant coverage. Seventy‐nine patients were enrolled between April 2014 and August 2015 all over Europe using a single protocol for patient selection and surgical procedure, according to the Association of Breast Surgery and British Association of Plastic Reconstructive and Aesthetic Surgeons joint guidelines for the use of acellular dermal matrix in breast surgery. The preshaped matrix completely wraps the breast implant, which is placed above the pectoralis major, without detaching the muscle. A total of 100 prepectoral breast reconstructions with complete implant coverage were performed. This series, with mean follow‐up of 17.9 months, had two cases of implant loss (2.0%) including one necrosis of the nipple and one wound breakdown (1.0% respectively). No implant rotations were observed. Good cosmetic outcomes were obtained with natural movement of the breasts and softness to the touch; none of the patients reported experiencing pain or reduction in the movements of the pectoralis major muscle postoperatively. The use of preshaped acellular dermal matrix for a complete breast implant coverage in selected patients is safe and gives satisfactory results, both from the aesthetic view point and the low postoperative complication rates. Further studies reporting long‐term outcomes are planned.     

Delayed‐immediate hybrid breast reconstruction—Increasing patient input and precision in breast reconstruction

The benefits of breast reconstruction via free tissue transfer with simultaneous implant placement, that is, hybrid breast reconstruction, in select patients are well‐known. Challenges exist, however, and are related to proper implant selection as well as postoperative mastectomy skin necrosis. Here, the authors present an approach that increases reconstructive precision while minimizing postoperative mastectomy skin necrosis. A retrospective analysis of patients who underwent immediate prepectoral tissue expander placement (stage 1) followed by delayed‐immediate hybrid breast reconstruction (stage 2) was performed. Parameters of interest included patient demographics, postoperative complications, and revision rates. A total of 31 patients with a mean age of 48.7 years (range, 30‐67 years) and a mean BMI of 26.3 kg/m² (range, 21.0‐35.3 kg/m²) who underwent bilateral breast reconstruction were included. Of the 62 free abdominal flaps, 45 (72.6%) and 17 (27.4%) were MS‐TRAM and DIEP flaps, respectively. The most common implant volume was 240 cc (range, 140‐445 cc). Following stage 1, minor and major complications were observed in nine (29%) and one (3.2%) patients, respectively. No major complications were noted after stage 2. Of note, no patient developed mastectomy skin necrosis or requested a change in implant size following stage 2. Delayed‐immediate hybrid breast reconstruction improves the ability to more precisely match patient expectations related to breast size and is associated with a reduction in the rate of mastectomy skin necrosis following the critical second stage of reconstruction.     

Evolution of the Vertical Reduction Mammaplasty: The S Approach

The vertical reduction mammaplasty has been popularized over recent years. It always produces marked puckering of the excess skin and requires revision surgery for the persistent dog-ears that develop. Minor complications are often common. As a result, the evolution with S approach is developed. A series of 36 consecutive patients who underwent the S approach reduction mammaplasty is presented. The S approach can be described as having 1) superior dermoglandular pedicle, 2) simple and safe S-shaped skin marking, 3) suspension of the residual glandular tissues transversely to the periosteum of the 5th rib, and 4) short-scar closure. The surgical techniques are described in a step-by-step fashion. An analysis is made of the results obtained from these patients. The mean follow-up period of this study is 21 months. As a result of surgical operation, the symptoms of breast hypertrophy were markedly improved. According to patient assessment, neck, back, or chest pain decreased from 64% to 25%, shoulder grooving improved from 56% to 25%, stooped posture decreased from 42% to 14%, intetrigo improved from 36% to 8%, psychological embarassment decreased from 33% to 8%. The postoperative complications included minimal areolar epidermolysis (11%), hypertrophic scar (8%), etc. All mammograms revealed hypertrophic patterns of the breast. The glandular tissues removed had a mean of 480 g from each breast. Two breasts (3%) had fibroadenomas. The sternal notch–nipple distance changed from a mean of 30.5 cm preoperatively to 20.5 cm, the length of infraareolar scar was 9 cm in average. Eighty-one percent of patients had minimal postoperative ptosis, and the sensitivity of nipple–areola complex was unchanged in 75% of patients. Nine patients (24%) retained the ability to lactate for more than 1 month postoperatively. Twenty-two patients (61%) were very satisfied with their operation, and eight (22%) were adequately satisfied. The technique presented is a simple and safe procedure that provides satisfactory results for patients with breast hypertrophy.     

Oncoplastic breast surgery combining partial mastectomy with immediate breast reshaping using a keyhole-shaped skin glandular flap for Paget’s disease

Oncoplastic breast surgery (OBS), which combines the concepts of oncologic and plastic surgery, is becoming more common worldwide. We herein report the results of OBS in Japanese patients with Paget’s disease. We performed OBS combining partial mastectomy with immediate breast reshaping using a keyhole-shaped skin glandular flap in two patients. In these two patients, who were diagnosed as having Paget’s disease with a restricted intraductal component in the central area of their non-ptotic breast, we performed oncoplastic surgery combining partial mastectomy with immediate breast reshaping using a keyhole-shaped skin glandular flap. Neither of the two patients received contralateral surgery to produce symmetrical breasts. The observation period ranged from 6 to 12 months, and the bilateral breast volumes and inframammary lines were symmetric. OBS combining partial mastectomy with immediate breast reshaping using a keyhole-shaped skin glandular flap was successfully performed in two patients with Paget’s disease.     

Pre-operative MRI for women with newly diagnosed breast cancer: Perspectives on clinician and patient decision-making when evidence is uncertain

The routine use of pre-operative MRI in women with newly diagnosed breast cancer highlights the complexities of the use of new technology when evidence of benefit is uncertain. There are both potential harms and benefits. In the short term patients may desire and feel reassured by further testing and the use of new diagnostic techniques. However, they may also experience greater anxiety and distress from further tests and related follow-up procedures such as biopsy. In the long term MRI may result in more radical treatment decisions which are associated with poorer quality of life for women. Both patients and clinicians often (wrongly) assume that more information via testing leads to better outcomes (information bias). So how should pre-operative MRI be integrated into breast cancer care? First women need to be made aware of the uncertain evidence surrounding MRI. However whether it is appropriate to burden women with complex information and yet another decision at a time of high vulnerability and emotional distress should be considered. One potential solution is to use a Community Informed Consent approach in which a representative sample of patients and healthy women are educated about the benefits and harms and give their informed opinion about whether pre-operative MRI should be offered. Another approach is to provide patients with an evidence based decision aid to support individual informed choice. Either or a combination of both approaches would be acceptable and should be investigated. At present women are poorly informed about pre operative MRI and it is likely that they assume outcomes are be improved as a result. Clear communication about the limits of MRI to patients is needed alongside randomised trials to provide the evidence that benefit indeed outweighs the harms so that all parties involved may be comprehensively informed.     

Single-stage immediate breast reconstruction using a skin-sparing incision and definitive saline implants compared with a two-stage reconstruction using tissue expansion plus implants

BACKGROUND:

Losing a breast to cancer has significant psychological ramifications, and it has been shown that minimizing this loss can have a profound impact. As a result, breast-conserving therapy or mastectomy followed by breast reconstruction have become the preferred surgical treatments for breast cancer. Limited available breast skin following mastectomy has traditionally necessitated the use of autologous tissue or tissue expansion; however, when reconstructing larger breasts, autologous tissue grafts rarely provide enough tissue and tissue expanders can often take several months to achieve the necessary tissue volume. The skin-sparing mastectomy offers a solution to this lack of skin, and as a result many new options for immediate breast reconstruction have presented. The present pilot study looks at a new method of immediate breast reconstruction involving a Wise pattern skin-sparing mastectomy with placement of a definitive, submuscular saline implant as a way to maintain a large breast size without requiring the patient to undergo a long and painful tissue expansion process.

METHODS:

A retrospective, case-control study was performed on 12 women who had undergone bilateral mastectomies with immediate reconstruction either with a tissue expander and later placement of definitive saline implant (control group) (n=5) or who had undergone a single-stage reconstruction involving the placement of a definitive submuscular saline implant (experimental group) (n=7). Patients were compared with respect to change in breast size, number of reoperations and operations in total, as well as satisfaction with their reconstruction.

RESULTS:

Patient satisfaction in both groups was relatively high and there was no statistically significant difference found between the two groups. The experimental group decreased in bra size by 1.4 cup sizes on average whereas the control group experienced no change on average; however, one-third of patient data had to be discarded for various reasons, making the change in size measurement inconclusive. Finally, the average number of reoperations was higher in the experimental group than the control (1.57 versus 1.00); however, the total number of operations required was less (2.57 versus 2.80).

CONCLUSIONS:

Immediate breast reconstruction using a definitive submuscular saline implant is a viable option for reconstruction in women with larger breasts that deserves further study on a larger scale. Although limited by sample size, the present pilot study showed, with a large effect size, that this new procedure reduces the total number of operations required for reconstruction when compared with a tissue expander followed by an implant while maintaining an equally high level of patient satisfaction.     

The latero-central glandular pedicle technique for breast reduction.

The relatively high number of complications and disadvantages of the conventional techniques in breast reduction combined with our expertise in restoring sensation in breast reconstructive procedures, led to the development of a new technique that was crystallised from the traditional techniques and is able to overcome most of their disadvantages. The key issue of the technique is that the nipple is vascularised and innervated on a column of glandular tissue that remains in contact in its posterior part with the pectoralis muscle and its perforators and in its lateral aspect to the lateral pillar of breast tissue. Due to the ptosis that develops during the process of hypertrophy, this column will gain sufficient length to be turned upwards into the new position of the nipple. Resection of glandular tissue is performed cranially, medial and inferior to this column. Undermining of the skin is reduced to an absolute minimum and glandular resections are always performed in the shape of a wedge. In this way, undermining of the breast gland over the pectoralis muscle is avoided. The glandular pedicles are sutured together after loosely fitting the glandular cone with the nipple into its new position. The long term results of the first 68 cases were reviewed and compared to our experience with the superior dermal pedicle technique combined with the vertical scar as described by Lassus and later by Lejour. Due to increased vascularisation of the nipple-areolar complex (NAC), wound complications were markedly reduced with the new technique. Sensation in the NAC was preserved in almost all cases. There was a high satisfaction about the obtained aesthetical results in regard to shape and volume. Increased viability of the NAC, a reduced rate of wound complications and preservation of sensation in NAC are the main advantages of this technique. Additionally, flattening of the NAC is avoided by the support by glandular tissue behind the NAC that improves projection and hereby the aesthetic conic appearance of both breast and nipple.     

Elliptical breast reconstruction: an improved and simplified technique.

An improved and simplified postmastectomy reconstruction by tissue expansion is presented. Utilizing a uniquely designed matched tissue expander and prosthesis, the technique is based on an elliptical concept of breast shape and corresponding volumetric relationships and permits controlled expansion of the lower chest skin. Horizontal and vertical base dimensions and the volume of the contralateral breast are used to determine the size and volume of the appropriate elliptically shaped tissue expander and, subsequently, of the mammary implant. This approach permits surgeons to achieve symmetry more readily by matching the implant to the patient, rather than the patient to the implant.     

Severe influence of early pregnancy on newly reconstructed breast

Since mastectomy may have a devastative effect on the patient's appearance, body image and psychology, especially in young women, immediate breast reconstruction is widely preferred to avoid the unpleasant results caused by the defect of mastectomy. Presented here is the case of a 33-year-old patient. Considering her fibrocystic mastopathy, atypical ductal hyperplasia and a history of familial breast cancer, subcutaneous mastectomy and breast reconstruction using an implant was planned with skin reduction and repositioning of the areola-nipple complex. During her postoperative follow-up examinations which were conducted periodically, it was expected that the formation of the breasts in relation to the prosthesis would take place in the healing time. In contrast, an increase in the skin thickness and breast fullness, massive filling in the submammary fold, a vertical suture depression and consolidation were observed. These unexpected deformities were based on a pregnancy beginning just after the last operation. Later, the breast findings were followed both clinically and photographically. After termination of the pregnancy, reduction in the skin thickness, involution of the glandular tissue and changes in the shape of the breasts were observed to continue for 6 months. The end result was the development of an unacceptable breast appearance which required a major revisional surgery. Early pregnancy after subcutaneous mastectomy with reconstruction severely affects development leading to distortions in the shape of the breast during pregnancy. Additionally, involution after delivery is not also good enough to provide acceptable outcomes.