Nguyên Lý Và Kỹ Thuật Trong Phẫu Thuật Ung Thư Vú Tạo Hình

PRINCIPLES AND TECHNIQUES IN
ONCOPLASTIC
BREAST CANCER SURGERY

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NEW JERSEY • LONDON • SINGAPORE • BEIJING • SHANGHAI • HONG KONG • TAIPEI • CHENNAI
World Scientific
PRINCIPLES AND TECHNIQUES IN
Editor
Mahmoud Bahij El-Tamer, MD, FACS
Memorial Sloan-Kettering Cancer Center & Cornell University, USA
ONCOPLASTIC
BREAST CANCER SURGERY

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PRINCIPLES AND TECHNIQUES IN ONCOPLASTIC BREAST CANCER SURGERY

To Hania, Bahij, Sarah, my parents, and my siblings, for all your
unconditional support.

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CONTENTS
List of Contributors
xiii
Acknowledgments
xvii
Introduction
xix
1.
Surgical Anatomy of the Breast
1
Mahmoud El-Tamer and Sunny Mitchell
1.1
Topology of the Breast: An Overview . . . . . . . . . . .
1
1.2
Fascia
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
1.3
Raising Flaps . . . . . . . . . . . . . . . . . . . . . . . .
2
1.4
Ligaments of Cooper and Horizontal Septum . . . . . . .
3
1.5
Arterial Supply of the Breast
. . . . . . . . . . . . . . .
3
1.6
Venous Drainage of the Breast . . . . . . . . . . . . . . .
7
1.7
Lymphatics . . . . . . . . . . . . . . . . . . . . . . . . .
7
1.8
Nerve Supply . . . . . . . . . . . . . . . . . . . . . . . .
8
1.9
Nipple Areola Complex . . . . . . . . . . . . . . . . . . .
9
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
2.
Surgical Landmarks and Measurements
13
Suri Ponamgi and Mahmoud El-Tamer
2.1
Breast Measurement . . . . . . . . . . . . . . . . . . . .
14
2.2
Breast Markings
. . . . . . . . . . . . . . . . . . . . . .
15
2.3
Vertical Mastopexy/Reduction Markings . . . . . . . . .
22
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
25
3.
Neoadjuvant Therapy
27
Laurie Kirstein, Susan K. Boolbol, and Mahmoud El-Tamer
3.1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . .
27
3.2
Background . . . . . . . . . . . . . . . . . . . . . . . . .
28
vii

viii
Principles and Techniques in Oncoplastic Breast Cancer Surgery
3.3
Staging . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31
3.4
Predictors of Response . . . . . . . . . . . . . . . . . . .
34
3.5
Gene Profiling . . . . . . . . . . . . . . . . . . . . . . . .
38
3.6
Hormone Receptor-Positive Tumors . . . . . . . . . . . .
38
3.7
Invasive Lobular Carcinoma . . . . . . . . . . . . . . . .
41
3.8
Surgery After NCT . . . . . . . . . . . . . . . . . . . . .
41
3.9
Locoregional Failure: Incidence and Predictors . . . . . .
45
3.10
Predictors of Relapse . . . . . . . . . . . . . . . . . . . .
46
3.11
Future Directions . . . . . . . . . . . . . . . . . . . . . .
47
3.12
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . .
48
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
52
4.
Skin Incisions
57
Mahmoud El-Tamer
4.1
Periareolar Incision . . . . . . . . . . . . . . . . . . . . .
60
4.2
Inframammary Incision . . . . . . . . . . . . . . . . . . .
62
4.3
Skin Closure . . . . . . . . . . . . . . . . . . . . . . . . .
62
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
63
5.
Margins in Breast Cancer Surgery
65
Adriana D. Corben and Monica Morrow
5.1
Methods of Margin Evaluation
. . . . . . . . . . . . . .
66
5.2
Margin Width and Local Recurrence: Invasive
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . .
71
5.3
Margin Width and Local Recurrence: DCIS . . . . . . .
78
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
80
6.
Resection of the Tumor
87
Mahmoud El-Tamer
6.1
General Principles and Preoperative Planning . . . . . .
87
6.2
Resection of the Primary . . . . . . . . . . . . . . . . . .
89
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
96
7.
Repair of Breast Defects
99
Mahmoud El-Tamer
7.1
General Principles
. . . . . . . . . . . . . . . . . . . . . 100
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

Contents
ix
8.
Oncoplastic Breast Reduction
129
Tara L. Huston, Christine H. Rohde, Mahmoud El-Tamer,
and Jeffrey Ascherman
8.1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 129
8.2
The Oncoplastic Approach . . . . . . . . . . . . . . . . . 130
8.3
Patient Selection and Preoperative Breast
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . 131
8.4
History and Physical . . . . . . . . . . . . . . . . . . . . 133
8.5
Types of Breast Reduction . . . . . . . . . . . . . . . . . 133
8.6
Relevant Anatomy
. . . . . . . . . . . . . . . . . . . . . 134
8.7
Technical Considerations . . . . . . . . . . . . . . . . . . 135
8.8
Incision
. . . . . . . . . . . . . . . . . . . . . . . . . . . 136
8.9
Pedicle . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
8.10
Radiation Therapy . . . . . . . . . . . . . . . . . . . . . 150
8.11
Complications . . . . . . . . . . . . . . . . . . . . . . . . 151
8.12
Long-Term Oncologic Results . . . . . . . . . . . . . . . 151
8.13
Breast Cancer Surveillance . . . . . . . . . . . . . . . . . 152
8.14
Cosmetic and Functional Outcomes . . . . . . . . . . . . 153
8.15
Future Directions . . . . . . . . . . . . . . . . . . . . . . 154
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
9.
Mastopexy
159
Mahmoud El-Tamer
9.1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 159
9.2
Dome Mastopexy . . . . . . . . . . . . . . . . . . . . . . 160
9.3
Benelli Mastopexy
. . . . . . . . . . . . . . . . . . . . . 172
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
10.
Skin-Sparing Mastectomy
177
Walter Paul Weber and Mahmoud El-Tamer
10.1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 177
10.2
Incision
. . . . . . . . . . . . . . . . . . . . . . . . . . . 178
10.3
Mastectomy . . . . . . . . . . . . . . . . . . . . . . . . . 183
10.4
Axillary Staging . . . . . . . . . . . . . . . . . . . . . . . 184
10.5
Reconstruction
. . . . . . . . . . . . . . . . . . . . . . . 185
10.6
Safety
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 186

x
Principles and Techniques in Oncoplastic Breast Cancer Surgery
10.7
Postoperative Complications . . . . . . . . . . . . . . . . 186
10.8
Completeness of Mastectomy
. . . . . . . . . . . . . . . 187
10.9
Completeness of Tumor Removal and Local
Recurrence Rates . . . . . . . . . . . . . . . . . . . . . . 187
10.10 Cosmesis . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
11.
Nipple-Sparing Mastectomy
193
Sunny Mitchell and Sheldon Feldman
11.1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 193
11.2
Rationale
. . . . . . . . . . . . . . . . . . . . . . . . . . 194
11.3
Why Not Perform NSM? . . . . . . . . . . . . . . . . . . 194
11.4
Most Frequently Cited Landmark Study . . . . . . . . . 194
11.5
Basic Science
. . . . . . . . . . . . . . . . . . . . . . . . 195
11.6
Proposed Metrics . . . . . . . . . . . . . . . . . . . . . . 195
11.7
Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
11.8
Exclusionary Criteria . . . . . . . . . . . . . . . . . . . . 198
11.9
Preoperative Evaluation . . . . . . . . . . . . . . . . . . 198
11.10 Plastic Reconstructive Surgery Considerations . . . . . . 199
11.11 Comorbidities . . . . . . . . . . . . . . . . . . . . . . . . 200
11.12 Intraoperative Technique . . . . . . . . . . . . . . . . . . 200
11.13 Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . 205
11.14 Additional Technical Notes
. . . . . . . . . . . . . . . . 207
11.15 Intraoperative Radiation with Electrons (ELIOT) . . . . 207
11.16 Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . 208
11.17 Clinical Pearls . . . . . . . . . . . . . . . . . . . . . . . . 210
11.18 Summary and Conclusions . . . . . . . . . . . . . . . . . 210
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
12.
Radiation Therapy
215
Robert R. Kuske, Jr.
12.1
Background . . . . . . . . . . . . . . . . . . . . . . . . . 215
12.2
Oncoplastic Surgery and 5-Day Interstitial
Brachytherapy . . . . . . . . . . . . . . . . . . . . . . . . 216
12.3
Oncoplastic Surgery with 3-Dimensional
Conformal PBI . . . . . . . . . . . . . . . . . . . . . . . 222

Contents
xi
12.4
Intraoperative Radiotherapy During
Oncoplastic Surgery
. . . . . . . . . . . . . . . . . . . . 222
12.5
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . 224
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Index
227

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LIST OF CONTRIBUTORS
Jeffrey Ascherman, MD
Professor of Clinical Surgery
Division of Plastic Surgery
New York-Presbyterian Hospital/Columbia
New York, NY, USA.
Susan K. Boolbol, MD
Chief, Division of Breast Surgery
Beth Israel Medical Center
New York, NY 10003, USA.
Adriana D. Corben, MD
Director, Breast Pathology Fellowship Program
Department of Pathology
Memorial Sloan-Kettering Cancer Center
New York, NY 10065, USA.
Mahmoud Bahij El-Tamer, MD, FACS
Breast Service, Department of Surgery
Memorial Sloan-Kettering Cancer Center
Professor of Clinical Surgery
Weill Medical College at Cornell University
New York, NY 10065, USA.
Sheldon Feldman, MD
Chief, Division of Breast Surgical Oncology
Columbia University Medical Center
New York City, NY 10032, USA.
xiii

xiv
Principles and Techniques in Oncoplastic Breast Surgery
Tara L. Huston, MD
Assistant Professor of Surgery
Division of Plastic and Reconstructive Surgery
Stony Brook University Medical Center
Stony Brook, NY 11794, USA.
Laurie Kirstein, MD
Assistant Professor, Division of Breast Surgery
Beth Israel Medical Center
New York, NY 10003, USA.
Robert R. Kuske, Jr., MD
Arizona Oncology Services Cancer Research Foundation
8994 East Desert Cove Avenue, Suite 100
Scottsdale, AZ 85260, USA.
Sunny Mitchell, MD
White Plains Hospital
41 East Post Road
White Plains, NY 10601, USA.
Monica Morrow, MD
Chief, Breast Service, Department of Surgery
Memorial Sloan-Kettering Cancer Center
New York, NY 10065, USA.
Suri Ponamgi, MD
Fort Lee Plastic Surgery
Fort Lee, NJ 07024, USA.
Christine H. Rohde, MD
Assistant Professor of Clinical Surgery
Division of Plastic Surgery
New York-Presbyterian Hospital/Columbia
New York, NY, USA.

List of Contributors
xv
Walter Paul Weber, MD
Breast Service, Department of Surgery
Memorial Sloan-Kettering Cancer Center
New York, NY 10065, USA.
Department of General Surgery
University Hospital of Basel
Basel, Switzerland.

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ACKNOWLEDGMENTS
I would like to thank Shan-san Wu, MSKCC, for his editorial assistance,
and Anne Erickson, Certified Medical Illustrator at Gnumedia, for her
artwork.
xvii

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INTRODUCTION
Oncoplastic surgery is becoming a discussion-generating topic in the field
of breast cancer surgery. There are, however, no parameters to clearly
define what is meant by the term “oncoplastic surgery.” Some believe that
oncoplastic surgery translates into larger resection of primary cancer with
“better” margins while simultaneously using plastic surgical techniques to
repair the defects created. Others define it as a combination of two surgical
disciplines: surgical oncology and plastic surgery.
When a patient presents with breast cancer to my office, I have three
priorities in mind: patient survival, local control of the disease, and quality
of life. I have listed these priorities by their order of importance. Breast
conservation is as effective as mastectomy in survival, and perhaps in local
control of breast cancer. It is currently performed in more than 60% of
cases with stage I and II disease.
Breast conservation seems to carry a better quality of life due to the
fact that the organ is preserved. It is intuitive, however, that the final
cosmetic result following resection of the cancer and radiation therapy will
impact quality of life and patient recovery. In modern societies, fashionable
clothing frequently molds to or exposes a significant part of the breast.
Furthermore, in Europe, it is becoming more customary to appear topless
on the beach; hence the importance of maintaining a cosmetically appealing
breast following breast-conservation therapy.
What we present in this textbook is our perception of oncoplastic breast
surgery: to resect the breast cancer in an oncologically sound manner while
maintaining — or perhaps enhancing — the cosmetic appearance of the
breast. Oncologically sound principles do not necessarily mean wider mar-
gins and larger resections. We have dedicated a chapter to presenting an
evidence-based definition of adequate margins.
We have divided oncoplastic approaches into two broad categories:
simple and complex. These categories are not etched in stone; there is
some crossover between the two. Simple oncoplastic procedures fall into
xix

xx
Principles and Techniques in Oncoplastic Breast Surgery
the category of when the tumor is small and when excision of such lesions
may require removal of less than 25% of the breast. The complex pro-
cedures usually fall into the category of when the tumors are relatively
large compared with the size of the breast. Resection of relatively large
tumors may necessitate excision of large volume, defined as greater than
25%, of the breast, with significant rearrangement of the tissue as part
of a mastopexy or breast-reductive procedure. We believe that breast and
general surgeons will be able to immediately implement all of the simple,
and some of the complex, oncoplastic techniques described in this book.
The more complex oncoplastic techniques will require specialized training
or consultation with a plastic surgeon. We strongly encourage approaching
the more complex oncoplastic procedures with a team composed of a gen-
eral/breast/oncologic surgeon, and a plastic surgeon who is well versed in
such procedures.
The main purpose of this book is to detail the basic principles and
techniques of oncoplastic procedures, and to attempt to elucidate the evi-
dence underpinning such procedures. We believe that the sound applica-
tion of oncoplastic techniques requires a fundamental understanding of
breast anatomy; basic breast measurements are presented here in separate
chapters.
Neoadjuvant therapy appears to be helpful in achieving a better cos-
metic result, and we have dedicated a chapter to discussing its implemen-
tation relative to oncoplastic techniques. We also address skin and nipple
sparing mastectomies in two separate chapters as these techniques may
enhance the final reconstructive result following mastectomy. These chap-
ters may be reviewed independently. It is, however, preferable to refer to
them that way after completing the book as a whole.
This book is directed to the general surgeon and the breast surgeon, as
well as to the plastic surgeons who will collaborate in these interventions.
It is my wish that this book will widen your horizons and enhance your
patients’ satisfaction.

Chapter 1
SURGICAL ANATOMY OF THE BREAST
Mahmoud El-Tamer∗and Sunny Mitchell†
∗Breast Service, Department of Surgery,
Memorial Sloan-Kettering Cancer Center,
New York, NY 10065, USA
†Women’s Breast Center, Department of Surgery,
Tully Health Center,
Stamford, CT 06902, USA
1.1 Topology of the Breast: An Overview
The breasts are the most superficial aspect of the anterior chest wall. The
skin immediately over the breast tissue is characterized with a nipple are-
ola complex (NAC), centrally located in young adults. The borders of the
breast are the second intercostal space superiorly, the midaxillary line lat-
erally, the inframammary line inferiorly, and the sternum medially. The
breast overlies the pectoralis major muscle and part of the serratus anterior,
external oblique, and rectus abdominus. The NAC is generally located in
the fourth and fifth intercostal spaces in males and prepubescent children.
Many studies have reported that women’s breasts are more frequently
asymmetric.1,2 In a recent study, Avsar et al. measured anthropometric
breast values in 386 female students and reported symmetric breast vol-
ume in only 35% of subjects.3 Multiple studies have been done over the
years on all aspects of breast anatomy, including arterial supply, venous
drainage, and lymphatic patterns. Discrepancies have existed in the pub-
lished literature in aspects such as lymphatic mapping, dominant arterial
supplies, and general vascular patterns. Information presented in the fol-
lowing paragraphs represents the most current research and findings. Along
with the currently supported theories, we have also listed papers of histor-
ical precedence which are of interest and relevance to all surgeons.
1

2
Principles and Techniques in Oncoplastic Breast Cancer Surgery
1.2 Fascia
The breast is enveloped by a pseudofascial plane: the superficial fascia of
the anterior thoracic wall. This fascia splits into an anterior and a poste-
rior layer. The posterior or deep layer of the superficial fascia is found deep
posterior to the breast tissue, overlying the retromammary space and pec-
toralis muscle fascia. The retromammary bursa is a distinct space between
the posterior fascia of the breast and the pectoralis fascia, which facilitates
mobility of the breast over the chest wall. The superficial fascia joins the
cervical fascia at the level of the second intercostal space and superficial
abdominal fascia of Camper after the inframammary line. The anterior
border of the breast is thought to lie in the subdermal plane.4
1.3 Raising Flaps
The identification of the appropriate plane is crucial when creating flaps
for breast-conservation surgery or mastectomy. Immediately below the skin
lies the subdermal system, the subcutaneous tissue, and, finally, the breast
parenchyma (Figure 1.1).4 A dissection in between the subdermal and sub-
cutaneous system results in excision of all breast tissue and preservation
of adequately perfused flaps (Figure 1.1, Plane 1). While raising flaps for
the repair of the defect, we recommend that flaps be raised between the
subcutaneous tissue and the breast (Figure 1.1, Plane 2).
Figure 1.1.
Raised flaps between the subcutaneous tissue and the breast. (1) Subdermal
plane. (2) Subcutaneous plane.

Surgical Anatomy of the Breast
3
When utilizing tumescent injection and sharp dissection for creating
flaps, the tumescent solution is injected into the subcutaneous space, and
dissection proceeds between the subcutaneous space and the subdermal
system. Flap thickness varies between patients. In the same patient, the
thickness of the flaps varies in different locations. Blood loss is minimal
when surgeons use the appropriate plane because the connecting vessels
between the breast and the subdermal tissue are miniscule.
1.4 Ligaments of Cooper and Horizontal Septum
The deep and superficial layers of the superficial fascia are linked through
fibrous bands, known as ligaments of Cooper. These ligaments originate
from the pectoralis fascia at the level of the fifth rib and extend into the
overlying skin as well as the pectoralis major muscle, dividing the breast
tissue into septae and aiding in suspending the breast to the chest wall.5,6
A ligamentous septum comprising a horizontal fibrous septum originat-
ing from the pectoralis fascia at the level of the fifth rib and its vertical
ligamentous suspension provides medial and lateral lines of fixation on
either side of the breast.5 This also gives rise to a superficial aspect that
merges into the overlying skin.5 The medial superficial ligament is thought
to be weaker and stretches into the skin overlying the sternum. The lateral
stronger superficial ligament creates a strong connection between the pec-
toralis minor as well as the skin and overlying fascia of the axilla along the
midaxillary line, producing the axillary hollow.5 The superficial part of the
horizontal septum is a thickening of the ligaments of Cooper, stretching
for the same origin at the level of the fifth rib to the inframammary line.5
The horizontal ligamentous septum guides the neurovascular supply of the
breast and nipple areola complex. Varying degrees of ptosis are a direct
reflection of the laxity of the ligaments of Cooper.
Between the breast and the pectoralis major fascia exists the space
known as the retromammary bursa, which facilitates the mobility of the
breast on the chest wall. Adhering to this space while raising local flaps for
breast-conservation surgery is crucial to the viability of the breast tissue; it
will preserve the integrity of the neurovascular supply to the breast tissue,
and minimize fat and tissue necrosis, particularly in older women with fatty
breasts.
1.5 Arterial Supply of the Breast
Salmon developed a successful injection technique in cadavers that allowed
him to delineate the arterial supply of the breast in fine detail.7 He

4
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Figure 1.2.
MRI reconstruction of the blood supply of the breast. (Courtesy of
Dr. Jennifer Kaplan, Memorial Sloan-Kettering Cancer Center, New York, NY.)
found that the blood supply to the breast originated from 3 systems, the
axillary, internal mammary, and intercostals, which are more commonly
known today as the lateral mammary, internal mammary, and intercostal
branches. The predominant vascular supply of the breast is from the inter-
nal mammary, anterior intercostal, lateral thoracic, and thoracoacromial
arteries.8 The inferior and central pedicles of the breast were thought to
be hypovascularized.9 This idea was challenged by Salmon, who attributed
this misconception to an inadequate injection technique. He has proposed
that the inferior and central portions of the breast receive arterial supply
from perforators through the pectoralis muscle. These perforators are well
visualized during a mastectomy while taking the breast offthe pectoralis
major muscle. Figure 1.2 represents a magnetic resonance imaging (MRI)
reconstruction of the blood supply of the breast, clearly showing the lateral
mammary, internal mammary, and intercostal perforators.
1.5.1 Lateral Mammary Artery
This artery supplies the lateral aspect of the breast; it is a direct branch
of the axillary artery or one of its tributaries.10 Salmon has observed the
lateral mammary artery to arise from the external mammary artery, lat-
eral thoracic artery, or directly from the axillary artery.7 Occasionally, it is
referred to as the lateral thoracic artery, which is thought to be incorrect as
the lateral thoracic artery supplies the lateral upper chest wall. The lateral
mammary artery enters the breast over the axillary tail laterally at the

Surgical Anatomy of the Breast
5
Figure 1.3.
Lateral mammary artery, traveling through the breast.
level of the third or fourth rib. The artery runs superficially and takes an
anterolateral course, sending branches into the breast tissue, the overlying
skin, and the chest wall. This artery consistently contributes deep subcu-
taneous branches to the NAC6 and has been cited as contributing 30%
of the blood flow to the breast.11 The branches of the lateral mammary
artery travel diagonally in a medial direction until fading beyond the lat-
eral aspect of the inframammary line (Figure 1.3). The lateral mammary
artery connects with the medial artery around the NAC either through the
superficial or posterior branches (Figure 1.2).
The lateral mammary artery is pivotal for the survival of the later-
ally based breast reduction. This artery may frequently be ligated during
an axillary node dissection. When planning an oncoplastic procedure in a
patient who is undergoing an axillary node dissection, one has to avoid
mammaplasties that are laterally based.
1.5.2 Internal Mammary Artery
The internal mammary artery (internal thoracic artery) originates from
the subclavian artery, traveling parallel and posterior to the lateral bor-
der of the sternum. This artery provides up to 60% of the blood supply
to the breast, mostly the medial portion. It sends anterior and poste-
rior perforating branches through the parasternal and intercostal spaces.
The largest branches perforate through one of the first few intercostal
spaces. The anterior perforators arise from the first 4 intercostal spaces,

6
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Anterior branch
Posterior branch
Internal mammary
Figure 1.4.
MRI reconstitution of the branches of the internal mammary, showing the
anterior and the posterior branches. (Courtesy of Dr. Jennifer Kaplan, Memorial Sloan-
Kettering Cancer Center, New York, NY.)
just medial to the sternum. Perforators from the second and third inter-
costal spaces are the most consistent, while those from the first and fourth
are not as common.12 These anterior perforators split into cutaneous and
breast branches (Figure 1.2). Preserving the integrity of the cutaneous
branches is crucial when performing a skin-sparing or nipple areola-sparing
mastectomy.
The posterior medial perforators of the internal thoracic artery (only
described by Salmon) arise more laterally from the intercostal spaces
through the pectoralis fascia into the breast and supply the deep portion of
the breast tissue. These vessels appear to be branches of the internal tho-
racic artery, emerging from the fourth and fifth intercostal spaces. These
vessels may have been reported by others and referred to as branches of
the intercostals. Figure 1.4 is an MRI reconstitution of the branches of
the internal mammary, showing the anterior and the posterior branches.
This blood supply supports a significant portion of the medial aspect of
the breast as well as the NAC. This is the main blood supply for medi-
ally based breast reduction. The posterior medial mammary arteries are
important contributors to the arterial blood supply of the inferiorly based
breast reduction pedicle.
1.5.3 Thoracoacromial Artery
The pectoral branch of the thoracoacromial artery is a less-important blood
supply source to the breast. It is located between the pectoralis major and

Surgical Anatomy of the Breast
7
minor muscles, entering the subcutaneous breast tissue at the deltopectoral
groove.6 Branches may reach the posterior aspect of the breast as well as
be accompanied by lymphatics that may allow for metastasis to Rotter’s
nodes.
1.5.4 Posterior Intercostal Arteries
The posterior intercostal arteries give offbranches that perforate the chest
wall and run laterally to the pectoral muscle, giving rise to vessels that
supply the lower outer quadrant of the breast. The contribution of these
vessels has been debated.
1.6 Venous Drainage of the Breast
Blood drains from the breast through a superficial and deep system. The
medial segment of the breast was found to have a superficial drainage
pattern, whereas the lateral venous drainage was found to run deeper.8
The dominant drainage pattern of the breast has been found to be super-
ficial. The subareolar plexus radiates most frequently to the superome-
dial and inferior pole.13,14 The dominant drainage route was found to
be via the third and fourth intercostal spaces.13,14 Superomedial drainage
is via the second and third intercostal spaces, while lower pole drainage is
via the fourth and fifth intercostal spaces.13,14 The subareolar plexus has
been found consistently in the subcutaneous plane.13 The nipple venous
drainage appears to run medially to the internal mammary veins.
Venous insufficiency is often the culprit for vascular compromise in
breast-reduction surgery. An important point to remember is that when
the lateral veins are divided, the venous drainage of the NAC becomes
dependent on the superficial veins in the superomedial pedicle.8 Additional
studies on breast vasculature are included.7,10−12,15,16 These studies are
interesting and include results commonly found today, along with multiple
discrepancies, including currently unrecognized vessels.
1.7 Lymphatics
The axilla is accepted as the main basin for lymphatic drainage of the
breast. Whether lymphatics drain into the subareolar complex prior to
traveling to the axilla is yet to be confirmed. Suami et al.,17 through radi-
ologic lymph injection into cadavers, summarized the following:
(1) No difference was found in superficial lymph vasculature between males
and females.

8
Principles and Techniques in Oncoplastic Breast Cancer Surgery
(2) The midaxillary line divides the lymph territories of the upper
torso.
(3) A sentinel node of the upper limb also covers a wide range of the
anterior upper torso.
(4) The lymph-collecting vessels from the nipple merge with the vessels
from the lower part of the torso before reaching the axilla.
(5) In the female breast, some torso lymph vessels run through the breast
tissue.
1.8 Nerve Supply
Initially described in detail by Sir Astley Cooper in 1840, the breast has
since been consistently found to be innervated from the lateral and ante-
rior cutaneous branches of the second to sixth intercostal nerves.18,19 The
lateral branches pierce the chest wall musculature at the midaxillary line
and travel medially. These nerves divide into a superficial branch and a
deep branch at the edge of the pectoral muscle (Figure 1.5).
The superficial branch travels subcutaneously, whereas the deep
branches travel along the pectoralis fascia for a few centimeters and then
merge through the breast tissue to the surface at the midclavicular line.
Figure 1.5.
Nerve supply to the breast. The lateral cutaneous nerve divides into super-
ficial and deep branches.

Surgical Anatomy of the Breast
9
The anterior cutaneous branches merge through the chest wall at the
edge of the sternum and travel superficially toward the nipple, thereby
supplying the medial aspect of the breast.
The NAC innervation is not consistent, hence the controversy. It is
agreed upon, however, that the innervation of the NAC is from the anterior
and lateral branches of the third to fifth intercostal nerves. The fourth
lateral cutaneous nerve is the most frequent source of sensation to the
NAC, mostly via its deep branches.
Hamdi and colleagues have reported that in 93% of breasts, the deep
branch of the lateral cutaneous nerve innervates the nipple. As previously
described, the deep branch runs within the pectoralis fascia, curves straight
up through the glandular tissue at the level of the midclavicular line, and
sends its terminal branches straight to the nipple.20
The third, fourth, and fifth anterior branches innervate the medial
aspect of the NAC. The nerves enter the NAC superficially at its medial
edge, mostly between 8:00 o′clock and 11:00 o′clock for the left breast
and 1:00 o′clock to 4:00 o′clock for the right breast. When planning a ter-
minal duct excision or removing a centrally located tumor, we strongly
recommend avoiding a medial periareolar incision because it will interrupt
the anterior cutaneous branches that will be the only innervation to the
NAC. Understanding the innervation of the NAC is important in planning
incisions and access for resection of a tumor. Historical papers on breast
innervation are included.21,22
1.9 Nipple Areola Complex
1.9.1 Innervation
Innervation of the NAC is derived from the anterior and lateral cutaneous
branches of the second to fourth intercostal nerves. The fourth lateral and
medial intercostal (anterior cutaneous) branches provide the most consis-
tent innervation (see Section 1.8).14,23
1.9.2 Blood Supply
The NAC’s most consistent blood supply source is medial via the internal
thoracic artery.4,6,24 The NAC is also supplied with blood from the anterior
intercostal arteries as well as the lateral thoracic artery. Very rarely do
direct branches of the axillary artery or posterior intercostal arteries supply
the NAC.4,24 This is of clinical relevance in understanding how to work
within the confines of the most likely patterns of arterial supply to the
NAC. For the most part, NAC venous drainage appears to run medially to
the internal mammary veins.8

10
Principles and Techniques in Oncoplastic Breast Cancer Surgery
1.9.3 Areola
The areola contains Montgomery glands. These are sebaceous glands, capa-
ble of secreting milk. The Morgagni tubercles are small, raised papules on
the areola through which Montgomery glands have egress.25
The NAC is an important landmark of the breast. Its position
and potential repositioning is of utmost importance in breast-conserving
surgery as well as nipple-sparing mastectomy. A periareolar incision of
half or less than half the circumference of the NAC is thought to be well
tolerated, resulting in minimal chance of epidermolysis. When utilizing
oncoplastic techniques, it is often necessary to reposition the NAC by de-
epithelializing the periareolar skin (as in the Benelli mastopexy). The NAC
is dependent on the lateral or medial dermal vasculature and underlying
parenchyma for blood supply.
Maintaining a 0.5 to 1.0 cm thickness of glandular tissue under the
NAC while raising flaps in breast-conservation cases helps in survival of
the NAC.26 The dermal vasculature is responsible for the blood supply of
a de-epithelialized NAC once it is separated from the underlying gland.26 In
an inferior pole mammoplasty, the vascular supply of the NAC is derived
from the inferior and posterior glandular tissue. The NAC maintains its
blood supply via the superior pedicle after a wide-local excision via a J-
mammaplasty or superior pedicle mastopexy.26
Operating on the breast is quite forgiving. To achieve excellent cos-
metic results after a sound oncologic procedure, a full understanding of
the anatomy, with particular emphasis on the blood supply, of the breast
and overlying skin is required.
References
1. Bostwick J. (1983) Correction of breast asymmetries. Aesthetic and Recon-
structive Breast Surgery. Mosby Company, St. Louis, Toronto, London,
p. 252.
2. Smith DJ, Jr., Palin WE, Jr., Katch VL, Bennett JE. (1986) Breast volume
and anthropomorphic measurements: Normal values. Plast Reconstr Surg
78(3):331–335.
3. Avsar DK, Aygit AC, Benlier E, et al. (2010) Anthropometric breast mea-
surement: A study of 385 Turkish female students. Aesthet Surg J 30(1):
44–50.
4. Pearl RM, Johnson D. (1983) The vascular supply to the skin: An anatomical
and physiological reappraisal — Part II. Ann Plast Surg 11(3):196–205.
5. Wueringer E, Tschabitscher M. (2003) New aspects of the topography of the
mammary gland regarding its neurovascular supply along a regular ligamen-
tous suspension. Eur J Morphol 40(3):181.

Surgical Anatomy of the Breast
11
6. O’Dey D, Prescher A, Pallua N. (2007) Vascular reliability of nipple-
areola complex-bearing pedicles: An anatomical microdissection study. Plast
Reconstr Surg 119(4):1167–1177.
7. Salmon M. (1939) Les arthres de la glande mammaire. Ann Anat Pathol 16:
477–500.
8. Michelle le Roux C, Kiil BJ, Pan WR, et al. (2010) Preserving the neurovas-
cular supply in the Hall-Findlay superomedial pedicle breast reduction: An
anatomical study. J Plast Reconstr Aesthet Surg 63(4): 655–662.
9. Maliniac JW. (1943) Arterial blood supply of the breast. Arch Surg
47:329–343.
10. Cunningham L. (1977) The anatomy of the arteries and veins of the breast.
J Surg Oncol 9(1): 71–85.
11. Nakajima H, Imanishi N, Aiso S. (1995) Arterial anatomy of the nipple-
areola complex. Plast Reconstr Surg 96(4):843–845.
12. Palmer JH, Taylor GI. (1986) The vascular territories of the anterior chest
wall. Br J Plast Surg 39(3):287–299.
13. CorduffN, Rozen WM, Taylor GI. (2010) The superficial venous drainage
of the breast: A clinical study and implications for breast reduction surgery.
J Plast Reconstr Aesthet Surg 63(5):809–813.
14. Jaspars JJ, Posma AN, van Immerseel AA, Gittenberger-de Groot AC.
(1997) The cutaneous innervation of the female breast and nipple-areola
complex: Implications for surgery. Br J Plast Surg 50(4):249–259.
15. Anson BJ, Wright RR, Wolfer JH. (1939) Blood supply of the mammary
gland. Surg Gynecol Obstet 69:468–473.
16. Wuringer E, Mader N, Posch E, Holle J. (1998) Nerve and vessel supply-
ing ligamentous suspension of the mammary gland. Plast Reconstr Surg
101(6):1486–1493.
17. Suami H, O’Neill JK, Pan WR, Taylor GI. (2008) Superficial lymphatic sys-
tem of the upper torso: Preliminary radiographic results in human cadavers.
Plast Reconstr Surg 121(4):1231–1239.
18. Sarhadi NS, Shaw Dunn J, Lee FD, Soutar DS. (1996) An anatomical study
of the nerve supply of the breast, including the nipple and areola. Br J Plast
Surg 49(3):156–164.
19. Sarhadi NS, Shaw-Dunn J, Soutar DS. (1997) Nerve supply of the breast
with special reference to the nipple and areola: Sir Astley Cooper revisited.
Clin Anat 10(4):283–288.
20. Hamdi M, Wurenger E, Schlenz I, Kuzbari R. (2005) Anatomy of the breast:
A clinical application. In: Hamdi M, Hammond DC, Nahai F (eds.), Vertical
Scar Mammaplasty, Springer Verlag, Berlin, p. 6.
21. Craig
RD,
Sykes
PA.
(1970)
Nipple
sensitivity
following
reduction
mammaplasty. Br J Plast Surg 23(2):165–172.
22. Regnault P. (1974) Reduction mammaplasty by the “B” technique. Plast
Reconstr Surg 53(1):19–24.
23. Schlenz I, Kuzbari R, Gruber H, Holle J. (2000) The sensitivity of the
nipple-areola complex: An anatomic study. Plast Reconstr Surg 105(3):
905–909.

12
Principles and Techniques in Oncoplastic Breast Cancer Surgery
24. van Deventer PV. (2004) The blood supply to the nipple-areola complex of
the human mammary gland. Aesthet Plast Surg 28(6):393–398.
25. Nicholson BT, Harvey JA, Cohen MA. (2009) Nipple-areolar complex: Nor-
mal anatomy and benign and malignant processes. Radiographics 29(2):
509–523.
26. Clough KB, Kaufman GJ, Nos C, et al. (2010) Improving breast cancer
surgery: A classification and quadrant per quadrant atlas for oncoplastic
surgery. Ann Surg Oncol 17(5):1375–1391.

Chapter 2
SURGICAL LANDMARKS
AND MEASUREMENTS
Suri Ponamgi∗and Mahmoud El-Tamer†
∗Fort Lee Plastic Surgery, Fort Lee, NJ 07024, USA
†Breast Service, Department of Surgery,
Memorial Sloan-Kettering Cancer Center,
New York, NY 10065, USA
Preoperative marking is an integral step for a successful outcome in
oncoplastic surgery procedures of the breast. Because of the diversity of
the female breast physiognomy, accurate and reproducible measurements
are difficult to achieve.
The young breast is a conical mound with the nipple and areola at its
highest point, which is the center of the mound. As the breast ages and
its size increases, it develops ptosis with a downward slant in the upper
pole, and descent of the nipple complex on the mound that is dependent on
the increase in volume. As the breast goes through the hormonal changes
that occur during pregnancy, there is an initial increase in its volume, with
eventual deflation and ptosis after childbirth. The breast can also change
in size and shape with obesity and weight gain; the fluctuations in volume,
associated with weight changes, are seen more in postmenopausal breasts,
where most of the breast tissue is replaced by fat.
Surgical treatment for breast cancer has varied greatly, from the most-
radical Hagensen mastectomy, to extended radical mastectomy, to the
present-day conservative nipple-sparing surgery in select cases. Several
papers have focused on how to reconstruct partial mastectomy defects by
rearranging the remaining breast tissue and relocating the nipple and are-
ola complex. In many instances, even in autologous tissue or staged-implant
reconstructions, the opposite breast must be treated to achieve symmetry.
Planning for surgery in such cases must be done simultaneously by marking
both breasts at the same time.
13

14
Principles and Techniques in Oncoplastic Breast Cancer Surgery
2.1 Breast Measurement
In the 1950s, Penn defined breast aesthetics by studying 150 healthy
women, 20 of whom had “perfect” breasts.1 He found that an equilateral
triangle existed between the suprasternal notch and both nipples in those
women whose limbs were approximately 21 cm in length. The distance was
also the same from the midclavicular line to the nipple. In Penn’s study, the
average nipple-to-inframammary–fold distance was 6.9 cm. Although these
symmetry findings are not absolutes because patients and their breasts
come in all shapes and sizes, they are a useful guide to keep in mind.
Most recently, Westreich published results of anthropometric measure-
ments in 50 women with aesthetically “perfect” breasts.2 His study cites
previously published studies by Penn1 in 1955 and Smith DJ et al.3 in
1986, and differs from them in that his subjects were women with only
“perfect” breasts. His study reported the following norms: (1) the acro-
mial span (obtained by doubling the distance between the acromium and
the suprasternal notch) had a mean value of 36.52 cm; (2) the range was
between 32 cm in a subject with a 425-cc breast volume and 41 cm in a sub-
ject with 325-cc breast volume; (3) the midclavicle-to-nipple distance was
18.6 cm with a range between 16.5 cm (305-cc breast volume) and 23 cm
(375-cc breast volume); (4) the mean nipple-to-inframammary–crease dis-
tance was 6.95 cm (Figure 2.1); (5) this distance increased with an increase
in volume; (6) in inverted “T” breast reductions, this measurement was
approximately between 5 cm and 6 cm, depending on the diameter of the
reconstructed areola, and the length of the vertical component of the scar
did not exceed 5 cm; (7) the mean value of the nipple-to-nipple distance was
19.35 cm; and (8) the suprasternal notch-to-nipple distance was 18.59cm.
In the clinical setting, wide variations can be seen depending on the
attachments of the breast to the chest wall. If such variations are not con-
sidered and measurements are made with the assumption that the breasts
are in normal position, disastrous results can occur. It is the breast base
(the attachment of the breast to the chest wall) that determines the breast’s
relative position on the chest wall. This issue was studied by Hall-Findley,4
who found that regardless of suspension technique used in breast reduction
and lift surgeries, a low-positioned breast will always remain low, and that
to achieve upper-pole fullness in these breasts, one may have to resort to
using an implant. She also suggests that a safer way to determine the new
position for the nipple in a low-positioned breast is to locate the upper
pole of the breast on the chest wall and position the upper pole of the
new areola at 8 cm from this point, inferiorly along the nipple meridian. To
avoid bottoming-out, most breast tissue that is removed should be from
the lower pole. In a markedly ptotic breast, it may even be appropriate to

Surgical Landmarks and Measurements
15
reduce the breast in the lower pole during mastopexy and add an implant
for volume if upper-pole fullness is desired. According to the observations
of Westreich, a high-positioned breast needs a smaller volume to appear
adequate whereas, in a low-positioned breast, a larger breast volume may
be appropriate.
In the oncoplastic setting, the shape, size, and location of the defect are
clearly dictated by the location and size of the primary. The surgical team
will have to plan the nipple repositioning, based on the oncologic procedure.
The mean inframammary-crease length has a high correlation with the
breast volume. In reduction patients with large pendulous breasts, there is
an extension of this fold laterally, resulting in dog-ears and extension of the
submammary scars laterally, with need for liposuction of the folds. In the
vertical technique, mere liposuction of the folds will improve the contour.
Westreich et al. also observed areola shape and size in their study,
reporting that 52% of the women studied had symmetrically round areo-
las, and that areola size increased with the size of the breast. The most
attractive areolar diameter is approximately 35–45mm, and the ideal nip-
ple projection is usually 4–7 mm.5
To achieve good results in breast surgery, there is still no substitute for
adequate preoperative evaluation, experience, and surgical skill. A cook-
book technique, based only on measurements, will not suit all patients.
Preoperative planning with a rough estimate of the size and location of
the defect, and good aesthetic sense with the ability to modify if neces-
sary during surgery, will reduce complications and yield better results. As
a result, the importance of an adequate review of all breast images and
appropriate discussion with all members of the surgical team is crucial.
2.2 Breast Markings
Measurements and breast markings should be made with the woman stand-
ing in the normal anatomic position, with the shoulders back, head facing
straight ahead, and arms alongside. First, the fixed landmarks are identi-
fied: the sternal notch; the clavicle; the midline; and the nipple meridian
(Figure 2.1). The nipple meridian is a vertical line that starts from a point
on the clavicle located 6–7 cm lateral to the midsternal notch. The line
drops down through the center of the nipple (Figure 2.2, Picture 1). The
inframammary lines are then identified on both sides. The surgeon must
pay particular attention to the level of the inframammary lines and their
symmetry on both sides. The surgeon must make every effort to keep the
final position of the nipple along the nipple meridian and at a distance of
approximately 19 cm to 22 cm from the midclavicular line.

16
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Figure 2.1.
Breast landmarks: (1) Acromial span. (2) Sternal-notch nipple meridian
(6–7 cm). (3) Nipple meridian. (4) Sternal-notch nipple. (5) Anteriorly transposed infra-
mammary line. (6) Midline.
Figure 2.2, Picture 1.
A vertical line that starts from a point on the clavicle located
6–7 cm lateral to the midsternal notch. The line drops down through the center of the
nipple.

Surgical Landmarks and Measurements
17
When a mastopexy or a breast reduction is considered as part of
the oncoplastic procedure, the markings for the final skin envelope vary
depending on the type of reduction, resection, or lift that is planned.
The nipple-meridian marking is extended across the inframammary line.
The most classical approach has been the Wise pattern or inverted-T
mastopexy/reduction. The new position of the nipple must be identified, as
well as the amount of skin to be excised or de-epithelialized. The location
for the future position of the nipple is marked along the nipple meridian.
The inframammary fold is transposed anteriorly on the breast along the
nipple meridian to mark the new position for the nipple. The new nipple
position will be at the intersection of the inframammary line and the nipple
meridian. This is done by placing 4 fingers of the hand behind the breast
in the fold and the thumb anteriorly, grasping the breast, and marking the
point of the fold transposed anteriorly (Figure 2.2, Picture 2).
In larger breasts, one hand is placed behind at the fold and the other
hand is used to palpate the level of the fold on the anterior aspect of the
breast.
The position of the nipples is marked symmetrically along the nipple
meridian, equidistant from the supra-sternal notch at the highest point of
the breast projection on both sides (Figure 2.2, Picture 3, Picture 4).
Marking nipple position using static measurements for reduction or
mastopexy incurs the risk of dislocation of the nipple by 1.0–1.5cm. Nip-
ples placed high or pointing upward may be visible in the cleavage line
and appear unaesthetic. A nipple placed low and laterally can be easily
Figure 2.2, Picture 2.
Transposing the inframammary fold anteriorly along the nipple
meridian to mark the new position for the nipple.

18
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Figure 2.2, Picture 3.
Marking the nipple symmetrically along the nipple meridian,
equidistant from the supra-sternal notch at the highest point of the breast projection
on both sides.
Figure 2.2, Picture 4.
Marking the nipple symmetrically along the nipple meridian,
equidistant from the supra-sternal notch at the highest point of the breast projection
on both sides.

Surgical Landmarks and Measurements
19
repositioned. A nipple placed high and medially, however, requires more
complex procedures with visible scarring. Most techniques mark the height
of the nipple along the nipple meridian measuring from anatomical fixed
points. We feel that positioning the nipple at 19–22 cm from the midclav-
icle will be safe. We recommend that surgeons who are novices place the
upper edge of the areola at the point of the new nipple.
From the new position of the nipple, a circle with a radius of 2 cm may
be marked to receive the areola; alternatively, this can be done after the
breast is shaped. The new top of the areola is identified 1.5–2.0 cm superior
to the new nipple. Freehand marking is widely used by most surgeons, and
requires experience and practice to achieve the desired shape. Imbricating
the breast parenchyma or the skin allows surgeons to estimate the amount
of skin to be removed in order to reshape the breast with adequate skin
tone and tension at the suture lines. Using parenchymal imbrication, the
medial and lateral limbs of the vertical ellipse are marked on either side of
the areolar complex (Figure 2.2, Picture 5, Picture 6).
The vertical limbs of the Wise pattern extend 7 cm from the position
of the future nipple inferomedially and inferolaterally. The nipple meridian
marking is extended across the inframammary line to marking point D
(Figure 2.2, Picture 7) where the end of vertical limbs will be positioned
(points B and C). The medial and lateral ends of the inframammary fold
are joined to the end of the vertical limbs, completing the Wise keyhole
pattern (Figure 2.2, Picture 7, Picture 8).
Figure 2.2, Picture 5.
Using parenchymal imbrication, the medial and lateral limbs of
the vertical ellipse are marked on either side of the areolar complex.

20
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Figure 2.2, Picture 6.
Using parenchymal imbrication, the medial and lateral limbs of
the vertical ellipse are marked on either side of the areolar complex.
A
B
C
D
New nipple position
Figure 2.2, Picture 7.
The Wise pattern. Points B, C, and D will be sutured together
when completing the reshaping of the breast.
Multiple devices are available to facilitate the marking of the breast
(Figure 2.2, Picture 9, Picture 10). The standard pattern consisting of
a keyhole and a fixed angle of divergence of 110 degrees was modified by
McKissock to allow for adjustment of the angle for breasts of varying shapes

Surgical Landmarks and Measurements
21
Figure 2.2, Picture 8.
Joining of the medial and lateral ends of the inframammary fold
to the end of the vertical limbs, completing the Wise keyhole pattern.
Figure 2.2, Picture 9.
McKissock Breast Marker. Miltex Instruments. Available in
38 mm, 42 mm, and 45 mm keyhole diameters.

22
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Figure 2.2, Picture 10.
Visual application of the McKissock Breast Marker.
and sizes. The lower border of the areola should be at least 5 cm from the
final inframammary line.
2.3 Vertical Mastopexy/Reduction Markings
The vertical mastopexy/reduction has gained popularity among surgeons
as these techniques have eliminated inframammary scars and given greater
projection to the breast with higher nipple appearance, especially after the
breast settles. In a vertical mastopexy/reduction, the inframammary fold
is transposed anteriorly onto the breast, and this point is marked as the
highest point of the areola and the nipple positioned 2 cm lower. Com-
pared to the Wise pattern, in the vertical mastopexy, the nipple is placed
1.5–2.0 cm lower; the upper edge of the areola is placed at the intersection
of the inframammary line and the nipple meridian. The nipple meridian
marking is extended across the inframammary line to the abdominal wall.
The vertical ellipse is marked by displacing the breast medially and later-
ally across the nipple meridian, assessing the horizontal excess of the skin
to be removed (Figure 2.2, Picture 11, Picture 12).
At the upper end of the ellipse, a “mosque” or “dome” pattern is marked
to inset the future areola, and the 2 vertical limbs of the ellipse are drawn
around the areola, stopping 2 cm short of the inframammary fold mark-
ing in smaller breasts and 4 cm short of the inframammary-fold marking
in larger breasts (Figure 2.2, Picture 13; Figure 2.3). After the markings
are completed, they are checked for symmetry, allowing for breast size

Surgical Landmarks and Measurements
23
Figure 2.2, Picture 11.
Marking of the medial vertical limb by displacing the breast
laterally and drawing a line that meets the extension of the nipple meridian on the
abdominal wall.
Figure 2.2, Picture 12.
Marking the vertical ellipse by displacing the breast medially
in a similar fashion to the medial limb.

24
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Figure 2.2, Picture 13.
“Mosque” or “dome” pattern.
Figure
2.3.
Markings
for
Vertical
Reduction.
(A)
Upper
pole
of
the
breast.
(B) “Mosque” pattern for areola. (C) Vertical ellipse of skin reduction. (D) Distance from
lower pole of vertical ellipse to inframammary crease (2 cm for small breasts and 4 cm
for large breasts). (E) Extension of nipple meridian across the inframammary crease.

Surgical Landmarks and Measurements
25
discrepancy. By imbricating the parenchyma and the skin, the width of
the vertical ellipse can be adjusted to avoid tension along the suture line
at closure. After breast shaping is completed, the areolar circle may be
adjusted if necessary to accommodate the areola in its new position, keep-
ing the upper pole constant. Lista et al., in their study of vertical reduction
mammaplasty,6 discuss how pedicle choice is dependent on the markings.
After the markings are made, if any part of the areola falls within the
mosque pattern, a superior dermo-glandular pedicle is used. If the are-
ola is below the mosque pattern, a medial pedicle is used. This facilitates
insetting the areola in its new location after the reduction procedure. In
oncoplastic procedures, the type of nipple areola pedicle is dictated by the
location of the tumor.
In June 2006, Fahmy et al. reported from United Kingdom7 on another
technique that makes freehand marking easier, even for surgeons with lim-
ited experience. The markings are made with the patient in sitting, supine,
and oblique positions. After marking the fixed point of the supra-sternal
notch, the breast (nipple) meridian is marked from the clavicle equidistant
from the supra-sternal notch on either side and through the center of the
nipple, carrying it across the inframammary fold. The new nipple posi-
tion is marked along the breast meridian. With the patient in the supine
position, the inframammary folds are marked with gentle pressure on the
breasts and with a dart along the intersection of the breast meridian with
the inframammary fold. This avoids tension on wound closure. The medial
limb of the vertical ellipse is marked by connecting the new nipple point
to the dart in a straight line.
With the patient in an oblique sitting position, as the breasts fall lat-
erally, the lateral limbs of the vertical ellipse are marked, connecting the
new nipple point to the inframammary dart in a straight line, marking the
right breast with the patient in the left lateral oblique position, and vice
versa. Finally, with the patient in an upright sitting position, 7 cm-long
medial and lateral limbs are marked from the new nipple point to intersect
with the medial and lateral limbs of the vertical ellipse for an inverted “T”
reduction. For a vertical scar reduction, new nipple markings are made
lower along the breast meridian, and the vertical ellipse is marked with
the lower end of the ellipse, ending 2–4 cm above the inframammary fold
according to the size of the breast reduction.
References
1. Penn J. (1955) Breast reduction. Br J Plast Surg 7(4):357–371.
2. Westreich M. (1997) Anthropomorphic breast measurement: Protocol and
results in 50 women with aesthetically perfect breasts and clinical application.
Plast Reconstr Surg 100(2):468–479.

26
Principles and Techniques in Oncoplastic Breast Cancer Surgery
3. Smith DJ, Jr., Palin WE, Jr., Katch VL, Bennett JE.(1986) Breast vol-
ume and anthropomorphic measurements: Normal values. Plast Reconstr Surg
78(3):331–335.
4. Hall-Findlay EJ. (2010) The three breast dimensions: Analysis and effecting
change. Plast Reconstr Surg 125(6):1632–1642.
5. Bostwick J. (1983) Aesthetic and Reconstructive Breast Surgery. The C. V.
Mosby Company, St. Louis, Missouri.
6. Lista F, Ahmad J. (2006) Vertical scar reduction mammaplasty: A 15-year
experience including a review of 250 consecutive cases. Plast Reconstr Surg
117(7):2152–2165; discussion 66–69.
7. Fahmy FS, Hemington-Gorse SJ. (2006) The sitting, oblique, and supine
marking technique for reduction mammaplasty and mastopexy. Plast Reconstr
Surg 17(7):2145–2151.

Chapter 3
NEOADJUVANT THERAPY
Laurie Kirstein∗, Susan K. Boolbol∗, and Mahmoud El-Tamer†
∗Division of Breast Surgery,
Beth Israel Medical Center,
New York, NY 10003, USA
†Breast Service, Department of Surgery,
Memorial Sloan-Kettering Cancer Center,
New York, NY 10065, USA
3.1 Introduction
Since the publication of large clinical trials showing equivalent survival
between mastectomy and lumpectomy followed by radiation for early-stage
breast cancer, more women have chosen breast-conserving surgery (BCS).1
Until recently, however, for patients with more locally advanced tumors or
those with a larger tumor-to-breast ratio, mastectomy has remained the
mainstay of surgical treatment. In order to achieve the desired cosmetic
outcome, these patients with larger tumors were better served with a mas-
tectomy, followed by immediate breast reconstruction.
In the mid-1980s, a new concept emerged that changed the course of
treatment for patients with locally advanced breast cancer. A proposal was
introduced whereby chemotherapy would be delivered prior to surgery with
the goal of decreasing the tumor burden. If successful, the chance of undergo-
ing BCS would be increased.2 Since then, multiple studies have been under-
taken to evaluate the safety and effectiveness of neoadjuvant chemotherapy
(NCT) on surgical outcome, overall survival (OS), and disease-free survival
(DFS). A pathologic complete response (pCR) is the ultimate goal, as well
as a complete clinical response (cCR). Not only does this have the best
prognostic significance for the patient, but a cCR also allows for breast
conservation in a setting that was not formerly thought possible. In this
chapter, the clinical and pathologic response to NCT will be discussed with
27

28
Principles and Techniques in Oncoplastic Breast Cancer Surgery
respect to various breast cancer subtypes. Finally, even patients with partial
responses may be eligible for BCS, taking into account techniques to localize
tumors, reduce re-excision rates, and increase surgical resection volume, by
utilizing oncoplastic reconstructive techniques.
3.2 Background
3.2.1 Early Trials
Neoadjuvant therapy has been in use by surgeons for more than 30 years.
The concept of medical therapy prior to surgical resection was first used in
patients who were deemed inoperable due to their extent of disease.3 The
first reports were encouraging as the vast majority of patients demonstrated
a significant response that was complete by 10% to 15%. This concept was
later applied in patients with locally advanced disease with a significant
improvement in survival when compared to historical control. In an attempt
to study the impact of preoperative chemotherapy on survival, multiple
prospective longitudinal and randomized trials were designed.
The National Surgical Adjuvant Breast and Bowel Project (NSABP)
B-18 trial evaluated 4 rounds of cyclophosphamide and doxorubicin given
either before or after definitive surgery.4 The results of this landmark trial
demonstrated that there was no difference in OS, DFS, or progression-
free survival (PFS) regardless of the timing of chemotherapy. In addi-
tion, pathologic tumor response correlated to OS, PFS, and DFS. Those
patients with a pCR displayed the highest OS, DFS, and PFS. The main
difference between the groups was the change in surgical treatment of
patients in the NCT group from mastectomy to BCS. In the group of
patients who received NCT, there was a significant increase in the number
of patients who underwent breast conservation compared to the adjuvant
group (p = 0.001).4
The NSBAP B-27 trial also evaluated NCT with a different regimen
than the B-18 trial. The patients were given four rounds of Adriamycin
and cytoxan (AC) preoperatively or postoperatively with or without a tax-
ane. Again, although there was no statistically significant difference in OS,
DFS, and PFS between the 2 groups, in the neoadjuvant group, BCS was
achieved 68% of the time compared with 60% of patients the adjuvant
group. The addition of a taxane to the neoadjuvant protocol did not affect
the breast conservation rate. About 63% of the patients underwent breast
conservation with the addition of the taxane, whereas about 60% used AC
alone (p = NS).5
With these encouraging data to support the option of chemotherapy
before surgery, especially in patients who desired breast conservation,
additional trials emerged examining the role for this treatment in different

Neoadjuvant Therapy
29
groups of breast cancer patients. In 2005, Mieog et al. reviewed the
Cochrane database and identified 14 randomized controlled trials that they
deemed appropriate. These studies compared neoadjuvant with adjuvant
chemotherapy in 5,500 women with operable breast cancer (T1–3 N0–2
M0). They reported that NCT downstaged 25.6% of the patients and sig-
nificantly decreased the mastectomy rate by 16.6% (p < 0.001). Only 4.3%
of the patients were upstaged.6
3.2.2 Patient Selection
3.2.2.1 Exclusionary criteria
There are subsets of patients for whom BCS is contraindicated. These
patients may be candidates for NCT for reasons other than breast conser-
vation. A patient with 2 or more cancers in different quadrants, or multi-
centric disease, would not be a candidate for breast conservation but may
still undergo NCT. In the ideal situation, in which this patient achieves a
cCR, she would not be a candidate for breast conservation. In general, it is
unusual to perform multiple lumpectomies in different quadrants. We con-
tinue to recommend excision of the tumor bed after NCT even in patients
who have achieved a complete clinical and radiological response. We believe
at this time that the only objective evidence of response remains the patho-
logic evaluation of the tumor site. Furthermore, all patients receiving NCT
are advised to receive postoperative radiation therapy to the whole breast
with a boost dose to the tumor bed. While cosmesis is important, it is
the penultimate consideration, with oncologic principles being the most
important.
Although currently, the standard of care in inflammatory carcinoma is
NCT, we have avoided BCS in these patients. The risk of local recurrence
is significantly high; hence, we feel that mastectomy after NCT remains the
optimal surgical procedure. Extensive microcalcifications that are beyond
the realm of breast conservation are another contraindication to NCT for
the aim of BCS. It has been our experience that although tumor masses
respond well to NCT with partial or complete radiologic response, micro-
calcifications tend to persist and have to be totally excised during any
attempt at BCS to confirm pathologic response. Other relative contraindi-
cations are patients with extensive cutaneous involvement where resection
would necessitate tissue coverage. In these clinical scenarios, we have rec-
ommended primary surgery with a mastectomy.
3.2.3 Tumor Size
Historically, tumors larger than 4 cm to 5 cm were considered too large for
BCS, and mastectomy was recommended. Therefore, this was the initial