Breast Surgery A Companion to Specialist Surgical Practice

Pathology and biology of breast cancer
43
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tic score in histological node negative breast cancer.
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122. Brown JM, Benson EA, Jones M. Confirmation of a
long term prognostic index in breast cancer. Breast
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1994;32:281–90.
124. Ravdin PM, Siminoff LA, Davis GJ, et al. Computer
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125. Goldhirsch A, Glick JH, Gelber RD, et al. Meeting
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126. Wishart GC, Azzato EM, Greenberg DC, et  al.
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22(3):221–7.
129. Ellis IO, et  al. Improvement of the Nottingham
Prognostic Index (NPI +). Cancer Res (In Press).

44
3
Sarah Tang
Gerald Gui
Nipple discharge and the role of ductoscopy
in breast diseases
Introduction
After breast lumps and mastalgia, spontaneous
­nipple discharge forms the next most common
symptom, comprising 3–8% of referrals to symp-
tomatic breast clinics.1,2 The majority of nipple
discharge is benign, with up to 20% being associ-
ated with an underlying malignancy.3 Conventional
methods of investigating nipple discharge include
mammography, ultrasound and smear cytology,
each of which have recognised limitations. Standard
operations such as microdochectomy and major
duct excision are undirected procedures that carry a
risk of leaving undiagnosed pathology in the breast.
Mammary ductoscopy allows direct visualisa-
tion of the duct epithelium to locate the lesion pre-
cisely and to map the three-dimensional anatomy.
Endoscopic instruments for diagnostic biopsy and
therapeutic excision are available. The ability to
visualise normal or benign ductal structures may
facilitate conservative management of symptomatic
nipple discharge and enable targeted excision of vi-
sualised lesions or indeterminate areas.
Causes of nipple discharge
The causes of nipple discharge are wide ranging.
The majority of discharge is physiological, hormone
related or results from benign breast change. A re-
cent meta-analysis that included over 3000 women
with nipple discharge demonstrated an overall inci-
dence of underlying breast malignancy of 18.7%,3
which is higher than the figure reported in many
individual series.
Bilateral multiduct discharge can be stimulated by
nipple manipulation in the majority of premeno-
pausal women. The production of such physiologi-
cal fluid is exploited by researchers of the intraductal
approach for cytological, molecular and protein-
based studies. This fluid is more likely to be released
from the ducts if the nipples are repeatedly stimu-
lated by chafing against clothing and during physical
activities such as jogging. Squeezing of the nipples to
elicit such discharge perpetuates symptoms. This is
because the nipple ducts are plugged by keratin and
repeated stimulation or squeezing removes the kera-
tin plugs and allows the fluid that is normally pres-
ent in the ductal tree to leak on to the surface of the
nipple. The fluid in physiological discharge ranges
from clear to white to yellow to green to black.
The most common physiological nipple discharge
is lactation. Ongoing milky discharge may occur up
to 2 years following a pregnancy and is a normal
phenomenon. Galactorrhoea can also result from
prolactin-secreting pituitary adenomas, medication
that influences the oestrogen, progesterone or pro-
lactin pathways, hypothyroidism and recreational
drugs such as marijuana. Commonly prescribed
medical drugs that may cause nipple discharge are
summarised in Table 3.1.

Nipple discharge and the role of ductoscopy in breast diseases
45
Duct ectasia and benign breast change are com-
mon causes of multiduct discharge. In duct ectasia,
the breast ducts become tortuous and dilated, pre-
disposing to fluid accumulation. This fluid may dis-
charge spontaneously or upon manipulation when
the sphincters distal to the lactiferous sinuses relax
and the keratin plugs are displaced. Common situ-
ations that may trigger loss of these keratin plugs
and sphincter relaxation include massage and warm
comfortable environments such as in a bath or un-
der bedsheets. Cysts do not usually communicate
directly with breast ducts. It has been suggested that
inflammation related to a cyst may result in erosion
into a duct system but this is unproven. The colour
of nipple discharge associated with duct ectasia and
fibrocystic change can vary from clear to white,
yellow, grey, green, brown or black. This is the same
colour range seen in physiological discharge. Nipple
discharge arising in relation to inflammation and
irritation of the lining of the ducts may be blood
stained and contain acute inflammatory cells.
Persistent spontaneous discharge from a single nip-
ple orifice is usually indicative of specific pathology
involving that duct. Benign intraductal papillomas
account for about 80% of single-duct bloodstained
nipple discharges.2,4,5 Papillomas give rise to nipple
discharge of varying colour but as these structures
can bleed intermittently, papillomas are often as-
sociated with blood staining. Recent bleeding may
manifest as frank blood, but stagnant bloodstained
fluid can be dark red, brown or black.
Periductal mastitis is a chronic and recurrent in-
flammatory condition associated with smoking in
younger women. Purulent nipple discharge can be
seen in later stages when the duct ruptures and an
abscess or mammary duct fistula has developed.
Invasive breast cancer is an uncommon cause of
spontaneous nipple discharge as the proliferating
mass usually obliterates the duct lumen. Ductal car-
cinoma in situ or an extensive area of in situ dis-
ease in association with an invasive breast cancer
may predispose to bloodstained nipple discharge.
Bloodstained nipple discharge should be distin-
guished from bleeding from the nipple surface that
may occur with Paget's disease.
Assessment
A thorough breast problem orientated history is
taken including a drug history, and a complete clini-
cal examination should also be performed.
Bilateral physiological multiduct discharge aggra-
vated by manipulation in younger patients usually
resolves when the triggering factors are removed.
Bilateral and profuse milky discharge in the younger
population should be investigated by measuring
Mechanism of action
Medication
Dopamine receptor blockade
Antidepressants:
Selective serotonin reuptake
inhibitors (citalopram,
fluoxetine, paroxetine,
sertraline)
Tricyclic antidepressants
Antipsychotics:
Risperidone
Butyrophenones (haloperidol)
Phenothiazines
(chlorpromazine)
Thioxanthenes
(chlorprothixene, flupenthixol)
Anti-emetics:
Metoclopromide
Domperidone
Dopamine depletion
Methyldopa
Reserpine
Monoamine oxidase
inhibitors
Inhibition of dopamine
release
Codeine
Heroin
Morphine
Histamine receptor blockade
Cimetidine
Famotidine
Ranitidine
Stimulation of breast tissue
and lactotrophs
Oral contraceptives
Mechanism unknown
Verapamil
Table 3.1  •  Common drugs that mimic galactorrhea and
the likely underlying mechanisms of action
Pathological nipple discharge is considered
to be discharge arising from a single duct that is
persistent (defined as more than twice per week).
At age over 50 years, the presence of blood
in the discharge and the presence of a clinical
lump increase significantly the risk of associated
malignancy,3,6 and it is recommended that these
patients are fully investigated by conventional
imaging techniques. Normal imaging should
direct further investigation as appropriate and
consideration of diagnostic surgical excision.

Chapter 3
46
serum prolactin and if elevated, supplemented by
magnetic resonance imaging (MRI) of the pituitary
gland. Thyroid function tests may be indicated if
there are appropriate clinical features.
The colour of nipple discharge is not a reliable
method of distinguishing between physiological, be-
nign or malignant aetiologies.
Mammography is indicated in women over the age
of 35 years and may demonstrate a mass or micro-
calcification in association with nipple discharge of
malignant aetiology. Even in younger women with
bloodstained discharge, mammography can demon-
strate calcification in women with widespread duc-
tal carcinoma in situ (DCIS). Other mammographic
features may also be evident in patients with be-
nign nipple discharge. Duct ectasia may occasion-
ally be visible on mammography. The sensitivity
of mammography in detecting pathology in nipple
discharge is 57.1% (positive predictive value (PPV)
of 16.7% and negative predictive value (NPV) of
91.4%).7 In a study of 306 patients with nipple
discharge who had normal mammography and ul-
trasound, 10% were subsequently found to have
underlying malignancy.7
Ultrasound can reliably diagnose duct ectasia and
can identify discrete intraductal lesions. Papillomas
below a threshold size of 1–2 mm may not be vis-
ible on ultrasound imaging. Ultrasound-guided core
biopsy can be used to obtain a tissue diagnosis of
any lesions visualised but papillary lesions are of-
ten assessed as an indeterminate B3 lesion and so
usually still require excision for a definitive tissue
diagnosis. A vacuum-assisted ultrasound-guided
mammotome biopsy can be both diagnostic and
therapeutic. Fine-needle aspiration of papillary le-
sions is usually unhelpful as cytology rarely resolves
diagnostic uncertainty.
Ductography is less widely used but is an inves-
tigation that gives clear delineation of the breast
anatomy. A small amount of radio-opaque contrast
is instilled into a cannulated nipple duct. Accurate
detection of small filling defect(s) caused by pap-
illomas and duct narrowing or obstruction from
malignant change can be recognised. However, duc-
tography does not provide a tissue diagnosis and
the precise position of the area of interest within
the breast is not usually available to the surgeon,
although it is possible to target the area of abnor-
mality with a wire localisation procedure. The use
of MRI to evaluate the ductal tree is gaining inter-
est but is not a standard investigation of nipple dis-
charge. In a comparative study of 163 patients with
nipple discharge who had normal mammography
and ultrasound, ductography was found to have a
PPV of 19% and an NPV of 63%. MRI was per-
formed in 52 patients and found to have a PPV of
56% and an NPV of 87%.7
Smear cytology of nipple discharge may show
the presence of malignant cells, papillary cells, red
blood cells, benign duct epithelium or foam cells of
macrophage origin. The available literature dem-
onstrates sensitivities of smear cytology ranging
from 11.1% to 16.7%8,9 and specificities ranging
from 66.1% to 96.3%. In Simmons et al.'s study
of 108 pathological specimens for nipple discharge,
the PPV of smear cytology was 50% and the NPV
was 76.5%.8 These data arise from an era before
mammary ductoscopy when surgery providing the
pathology used as the gold standard could not be
targeted, so some of the pathologies present may
have been missed at surgery, hence lowering the
PPV of cytology. A further limitation arises when
insufficient epithelial cells are available for a reli-
able diagnosis. This may be overcome by enhanced
techniques of obtaining nipple fluid such as ductal
lavage to increase the cell yield, which can improve
the performance of cytological assessment.
Conventional surgery
The indications for surgical intervention are persis-
tent (defined as >2 per week) single-duct discharge
in a woman over the age of 50 years, guided further
by the results of abnormal investigations. Pressure
over a discrete lesion such as a symptomatic pap-
illoma often results in duct-specific discharge. The
target lesion may be skin marked or wire localised if
impalpable, to ensure excision of the target lesion.
Current surgery for pathological nipple discharge
consists of major duct excision and ­microdochectomy.
However, a recent meta-analysis found
a higher incidence of underlying malignancy
in patients with bloodstained nipple discharge
compared to those with non-bloody discharge
(of any colour description; odds ratio (OR) = 2.27,
95% confidence interval (CI) = 1.32–3.89) or when
compared to those with serous discharge alone
(OR = 2.49, 95% CI = 1.25–4.93).3 It is therefore
recommended that all patients with bloodstained
nipple discharge are investigated fully.

Nipple discharge and the role of ductoscopy in breast diseases
47
Major duct excision in the absence of an imaging ab-
normality is an undirected operation where a disc or
wedge of retroareolar tissue is excised. The amount
of breast tissue that is excised is at the discretion of
the surgeon's clinical judgment but often includes
a considerable amount of tissue that does not need
to be resected for a benign process. The greater the
amount of tissue resected, the higher the risk of sur-
gical complications including altered sensation, hae-
moseromas, poor aesthetic outcome from volume
loss and nipple ischaemia. Microdochectomy aims
to resect a single duct guided by passing a lacrimal
probe down the offending duct system. The branch-
ing system of the ductal tree makes this procedure
imprecise and the surgeon is blind throughout the
operation as to the location, depth and number of
lesions that form the target of the resection. The risk
of perforating the cannulated duct with the probe is
high and if the surgeon performs a wide resection
around the probe then it in effect becomes a much
bigger procedure. Proximal lesions further than 3 cm
from the nipple base are likely to be missed by these
undirected techniques.
Despite the limitations, these operations do form
the current standard surgical practice. Surgery to
the breast ducts should be avoided in women of
childbearing age who wish to breast feed, as surgi-
cal injury or scarring are likely to lead to restricted
or failed lactation.
Mammary ductoscopy and
nipple discharge
Spontaneous nipple discharge lends itself well to
mammary ductoscopy (MD) as the ductal orifice is
readily identified and coexisting duct ectasia can aid
scope passage. Positive endoscopic findings can be
used to guide surgery resulting in targeted excision.
Visualisation of remaining ducts can rule out coex-
isting pathology and avoid unnecessary resection
of normal parenchyma. MD is not widely available
and its role as an established procedure remains to
be defined.
MD by an experienced endoscopist can be more
accurate than mammography in identifying exten-
sive in situ disease (65% vs. 50%).10 Ling et  al.
found that MD-guided intraductal biopsy had a
significantly higher papilloma detection rate than
undirected miocrodochectomy (92.6% vs. 40.7%,
P<0.05).11 Normal findings at MD may endorse a
conservative approach or alternatively facilitate a
recommendation for duct transaction alone to man-
age symptomatic nipple discharge.
History and technology
Microendoscopic technology has advanced and earlier
limitations of poor optical resolution and problems
with access because of the large calibre of scopes have
been overcome. The development of working channels
within microendoscopes has made it possible to biopsy
lesions under direct vision using cytology brushes and
microbiopsy forceps. Accessories for localisation, such
as self-retaining hookwires or rhomboids that are im-
mobilised by expansion within the duct, can be passed
down the working channel to demarcate the area of
interest for open therapeutic excision.
Current scopes can be flexible or rigid, with di-
ameters that range from 0.7 to 1.2 mm (Fig.  3.1).
Microendoscopes magnify up to 60 times to pro-
duce high-quality images with saline for insufflation
and irrigation of the ducts. More recent develop-
ments include autofluorescence technology,12 which
may help to distinguish between benign, premalig-
nant and malignant lesions.
Technical considerations
The duct orifices are identified by nipple fluid ex-
pression by warming, massage or gentle pressure.
The orifice may be dilated and some systems require
a working shaft to be inserted, through which the
scope is passed.
c
b
a
d
e
Figure 3.1  •  The dissembled components of a 0.9-
mm LaDuscope® (PolyDiagnost GmbH, Pfaffenhofen,
Germany) comprising the fibreoptic scope (a), disposable
two-port cannula (b), cannula sheath (c), shifter (d) and
protective metal sheath for the fibreoptic for use during
sterilisation (e).

Chapter 3
48
MD, when associated with a standard surgical
procedure, is often performed under general an-
aesthetic. Diagnostic MD can be performed as an
outpatient procedure with topical local anaesthetic
applied to the nipple, followed by periareolar in-
filtration and/or infusion down the cannulated
duct, the latter facilitating relaxation of the muscle
sphincters.13,14 Methylene blue dye, marking wires,
clips and transillumination15 may be used for ori-
entation, to localise lesions, guide surgical excision
and facilitate pathological assessment.15–17
Complications of MD are uncommon and include
pain, inflammation and infection. Duct perfora-
tion by the scope creates a false passage that can
be recognised by the yellow cavernous honeycomb
appearance of adipose tissue.
Intraduct appearances
There is general consensus on the intraductal ap-
pearances of common lesions from studies that
have used histological correlation (Figs 3.2 and 3.3).
Malignant lesions are more likely to display haem-
orrhagic characteristics, streaking, fissuring and
irregularity of the ductal walls or present with a lu-
minal mass that might obstruct the duct. In contrast,
benign non-papillomatous lesions have a smooth,
level surface without haemorrhagic features.4,18–21
MD sensitivity at detecting papillomas is high at
96–97%11,19 with a PPV of 73%.21 Benign duct
strictures may on occasion limit MD access.21
Sensitivity for detecting DCIS and invasive disease is
lower, with reports ranging from 41% to 81%.19,22
The presence of an extensive non-invasive compo-
nent associated with an invasive cancer increases
significantly the likelihood of abnormal ductoscopic
findings (71% vs. 16%).23
Pathological considerations
The diagnostic sensitivity of MD can be improved
by incorporating ductal lavage cytology,24 which
generates information from the proximal ducts that
may be out of reach of the ductoscope. In a study
of 415 women, the PPV of 80% of MD alone in
detecting DCIS was improved to 100% by the addi-
tion of lavage cytology.25 The cell count can be fur-
ther enhanced using fine brushes passed down the
working channel to exfoliate intraluminal lesions
under direct vision, yielding up to 33 000 cells.26,27
A cell-rich endoscopy specimen allows better dis-
crimination between benign cells, mild to severe
atypia and malignant cells. A normal duct on MD
is infrequently associated with abnormal cytology.14
Reliable methods of intraductal biopsy are es-
sential if MD is to achieve a histological diagnosis
without surgical excision. Various techniques have
been developed using vacuum-assisted biopsy sys-
tems, endobaskets and grasping clips.11,23,28 The
intraductal breast biopsy (IDBB) system pioneered
by Hunerbein and Matsunaga consists of a 0.7-mm
gradient index endoscope covered by an external
metal sheath containing a side opening aperture near
its tip.23,28 This technique yields diagnostic material
in 89–92% of cases with a sensitivity of 76.2% and
a specificity of 100% for papillomas.10,23 Using bi-
opsy clips, Ling et al. were able to produce diagnos-
tic samples in 90% of patients.11 Biopsy techniques
can be extended to perform therapeutic endoscopic
papillomectomy.29,30 In two studies, IDDB stopped
symptomatic nipple discharge with therapeutic ef-
ficacies of 77.6% and 95.4%.28,29 Carcinomas are
associated with a lower diagnostic biopsy yield
(58.3%).28 It is postulated that carcinomas are
Figure 3.2  •  A still image from mammary ductoscopy
showing a large papilloma within a duct with otherwise
normal epithelium.
Figure 3.3  •  A still image from mammary ductoscopy
showing DCIS and invasive disease in branching ducts.

Nipple discharge and the role of ductoscopy in breast diseases
49
generally located more peripherally in the terminal
ducts and can be difficult to access by MD.28
Limitations
In the context of nipple discharge, the majority of le-
sions are found within 5 cm of the nipple but up to
37% may be proximal and therefore out of the reach
of a 6-cm ductoscope.15,21 Unlike other applications
for microendoscopy such as the salivary gland, where
there is a sizeable single-duct orifice, breast ducts open
via multiple tiny orifices at or just below the nipple
surface. There is variability in the number of duct sys-
tems, with one anatomy study demonstrating 29 ducts
arising from 15 orifices.31 This study also found that
some ducts branch within the nipple itself and may not
be accessed readily by lavage cannulae or MD.
Ductoscopy and breast
cancer
MD as an adjunct to breast conservation sur-
gery for cancer is technically feasible, with high
rates of tumour visualisation.13 In a subsequent
publication, Dooley successfully identified the
malignant lesion on MD in 150 out of 201
patients (74.6%), found additional lesions out-
side the planned excision site in 83 cases (41%)
and decreased the positive margin rate from
23.5% to 5%.32 Louie et al. reported lower tu-
mour visualisation rates in 6 of 14 (43%) pa-
tients and did not show any benefit of MD in
reducing positive margin rates.22 The role of duct
endoscopy in breast cancer management is cur-
rently limited outside clinical trials.
Key points
• Nipple discharge is the third most common presenting symptom to breast clinics.
• More than 80% of nipple discharge is benign.
• Mammography and ultrasound have a low sensitivity and specificity for diagnosing the cause of
nipple discharge.
• Nipple smear cytology has a low sensitivity and positive predictive value.
• The risk of an underlying malignancy is increased if the nipple discharge is spontaneous, single
duct, persistent (occurs more than twice per week), bloody, age >50 years and associated with a
palpable abnormality.
• Mammary ductoscopy allows direct visualisation of the ductal epithelium and can be used to direct
surgical resection of target lesions while limiting resection of normal breast tissue.
• The development of microbiopsy forceps, cytology brushes and intraductal localisation wires has
enhanced the role of mammary ductoscopy as an interventional diagnostic and therapeutic procedure.
References
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51
4
J. Michael Dixon
Breast-conserving surgery: the balance between
good cosmesis and local control
Introduction
The aim of local treatment of breast cancer is to
achieve long-term local disease control with the
minimum of local morbidity. The majority of
women presenting symptomatically to breast clin-
ics and those who are diagnosed through screening
programmes have small breast cancers, which are
suitable for breast-conserving surgery.
One of these reviews (search date 1995) anal-
ysed data from six randomised controlled trials
that compared breast conservation treatment with
mastectomy.4 A meta-analysis of data from five of
these six trials involving 3006 women found no sig-
nificant difference in the risk of death at 10 years
(odds ratio 0.91, 95% confidence interval (CI)
0.78–1.05). The sixth randomised trial used differ-
ent protocols. In the second systematic review, nine
randomised controlled trials involving 4981 women
randomised to mastectomy or breast-­conserving
treatment were included in the analysis.5 A meta-
analysis of these nine trials found no significant
difference in the risk of death over 10  years: the
relative risk reduction for breast-conserving sur-
gery compared with mastectomy was 0.02 (95%
CI −0.05 to +0.09).5 There was also no difference in
the rates of local recurrence in the six randomised
controlled trials involving 3006 women where data
were available: the relative risk reduction for mas-
tectomy versus breast-conserving surgery was 0.04
(95% CI −0.04 to +0.12).4
It is thus important in patients selected for breast-
conserving surgery to minimise local recurrence
while at the same time achieving a good cosmetic
outcome.
Selection of patients for
breast conservation
Traditionally, single cancers clinically measuring
4 cm or less, without signs of local advancement,
have been managed by breast-conserving treatment
(Box 4.1). Different units have different size crite-
ria and many units have a tumour size cut-off for
breast-conserving surgery of 3 cm or less clinically.
The major advantages of breast-conserving
treatment are as follows:
• breast-conserving treatment produces an
acceptable cosmetic appearance in the majority of
women with breast cancer;1
• breast-conserving treatment results in lower levels
of psychological morbidity, with less anxiety and
depression and improved body image, sexuality
and self-esteem, compared with mastectomy;2,3
• two systematic reviews have shown equivalence
in terms of disease outcome for breast-conserving
treatment and mastectomy.4,5
Originally it was thought that local therapy had
little influence on overall survival but it is clear that
local failure is responsible, at least in part, for some
patients developing metastatic disease.6,7

Chapter 4
52
Clinical tumour size overestimates actual tumour
size. There is a much better correlation between
pathological tumour size and the size measured on
imaging, with ultrasound assessment being more
accurate than mammographic measurements.8
Magnetic resonance imaging (MRI) appears better
than ultrasound in assessing disease extent, particu-
larly in invasive lobular carcinoma.9 The problem
with MRI is that it has a low specificity and a low
positive predictive value in that only two-thirds of le-
sions identified by MRI as suspicious of malignancy
are subsequently confirmed as malignant.10 The role
of MRI in assessing patients for breast-conserving
surgery has been investigated in a randomised study
and the conclusions of this study were that routine
use of MRI is not worthwhile.8,11 MRI did not re-
duce the rate of incomplete excisions and was not
associated with a reduction in short-term local
recurrence but did significantly increase the mas-
tectomy rate in patients who were otherwise consid-
ered good candidates for breast-­conserving surgery.
It is the balance between tumour size as assessed by
imaging and breast volume that ­determines whether
a patient is suitable for breast-conserving surgery
rather than tumour size per se. Options for patients
with tumours considered too large, relative to the
size of the breast, for breast-conserving treatment
include neoadjuvant systemic therapy to shrink the
tumour, an oncoplastic procedure (see Chapter 6)
involving either transfer of tissue into the breast or
remodelling of the breast with surgery to the oppo-
site breast to obtain symmetry (see Chapter 6).12,13
In a patient with small breasts, excision of even
a small tumour may produce an unacceptable
cosmetic result.
Patients with multiple tumours in the same breast
have not previously been considered good candi-
dates for breast-conserving treatment because they
were reported to have a high reported incidence of
in-breast recurrence14,15 and so have usually been
treated by mastectomy, combined in appropriate
patients with immediate reconstruction. Recent evi-
dence has, however, demonstrated similar rates of
local recurrence for both patients with unifocal and
with multifocal and even multicentric disease.16,17 If
it is feasible to excise the separate cancers in differ-
ent parts of the breast and produce an acceptable
cosmetic outcome then such patients should no lon-
ger be treated routinely by mastectomy. Satisfactory
rates of local control following breast-conserving
treatment for multifocal or multicentric cancers
are achieved providing all disease is excised to
clear margins.16,17 Early studies on multifocal and
multicentric cancers often failed to achieve clear
margins and this explains the high rates of local
recurrence reported in these early series.15 Patients
with bilateral cancers can also be treated by bilateral
breast conservation. The rates of breast-conserving
surgery vary significantly between countries and
within countries. These rates are clearly influenced
as much by the views of the surgeon treating the
patient as the availability of radiotherapy locally.
Failure to offer breast-conserving surgery to suit-
able and appropriate patients has become a medico-
legal issue. If a patient who fulfils the criteria for
breast-conserving surgery is treated by mastectomy
then the exact reasons for the decision to proceed
to mastectomy should be recorded legibly in the
patient's notes. Some patients choose mastectomy
in preference to breast-conserving surgery but do
so based on an inadequate understanding that out-
comes for the two treatments are identical. In one
series of patients choosing mastectomy rather than
Increasing tumour size does not equate with
increasing local recurrence rates and limiting breast-
conserving surgery to cancers below a certain size
is illogical.
Indications
• T1, T2 (<4 cm), N0, N1, M0
• T2 > 4 cm in large breasts
• Single clinical and mammographic lesion
Relative contraindications*
• T4, N2 or M1
• Patients who prefer mastectomy†
• Clinically or radiologically evident multifocal/multicentric
disease
• Collagen vascular disease
• Large or central tumours in small breasts
• Women with a strong family history of breast cancer
or who are proven BRCA1 and BRCA2 mutation
carriers
Box 4.1   •  Indications and contraindications for
breast-conserving surgery
*None of these are absolute contraindications.
†Following a fully informed discussion of the pros and cons of
breast-conserving surgery vs mastectomy.

Breast-conserving surgery: the balance between good cosmesis and local control
53
breast-conserving surgery, over half of patients did
not know that mastectomy and breast-conserving
surgery produces identical rates of survival.18
A range of clinical and pathological factors have
influenced surgeons selecting patients for breast-
conserving surgery because of their perceived im-
pact on local recurrence. These include young age
(under 35–39 years), the presence of an extensive in
situ component associated with an invasive tumour,
grade 3 histology and widespread lymphatic/vascular
invasion. These are considered in detail below.
Breast-conserving surgery
Two surgical procedures have been studied exten-
sively: quadrantectomy and wide local excision.
Quadrantectomy was based on the belief that the
breast is organised into segments, with each seg-
ment draining into its own major duct, and that in-
vasive cancer spreads down the duct system towards
the nipple.19 Both of these premises are incorrect.
The effectiveness of quadrantectomy relates to
the large amount of tissue excised around the tu-
mour rather than to the removal of a cancer and
its draining duct. In an early randomised study of
lumpectomy or quadrantectomy, a significantly
greater number of patients who had lumpectomy
had incomplete local excisions.20 Not surprisingly,
therefore, local recurrence was more common after
lumpectomy than after quadrantectomy, although
survival was no different.20 Other non-randomised
studies have shown similar rates of local recur-
rence for both quadrantectomy and wide local ex-
cision, providing margins of excision are clear.21
Quadrantectomy or segmental excisions are no
longer appropriate breast-conserving options be-
cause they produce identical rates of local recur-
rence to wide excision but produce a significantly
poorer cosmetic outcome compared with wide
excision.22
Special technical details: wide
local excision
The aim of wide local excision is to remove all
invasive and any ductal carcinoma in situ with
a margin of normal surrounding breast tissue.
Controversy has surrounded which incisions
give the best cosmetic results. The predominant
orientation of collagen fibres in the skin was de-
scribed by Langer25 and these skin crease lines
around the breast are essentially circular (Fig. 4.1).
Subsequent work by Kraissl26 demonstrated that
the lines of maximum resting skin tension run in
a more transverse orientation across the breast
(Fig. 4.1). In general, scars that are parallel both
to the lines of maximum resting skin tension and
to the orientation of collagen fibres are quickest
to heal and produce the best cosmetic outcomes,
with the lowest rates of scar hypertrophy and ke-
loid formation.
A knowledge of Langer's lines and Kraissl's lines
thus allows a surgeon to make incisions that en-
hance the cosmetic outcome of breast-conserving
surgery. It has been tradition to place an incision
to excise a cancer directly over the lesion, but this
can result in an unsightly scar, particularly if the
cancer is high and medial. In such instances plac-
A single major subareolar duct does not
drain a localised segment of tissue but can drain
widespread areas of the breast.
Patients having breast-conserving surgery are
adequately treated by wide local excision and
do not require either a segmental or quadrantic
excision.23,24
b
a
Figure 4.1  •  The direction of Langer's lines (a) and lines
of maximum resting skin tension in the breast (b) (so-
called dynamic lines of Kraissl).
Incisions that follow the lines of maximum
resting skin tension produce the most cosmetically
acceptable scars.

Chapter 4
54
ing the scar some ­distance below in the skin crease
lines and tunnelling up to the lesion produces a bet-
ter cosmetic result. Cancers close to the nipple and
even those some distance away in the upper half
of the breast can be excised through circumareolar
­incisions. A cancer low in the breast close to the in-
framammary fold can similarly be excised through
an incision placed in the fold. A cancer in the up-
per outer quadrant can be excised easily through an
axillary incision. Excising skin directly overlying a
cancer is only necessary if the skin is involved. It is
not necessary to remove dimpled or tethered skin.
The cosmetic result after breast-conserving surgery
is influenced by the amount of skin excised, with
poor results being obtained in those patients who
have most skin removed. In patients with direct skin
involvement, the aim should be to minimise the skin
excised and to remove only enough skin to get mi-
croscopically clear margins.
Limiting the length of incision is also important,
as longer incisions produce significantly poorer cos-
metic outcomes. A knowledge of the depth of the
cancer within the breast provided by preoperative
or intraoperative breast ultrasound can be valuable
when planning the extent of excision. For instance,
if a cancer is 2 cm deep within the breast, then at
least 1 cm of fat and subcutaneous tissue can be left
on the skin flaps; leaving this tissue improves the
cosmetic outcome. Whatever incision is used, it is
important to have discussed the position of all scars
with the patient prior to surgery.
Having made the skin incision, the skin and subcu-
taneous fat are dissected off the breast tissue. Care
should be taken when elevating skin not to remove
subcutaneous fat unnecessarily as thin skin flaps
give a poor postoperative cosmetic result. Where
the cancer is close to the skin, hydrodissection in-
filtrating 1 in 400 000 adrenaline in saline can help
to separate the skin and subcutaneous fat from the
breast tissue and breast fat, and facilitates skin el-
evation over the cancer. Skin flaps beyond the edge
of the cancer for at least 1–2 cm are mobilised. This
allows the fingers of the non-dominant hand to be
placed over the palpable cancer. The breast tissue is
then divided beyond the fingertips. The line of in-
cision through the breast should be ­approximately
1 cm beyond the limit of the palpable mass. Having
incised through the breast tissue, dissection contin-
ues under the cancer. In the majority of patients it
is necessary to divide the whole thickness of breast
tissue down to the pectoral fascia, to ensure that
there is an adequate margin of tissue removed deep
to the cancer. If the lesion is superficial, and there
is a significant amount of breast tissue deep to
the cancer, it may not be necessary to remove full
thickness of breast tissue. Likewise if the lesion is
deep, more tissue can be left superficially on the
skin flaps. Having reached the deep margin, which
is usually the pectoral fascia, the breast tissue and
cancer are lifted from this fascia. It is not necessary
to excise pectoral fascia unless it is tethered to the
tumour or the tumour is involving it. If a carcinoma
is infiltrating one of the chest wall muscles, then a
portion of the affected muscle should be excised
beneath the tumour, the aim being to remove suf-
ficient muscle to get beyond the limits of the cancer.
Having dissected under the cancer, the cancer and
surrounding tissue are grasped between the finger
and thumb of the non-dominant hand and excision
of the cancer at the other margins is completed. The
specimen should be orientated immediately follow-
ing excision with Liga-clips, sutures or metal mark-
ers, prior to specimen radiography and submission
to the pathologist.27 Metal markers or Liga-clips are
preferred because they can be seen on specimen ra-
diography. Routine X-ray of orientated specimens is
recommended because it has been shown to help the
surgeon confirm the target lesion has been excised
and allows assessment of completeness of excision
at the radial margins.27 If the specimen radiograph
shows the cancer or any associated microcalcifica-
tion is close to a particular margin, then further
tissue can and should be removed from the mar-
gin of concern, before being orientated and sent to
pathology.
A number of studies have evaluated the use of
cavity shavings and bed biopsies, but few have
compared these with standard assessment of mar-
gins. A minority of surgeons continue to take cav-
ity shavings and bed biopsies routinely. Neither
has been shown to be reliable indicators of lo-
cal recurrence. A major concern of taking cavity
shavings routinely is that significant amounts of
extra breast tissue can be removed, particularly
if the whole cavity is shaved; this unfortunately
can adversely affect cosmetic outcome. Most
Routine excision of skin when performing a wide
excision cannot be justified.23

Breast-conserving surgery: the balance between good cosmesis and local control
55
­importantly, however, centres who do not use
these techniques report excellent local control
rates, which have continued to fall over time.28,29
Wide excision with standard examination of mar-
gins thus provides sufficient information on mar-
gin status for clinical use. Bed biopsies or cavity
shavings are only of value and warranted where
there is concern at operation that one particular
margin is involved.
New devices that use ultrasound or rely on the
electrical properties of the tissue are in trials and are
being used to assess whether they can detect margin
involvement and facilitate increased rates of com-
plete excision at the first operation.
Having excised the cancer from the breast, sutur-
ing the defect in the breast without mobilisation of
the breast tissue usually results in distortion of the
breast contour. Defects in the breast are best closed
by mobilising surrounding breast tissue from the
overlying skin and subcutaneous tissue and in some
patients mobilisation from the underlying chest wall
is required. Large defects (>10% breast volume)
that are left open fill with seroma, which often ab-
sorbs later, following which scar tissue develops and
contracts and can result in an ugly distorted breast.
Following large-volume excisions, after mobilisation
it is usually possible to close the defect in the breast
tissue by a series of interrupted absorbable sutures.
Given the success of lipofilling or lipomodelling
for improving some patients with poor cosmetic
outcomes following breast-conserving surgery and
radiotherapy, a number of surgeons are exploring
whether immediate lipofilling after wide local exci-
sion can improve outcomes, particularly for women
with small breasts. Very large defects require onco-
plastic breast reshaping (see Chapter 6) or a latis-
simus dorsi miniflap.12,13 Drains are not necessary
after wide local excision and should not be used
routinely. They do not protect against haematoma
formation and increase infection rates. Breast skin
wounds should be closed in layers with absorbable
sutures, finishing with a subcuticular suture.
Complications of wide excision include hae-
matoma, infection, incomplete excision, seroma
and poor cosmetic results. Haematoma requiring
­evacuation is uncommon but occurs in approxi-
mately 2% of patients. Infection requiring treatment
affects 5–10% and is more common when combined
with an axillary dissection. Incomplete excision rates
should be in the range 10–25%. The most common
problem following surgery by wide local excision is
a poor cosmetic result. Factors influencing cosmetic
outcome and methods of avoiding this are consid-
ered in detail below.
Excising impalpable cancers
Impalpable lesions can be localised prior to surgery
using one of a number of different techniques, in-
cluding skin marking, injection of blue dye, carbon
or radioisotope, insertion of a hooked wire, or in-
traoperative ultrasound. Although excising an im-
palpable cancer is easier if the skin incision is made
directly over the cancer, remote incisions produce the
best cosmetic results. Most impalpable small cancers
should thus be approached through a cosmetically
placed incision. The location of the lesion can be de-
termined in a number of ways: (i) the surgeon can
calculate the position of the breast lesion from the
mammogram taken after wire insertion; (ii) the ra-
diologist or the surgeon can mark the skin overlying
the lesion using ultrasound; or (iii) if radioactivity
has been injected to localise the cancer, the surgeon
can use a gamma probe to localise the area of maxi-
mum radioactivity. After making an appropriately
sized and cosmetically placed skin incision, this is
deepened. If a wire is in place, then dissection con-
tinues towards the wire in the plane between the
breast and subcutaneous fat so that the wire can
be located some distance before it enters the lesion.
For instance, if a mammographic abnormality has
been localised in the craniocaudal position, then it
helps to identify the wire superiorally before it en-
ters the cancer. Wires that are marked with beads or
that change in diameter, or have a guide that can be
placed over the wire, help the surgeon to determine
exactly how far along the wire the lesion is situated.
Ideally the hook of the wire should be 1 cm through
the lesion rather than within its centre. The direc-
tion of the wire on the preoperative mammogram
is not always a reliable guide to the course of the
wire through the breast. Once the wire is in place
standard mammographic views are not always pos-
sible and thus a lesion that is apparently lateral to
Staples and interrupted sutures do not produce
satisfactory results and are not an acceptable
method of wound closure in the breast.

Chapter 4
56
the entry point of the wire may not be lateral on the
check craniocaudal film once the compression from
the breast has been released. The aim is to remove
the mammographic lesion with a 1-cm clear radio-
logical margin and in most women to excise tissue
up to subcutaneous fat and down to pectoral fascia.
As for palpable lesions, all specimens should
be orientated with Liga-clips or metal markers,
or secured to an orientated grid so that an orien-
tated specimen radiography can be performed.
Radiography is best performed in an X-ray machine
designed specifically to X-ray specimens, such as a
Bioptics® machine. There have been conflicting re-
ports about whether compressing the specimen af-
fects the incidence of subsequent positive margins
as reported by the pathologist. Orientated specimen
radiography improves the rate of complete excision
of impalpable cancers.27 Cooperation between sur-
geon and pathologist is required so that the area of
concern can be identified and assessed by the pa-
thologist to ensure adequacy of excision.
The majority of wide excisions of palpable and im-
palpable cancers are performed under general anaes-
thesia, but it is possible to perform these procedures
under local anaesthesia.
Factors affecting local
recurrence after breast-
conserving surgery
Until recently there was a reported large variation
between different centres in recurrence rates follow-
ing breast-conserving surgery combined with whole
breast radiotherapy for invasive breast carcinoma.
Over 80% of all local recurrences were reported to
be located adjacent to the site of initial excision. This
is no longer true and an increasing percentage of ‘re-
currences’ in treated breasts are actually second pri-
maries.25 Megavoltage radiation therapy delivered
to the whole breast in a dose of 4000–5000 cGy
given over 3–5 weeks continues to be used in most
patients after breast-conserving surgery because ra-
diotherapy both reduces the rate of local recurrence
and improves overall survival.30 Studies continue to
evaluate whether localised radiotherapy delivered
either during or within a few days of surgery is as
effective as whole-breast radiotherapy. As yet it has
not been possible to identify groups of patients who
do not require radiotherapy. However, there is likely
to be a group of older patients with low-risk cancers
(completely excised, node negative and hormone re-
ceptor positive on hormone treatment) and women
of any age whose cancers have an extremely good
prognosis (small grade 1 or special type cancers that
are completely excised, node negative and hormone
receptor positive on hormone treatment) whose
rates of local recurrence without radiotherapy are
acceptable. Following whole-breast radiotherapy, it
is possible to increase the local dose of radiotherapy
by boosting the tumour bed. This reduces local re-
currence rates, particularly in younger women, al-
though there are cosmetic penalties associated with
the use of boost.31
The rates of in-breast tumour recurrences continue
to fall over time28,29 (Fig. 4.2). Whereas a 1 % an-
nual rate of in-breast cancer events was formerly
considered acceptable, rates are now less than 0.5 %
per annum. The rates of in-breast tumour events
continue at a similar rate for at least 20 years. This
needs to be borne in mind when considering surveil-
lance programmes for such patients.
Patient-related factors
In contrast, local recurrence is much less of a prob-
lem in older patients (>65 years).
Recurrence is less frequent in women with large
breasts but whether this relates to the larger ­excisions
Cumulative local
recurrence
0.00
0.25
0.50
0
2
4
6
8
10
p<0.00001
1981-1989
1990-1992
1993-1998
1999-2006
5y
6.5
4.4
3.9
1.7
10y
12.4
9.2
6.2
4.1
Figure 4.2  •  Local recurrence rates in Edinburgh over four
separate time periods showing a significant and continued
fall in local recurrence rates over time. (Data unpublished,
courtesy of Gill Kerr, Edinburgh Cancer Centre.)
Local recurrence following breast-conserving
therapy is significantly more common in younger
patients.32–35

Breast-conserving surgery: the balance between good cosmesis and local control
57
that can be performed in these patients or to alterations
in steroid metabolism (fat is known to be an impor-
tant site of conversion of androgens to oestrogens) is
uncertain.36 A family history of breast cancer, particu-
larly carriage of a mutation in one of the breast can-
cer genes, predisposes a patient to an increased rate of
second primary cancers in both the treated and contra-
lateral breast unless these women undergo a prophy-
lactic oophorectomy, when local recurrence rates fall
to levels similar to those of the general population.37,38
Tumour-related factors
Tumour location, tumour size, the presence of
skin or nipple retraction, and the presence or ab-
sence of axillary node involvement have not been
shown consistently to predict for local recurrence
after breast-conserving surgery.39–42 The hormone
receptor status of a breast cancer does not seem to
exert any influence on local control rates.31–35,39–42
In-breast tumour recurrence has been reported to be
more common in human epidermal growth factor
receptor (HER2)-positive cancers.
Tumour size
Size is not significantly associated with local recur-
rence. Only 3 of 28 series that have examined the
relationship of tumour size and occurrence have
shown any significant association between tumour
size in breast recurrence.43,44 A large study from
Boston44 demonstrated that cancers over 4 cm in
size that were treated by breast conservation sur-
gery had a rate of recurrence similar to that of
smaller cancers (Table 4.1).
Tumour grade
A number of reports have analysed the relationship
between tumour grade and local recurrence.
Although some series report a higher recurrence
rate in grade 3 compared with grade 2 cancers,
this is by no means universal.31–35,39–42 The rela-
tive risk of local recurrence between grade 1 and
grade 2/3 cancer is approximately 1.5. The British
Association of Surgical Oncology undertook a trial
that randomised patients with node-negative grade
1 or special-type cancers to no further treatment,
tamoxifen alone, radiotherapy alone or both ra-
diotherapy and tamoxifen. A recent update of this
study reported an exceedingly small rate of recur-
rence in patients randomised to radiotherapy and
tamoxifen, and acceptably low rates of annual re-
currence in patients treated with either tamoxifen
alone or radiotherapy alone. Higher rates of recur-
rence were seen in patients who received neither ra-
diotherapy nor tamoxifen. In these low-risk cancers
treatment by radiotherapy alone or tamoxifen alone
may therefore produce an acceptable rate of long-
term control.
Histological type
There are few data relating histological tumour type
to recurrence. Invasive lobular cancer has not been
reported to be associated with a higher recurrence
rate than so-called invasive ‘ductal’ carcinoma.45–48
One study did suggest that patients with invasive
lobular carcinoma who developed local recurrence
were more likely to develop multifocal recurrence42
but this has not been confirmed by others. Patients
with invasive lobular cancer appear more likely
than patients with no special-type tumours to have
an incomplete excision. This is explained in part
by the underestimation of tumour extent by mam-
mography and ultrasound and the inability of sur-
geons to feel the extent of the cancer at operation.
Patients with invasive lobular cancer on core biopsy
should be warned of an increased likelihood of posi-
tive margins and where the extent of disease is not
easy to assess on mammography and/or ultrasound,
MRI may be valuable.9
Lymphatic/vascular invasion
Increased local failure rates have been reported
in most, but not all, series in patients with histo-
logical evidence of lymphatic/vascular invasion
(LVI).31–35,39–42,45–48 Of concern, the percentage of
Size (cm)
Local recurrence (%)
0–1
21
1.1–2
8
2.1–3
13
3.1–4
17
4.1–5
4
Table 4.1  •  Size of tumour related to local recurrence
Data from Eberlein TG, Connolly JN, Schnitt JS et al. Predictors
of local recurrence following conservative breast surgery and
radiation therapy. The influence of tumour size. Arch Surg 1990;
125:771–9.
The lowest rates of local recurrence are reported
in grade 1 tumours.

Chapter 4
58
tumours reported to have LVI varies widely be-
tween different series by up to a factor of 4.
LVI is more common in and around the cancer of
younger women (<35 years) compared with cancers
in older women (>50 years).
Extensive in situ component
The histological factor that was initially thought to
be associated with an increased rate of local recur-
rence was the presence of an extensive in situ com-
ponent (EIC) within and surrounding an invasive
cancer. A tumour is defined as having EIC if 25% or
more of the tumour mass is non-invasive and non-
invasive carcinoma is also present in the breast tissue
surrounding the invasive cancer.48 EIC was consid-
ered not only a predictor of local recurrence but
also of residual disease within the breast following
an incomplete wide excision. Early reports indicated
that local recurrence rates were three to four times
higher in cancers with EIC.31–35,39–42,45–48 The major-
ity of these studies did not, however, take account of
margins and the authors did not perform multivari-
ate analysis. Providing clear margins are obtained, it
is now known that there is no increased rate of local
recurrence in patients with EIC.49–51 There is an in-
teraction between age and EIC, with younger women
being more likely to have EIC. It has been suggested
that the higher frequency of EIC in younger women
might explain some of the increased rate of local re-
currence seen in younger women.42
Multiple tumours
Patients with macroscopically multiple cancers were
formerly considered to have an increased risk of lo-
cal recurrence compared with a patient with a uni-
focal cancer but patient numbers in such early series
on which this evidence is based were small.14,15 If
multifocality is identified by the pathologist or there
are two cancers that are adjacent, then acceptable
local recurrence rates can be obtained provided
that all margins of excision are clear of disease.
This led some to attempt breast-conserving surgery
for patients with multiple separate tumours in the
same breast. Provided that the cancers are excised
completely and clear margins obtained then reports
indicate a satisfactory rate of local control can be
obtained with breast-conserving surgery in patients
with both multifocal and multicentric cancers.16,17
Treatment-related factors
Controversy has surrounded how much extra tissue
around a cancer needs to be removed and what con-
stitutes an involved or positive margin. Some studies
have defined a positive or involved margin as disease
at the margin, others consider disease within 1 mm or
even disease within 2 mm of the margins as involved.
Conversely, negative margins or uninvolved mar-
gins have been variably defined as no tumour at the
margin, or tumour within 1, 2, 5 and 10 mm of the
margin. Whatever definition has been used, almost
all studies have reported an increased rate of local
recurrence in patients with positive, non-negative or
involved margins. When comparing patients with in-
volved margins to those with uninvolved or negative
margins, the relative risk of local recurrence varies
between 1.4- and 9-fold.28,29,31–35,39–42,45–47,49–54 This
is despite, in almost half of these series, patients with
involved or close margins having received higher
doses of radiotherapy than patients with clear mar-
gins. In the few studies which found that margins
are not important predictors of local recurrence, the
dose of radiotherapy delivered to the tumour bed
ranged from 65 to 72 cGy, i.e. a dose range that is
effective without surgery.51–54 In one study, patients
with involved margins who underwent re-excision to
achieve a negative margin had a zero local recurrence
rate; this compares with a 22% local recurrence rate
in those patients who had re-excision but still had
non-negative margins (P = 0.001).50 Surveys in the
UK and USA have demonstrated that approximately
50% of surgeons aim for a margin of more than
2 mm, whereas 50% of surgeons are happy with a
margin of 2 mm or less.55 There is thus no consen-
sus about what constitutes an adequate margin of
excision for breast-conserving surgery. A systematic
review of margins and local recurrence was con-
ducted by Singletary, who reported that some of the
lowest rates of local ­recurrence were in centres that
had used narrow margins of excision (1 or 2 mm).28
Carcinomas with LVI have approximately double
the rate of local breast recurrence compared with
tumours with no evidence of this feature.
The most important surgical-related factor is
completeness of excision. Current practice is to aim
for at least microscopically disease-free margins.
Ideally, there should be a clear rim of normal
tissue (≥1 mm) around the carcinoma at all radial
margins.28,29

Breast-conserving surgery: the balance between good cosmesis and local control
59
A recent large comprehensive meta-analysis of mar-
gins has confirmed that wider margins do not reduce
local recurrence.29 Wider margins remove more tissue
and so impact on cosmetic outcomes. The meta-anal-
ysis confirmed an increased rate of local recurrence
for both involved and close (<1 mm) margins.29
Compared with no ink on cancer cells a 1-mm mar-
gin was associated with a significantly lower rate of
local recurrence. Recent data from Edinburgh show
there is no need to re-excise if anterior or posterior
margins are <1 mm, providing full thickness of breast
tissue has been excised and boost radiotherapy given.
Unpublished data from Edinburgh show similar local
recurrence rates whether the distance to the nearest
margin was in the range 1–5 mm or 5–10 mm, con-
firming the results from the meta-analysis that nar-
row 1-mm margins are sufficient.
A recent large series of patients treated by breast-
conserving surgery with a ≥1 mm margin re-
ported rates of local recurrence of <0.5% per year
(Fig.  4.2).56 The majority of these so-called recur-
rences were in fact second primaries. In conclusion, a
1- or 2-mm margin is adequate and produces accept-
able rates of long-term control. Any centre excising
margins wider than 1 or 2 mm on breast-conserving
excisions should consider their protocols.
Studies have looked at the presence of lobular carci-
noma in situ57 and atypical ductal hyperplasia58 at the
margins of excision. Neither of these features signifi-
cantly increases local recurrence rates and so there is
no need for re-excision if the pathologist reports these
features alone at any of the margins of excision.
Age interacts with margins. Involved margins have
their greatest impact on local recurrence in younger
rather than in older women.53
There is a direct interaction between EIC and
margins (Table 4.2). Patients with EIC and positive
margins who proceeded to radiotherapy without
re-excision had a 37% local recurrence rate in a se-
ries from Boston48 and a 21% recurrence rate in a
Stanford series.50 In contrast, patients with EIC and
negative margins, on primary or re-excision, had a
zero local recurrence rate. These two studies demon-
strate that patients with EIC do not have an increased
rate of local recurrence providing the margins of ex-
cision are clear of invasive and in situ cancer.
Patients undergoing re-excision for close or in-
volved margins have only a 30% incidence of re-
sidual cancer in re-excised tissue.59 More than two
foci of microscopic margin involvement in the origi-
nal wide excision appears to be associated with a
greater incidence of residual cancer (65%) compared
with fewer than two foci, which had a much lower
rate of residual cancer. If there was no residual dis-
ease at re-excision then there was a 4% local failure
rate at 4.7 years compared with a 13% failure rate
in patients who had residual disease at re-excision.
Patients younger than age 50 in this study were also
more likely to have disease in the re-excision speci-
men. The conclusion was that the majority of pa-
tients who undergo re-excision do not benefit from
this procedure. Patients with lucent breasts and a
well-defined lesion appear particularly unlikely to
benefit from re-excision, if margins are close or fo-
cally positive, whereas younger women with dense
breasts are much more likely to benefit from further
surgery, as many of these women will have residual
disease in the re-excision specimen.59 Further stud-
ies in this area are required. If it were possible to
identify a group of women who do not benefit from
re-excision, this would have great clinical utility.
Adjuvant systemic therapy
Aromatase inhibitors, tamoxifen and chemother-
apy, in the presence of radiotherapy, reduce local
A recent meta-analysis concluded that wider
margins do not reduce rates of local recurrence.
Incomplete excision, i.e. tumour at a margin, does,
however, result in an unacceptable rate of local
control.28,29 A 1-mm margin is sufficient.
Margins
Boston
Stanford
EIC+
EIC−
EIC+
EIC−
Positive/non-negative
37
7
21
11
Close
0
5


Negative
0
2
0
1
Table 4.2  •  Local recurrence rates (%) at 5 years in patients from Boston48 and Stanford50 subdivided by margin status
and the presence (EIC+) or absence (EIC−) of an extensive in situ component

Chapter 4
60
recurrence rates after breast-conserving surgery.60,61
In the absence of radiotherapy, aromatase inhibi-
tors, tamoxifen or chemotherapy alone do not pro-
duce satisfactory rates of local control apart from
in low-grade, node-negative cancers.62 The interval
between surgery and radiotherapy may be impor-
tant and there are suggestions that the rates of lo-
cal recurrence increase if radiotherapy is delayed.
The sequencing of radiotherapy and chemotherapy
is the subject of ongoing trials but it appears that
giving both synchronously rather than sequentially
improves local recurrence.
Factors influencing cosmetic
outcome after breast-
conserving surgery
There is a great variation in different series in the
number of patients with good to excellent cosmetic
results after breast-conserving surgery (Fig. 4.3).
Patient factors
There is conflicting evidence about whether age
influences cosmetic outcome, with some studies
claiming that older women have worse cosmetic
results than younger women.1 One problem in
younger women is that as the patient ages the nor-
mal contralateral breast tends to increase in size,
whereas the treated breast tends not to and some
treated breasts shrink. A treated breast that is sym-
metrical immediately following treatment can thus
become asymmetrical over time.
There is a trend towards increased fibrosis in
larger breasts, which leads to poorer cosmetic re-
sults than seen in smaller breasts.63 For this reason
large-breasted women may be best treated by an
operation that excises their cancer and at the same
time reduces the volume of the breast (therapeutic
mammaplasty). The best option to achieve symme-
try in such women is to reduce both breasts through
reduction-type incisions. Better cosmetic results fol-
lowing breast-conserving surgery and radiotherapy
are obtained in medium- and moderate-sized breasts;
achieving a good cosmetic outcome can often be a
problem in small breasts.1
Tumour factors
Increasing tumour size means that increasingly
large amounts of tissue have to be removed. The
volume of tissue excised is the most important fac-
tor relating to cosmetic outcome and so not sur-
prisingly patients with larger tumours tend to have
worse cosmetic results than women with smaller
cancers.64,65 There are some data indicating that in
surgery for small and impalpable cancers, a dispro-
portionately large amount of normal surrounding
breast tissue is removed to ensure that all the af-
fected tissue is excised. The role of the surgeon is to
excise the cancer completely in as small a volume
as possible. Removing large volumes of tissue when
excising small screen-detected cancers is not satis-
factory surgical practice.
Figure 4.3  •  Examples of excellent (a) and poor (b)
cosmetic results from breast-conserving surgery and
radiotherapy.
a
b
The importance of a good cosmetic outcome
is based on studies that have shown a significant
correlation between poor cosmetic outcome and
increased levels of anxiety, depression, poor
body image, problems with sexuality and low self-
esteem.2

Breast-conserving surgery: the balance between good cosmesis and local control
61
Location of tumour
Cosmetic outcomes tend to be better if the tumour
is located in the upper outer quadrant.66 Studies
have shown that major downward displacement of
the nipple occurs when surgery is performed on tu-
mours located in the inferior half of the breast. This
can be corrected at the time of initial surgery by de-
epithelialising a crescentic portion of skin above the
nipple to re-centre it on the new breast mound (see
Chapter 6). If the tumour is central and the nipple–
areola complex needs to be removed, then this can
have a major effect on cosmetic outcomes.1 This is
why central tumours were at one time considered
a relative contraindication to breast-conserving sur-
gery. However, studies have suggested that excision
of central cancers not directly involving the nipple–
areola complex can be treated by wide excision and
nipple preservation, without significantly increasing
the rate of local recurrence compared with more
peripherally situated cancers.67 Good cosmetic out-
comes are possible in some women with this ap-
proach (Fig.  4.4). In women with moderate-sized
breasts who have cancers that directly involve, or
are very close to the nipple, the nipple and/or areola
can be excised in continuity with the cancer and
the skin closed by a purse-string suture (Fig. 4.5).
Another option is to rotate a dermoglandular local
flap from the lower part of the breast to fill the de-
fect (Fig. 4.6). This produces very satisfactory cos-
metic outcomes.68 In women with central superficial
cancers in larger breasts, the nipple can be excised
as part of a reduction-type procedure with direct
closure, or the defect caused by excising the nipple
and areola can be filled with a new island of skin
developed on an inferior dermoglandular pedicle.
This can only be performed if there is at least 9 cm
of skin between the margin of skin excision and the
inframammary fold (Fig. 4.7).
Surgical factors
The poorer cosmetic results obtained with quadran-
tectomy, even in the most experienced hands, com-
pared with wide excision are well documented and
are related to the much larger volumes of tissue re-
moved by quadrantectomy.69
Even more critical than the volume of tissue re-
sected is the percentage volume of the breast excised.
There is a highly statistical correlation between cos-
metic outcome and percentage volume of the breast
excised (Fig. 4.8), with excisions of less than 10%
of breast volume generally being associated with
a good cosmetic outcome, whereas excisions over
10% often produce a poor cosmetic result (Fig. 4.9).
Where it is clear that more than 10% of breast
volume needs to be excised in order to remove the
cancer, then consideration should be given to one
of a number of procedures that can improve the fi-
nal cosmetic result. These include volume replace-
ment with a myocutaneous or local lipocutaneous
flap,12,13 volume replacement using immediate lipo-
filling following the tumour excision, an oncoplastic
reduction procedure (therapeutic mammoplasty),
neoadjuvant drug therapy or a mastectomy with or
without immediate reconstruction.
Figure 4.4  •  Good cosmestic results from excision of a
subareolar cancer left breast via a circumareolar incision.
Figure 4.5  •  Result after a central excision of a cancer
and use of a purse-string suture to close the central
defect.
The extent of surgical excision or the volume
of resected breast tissue is the most important
factor affecting cosmesis.1,64

Chapter 4
62
Figure 4.6  •  (a) How to excise a central cancer under the nipple
and produce a satisfactory cosmetic outcome without major breast
distortion. This procedure has been called central quadrantectomy.
The nipple–areola complex is excised and a portion of skin inferior is
marked out. An incision around the circular skin island is made and the
remaining skin around the island is de-epithelialised. A full-thickness
incision is then made in the breast and the skin island is rotated to fill
the central defect. Staples are useful to position the flap. When the flap
is deemed to be in an optimal position, the staples are removed and
the wound closed in two layers with absorbable sutures. (b) Final result
from a right wide local excision Grissotti flap and nipple reconstruction.
a
Skin
island
De-epithelialised skin
b
Figure 4.7  •  (a) Patient prior to operation – cancer under right nipple evident by asymmetry with right nipple flatter
and right nipple higher than left. (b) Preoperative markings showing the area around the nipple that will be excised.
(c) Operative view of the island of skin that is mobilised on a de-epithelialised inferior dermoglandular flap. (d) Final result
after radiotherapy prior to nipple reconstruction.
a
b
c
d

Breast-conserving surgery: the balance between good cosmesis and local control
63
Re-excision and number of procedures
Re-excision of the tumour bed has a negative im-
pact on cosmesis.64 This is mainly as a consequence
of the increased total volume of tissue excised from
the breast. There is no limit to the number of re-
excisions that a patient can have to achieve com-
plete removal of all invasive and in situ disease,70
but with the greater number of re-excisions more
tissue is removed and so the likelihood of a good
cosmetic result decreases. For patients who require
multiple excisions to get clear margins then con-
sideration should be given to correcting any vol-
ume deficit prior to delivery of radiotherapy or
considering subsequent contralateral symmetrising
surgery.
Axillary surgery
Axillary clearance does appear to be associated with
a worse cosmetic outcome compared with sentinel
node biopsy, primarily because of the volume of tis-
sue removed, which results in an axillary deficit, but
also because removing all nodes increases the risk of
breast oedema.63,64,71
Postoperative complications
Development of a haematoma, seroma or postop-
erative infection tends to increase the chances of the
patient getting a poor cosmetic result.1
Breast-conserving surgery after
neoadjuvant therapy
Significant numbers of patients are diagnosed with
large or locally advanced breast cancer, many of
whom are treated initially by neoadjuvant chemo-
therapy or endocrine therapy. Up to a half of these
patients will subsequently become candidates for
breast-conserving surgery. To improve complete
excision rates and minimise cosmetic deformity
in these patients there are some guiding principles
when performing breast conservation surgery after
completion of neoadjuvant therapy. First, it is im-
portant to know the exact site of the tumour within
the breast, as significant numbers of patients with
HER2-positive and triple negative cancers will have
a complete pathological response. All patients un-
dergoing neoadjuvant chemotherapy who might
be candidates for subsequent breast-conserving
surgery should therefore have one or more tumour
markers placed centrally prior to or early during
treatment. The patterns of response to neoadjuvant
chemotherapy and neoadjuvant endocrine therapy
differ.72 The most common form of pathological
change in patients undergoing neoadjuvant endo-
crine therapy is central scar formation,72 which
results in concentric reduction in tumour size and
tumour volume. Breast-conserving surgery follow-
ing neoadjuvant endocrine therapy is therefore
usually successful at excising all disease in one op-
eration and few patients have involved margins.
In contrast, a significant number of patients after
neoadjuvant chemotherapy have a diffuse pattern
of response to chemotherapy, with reduction in
tumour cellularity but without significant shrink-
age of volume. This diffuse tumour may be impal-
pable and more than 25% of patients ­undergoing
30
20
25
15
10
5
0
Volume loss (%)
0
10
20
30
40
50
P<0.0001
60
Body image score
Figure 4.8  •  Percentage of breast excised compared
with body image score. Percentage of breast excised
calculated by measuring total weight of excision
and estimating breast volume (from initial diagnostic
craniocaudal mammogram). Body image score based on
patient-administered questionnaire of 15 questions (score
runs from 15, the best possible score, to 60, the worst
and highest possible score). Data from a series of 120
patients treated in the Edinburgh Breast Unit.
100
94%
80
60
40
20
0
Percentage
≤ 10%
> 10%
Breast excised
40%
P <0.001
Excellent/good
Moderate/poor
Figure 4.9  •  Percentage of good/excellent results in
patients subdivided according to whether 10% or less or
more than 10% of breast volume was excised by breast-
conserving surgery.

Chapter 4
64
­breast-conserving surgery after neoadjuvant che-
motherapy will have incomplete excision of dis-
ease. All patients undergoing breast-conserving
surgery after neoadjuvant chemotherapy should be
warned of this rate of incomplete excision and the
possible need for a further operation.
Radiotherapy
Increasing doses of radiotherapy, particularly with
the addition of boost, have a detrimental effect on
cosmetic outcomes.31,63,64 Long-term follow-up is
necessary to assess cosmetic outcome; 3  years af-
ter treatment, radiotherapy effects tend to stabilise.
Fibrosis is a late effect of radiotherapy and pro-
duces breast retraction and contour distortion. The
treated breast tends not to increase in size to the
same extent as the opposite untreated breast, so pa-
tients as they age can develop asymmetry even when
the initial cosmetic result was excellent. Boost has
a negative impact on cosmesis because it produces
intense fibrosis and unsightly skin changes, includ-
ing telangiectasia.31
Other treatment effects
Tamoxifen and aromatase inhibitors have little if
any effect on cosmetic outcome, whereas some stud-
ies have suggested that chemotherapy has a negative
impact on the cosmetic outcome of breast-conserving
surgery.1
Treatment of poor cosmetic
results after breast-conserving
surgery
Prevention is better than treatment, so minimis-
ing volume, closing breast defects and immediate
lipofilling (Fig. 4.10) are much better options than
trying to correct asymmetry once it has developed.
Options for improving poor cosmetic outcomes in-
clude increasing the volume of one or both breasts
if the main problem is essentially loss of volume
rather than significant radiation fibrosis. While
­placement of silicone prosthesis or prostheses has
been described, they are successful only for patients
with little or no deformity and absence of marked
skin changes.74 Swelling following implant insertion
in a radiotherapy-treated breast is often marked and
takes many months to settle. Some patients develop
marked capsular contraction after implant place-
ment following radiotherapy but there are no data
on whether this incidence is greater than in women
having augmentation with no prior radiotherapy.
The use of implants has been largely superseded
by lipofilling. Fat is aspirated from the abdomen
and thighs and centrifuged, washed or filtered.75,76
Having removed the oil and blood it is then injected
as microdroplets into the area of distortion and/or
asymmetry. Approximately 40% of the injected fat
survives. Multiple episodes of lipofilling combined
with scar release or scar excision are often required
to correct significant breast deformity and asym-
metry (Fig. 4.11).76 If the problem is simply one of
asymmetry and the treated breast is a satisfactory
shape but smaller than the normal contralateral
breast, then the contralateral breast can be reduced.
If the treated breast is shrunken, misshapen and
scarred, then another option is to excise part or
the whole of the treated breast and reconstruct ei-
ther part of the breast or the whole breast. Pedicled
myocutaneous latissimus dorsi or transverse rectus
abdominis myocutaneous (TRAM) flaps offer an
opportunity to excise unsightly areas of skin and/
or breast distortion and scarring, and provide one
option to regain symmetry (Fig. 4.12).
MRI following neoadjuvant chemotherapy is the
best of the currently available imaging methods to
assess extent of disease and is the best predictor of
whether a cancer is suitable for breast-conserving
surgery.73
Figure 4.10  •  Result from wide local excision right of
a cancer in the upper inner quadrant via a circumareola
incision with immediate lipofilling and postoperative
radiotherapy.

Breast-conserving surgery: the balance between good cosmesis and local control
65
Pre Lipofilling
After Lipofilling
Scar Release + 2nd Fill
Figure 4.11  •  Patient with a defect from a previous wide local excision and radiotherapy before and after lipofilling and
then scar release and lipofilling of the left breast.
Figure 4.12  •  Patient with a poor cosmetic result after breast-conserving surgery before (a) and after (b,c) partial breast
reconstruction with a pedicled latissimus dorsi myocutaneous flap.
a
b
c

Chapter 4
66
Significance and treatment
of local recurrence
Local recurrence rates of 0.5% or less per year after
breast-conserving treatment are now achievable.
Isolated recurrences of the breast can be treated by
re-excision or mastectomy.77–79 Re-excision alone is as-
sociated with a high rate of subsequent local recurrence
if the initial recurrence occurs within the first 5 years of
treatment.78 Until recently 80% of local recurrences in
the conserved breast occurred at the site of the origi-
nal breast cancer, with 90% of these local recurrences
following breast-conserving surgery being invasive.
This is no longer true and an increasing percentage of
‘­recurrences’ in treated breasts are now second primary
cancers. Local recurrence within the first 5 years is asso-
ciated with a worse long-term outlook than recurrence
thereafter.7,77–79 The role of systemic therapy following
mastectomy for an apparently localised breast recur-
rence appears to be of benefit.79 Uncontrollable local
recurrence is uncommon after breast conservation, but
when it does occur it is difficult to treat.
Prolonging adjuvant hormonal therapy beyond
5 years has a significant impact on the rate of subse-
quent local relapse in postmenopausal patients with
hormone receptor-positive breast cancer.
An isolated local breast recurrence does
not appear to be a threat to survival, but breast
recurrence is a predictor of distant disease,7,77,78
and the aim of primary treatment is to avoid local
recurrence if at all possible.
Extended hormonal treatment with letrozole
following completion of 5 years of tamoxifen
reduces' in breast. Local recurrence is reduced by
letrozole compared with tamoxifen given as adjuvant
therapy to postmenopausal women with ER positive
breast cancer (Table 4.3). Extended recurrences
by almost two-thirds and also reduces the rate of
contralateral breast cancer development.79

Letrozole (n = 2463)
Tamoxifen (n = 2459)

No. of patients
%
No. of patients
%
Disease-free survival events
352
14.3
418
17.0
Local
19
0.8
38
1.6
Contralateral breast
14
0.6
26
1.1
Regional
13
0.5
11
0.5
Distant
182
7.4
212
8.6
Deaths without cancer
60
2.4
48
2.0
Deaths (overall survival events)
194
7.9
211
8.6
Systemic failures
331
13.4
374
15.2
Table 4.3  •  Efficacy end-points in 4922 patients enrolled into the BIG 1-98 trials
Modified from Coates AS, Keshaviah A, Thurlimann B et al. Five years of letrozole compared with tamoxifen as initial adjuvant therapy for
postmenopausal women with endocrine-responsive early breast cancer: update of study BIG 1–98. J Clin Oncol 2007; 25(5):486–92.
Published by the American Society of Clinical Oncology.
Key points
• For patients with single breast cancers, survival outcomes from breast-conserving treatment are
equivalent to that of mastectomy.
• Radiotherapy (after breast-conserving surgery) reduces the rate of local recurrence and improves
overall survival. No subgroup of patients has yet been identified that can avoid radiotherapy.
• The major surgical factor influencing local recurrence is completeness of excision, and clear
margins (≥1 mm) must be obtained when performing breast-conserving surgery.
• Wider margins (>5 mm) do not appear to achieve better local control rates than narrow margins
(≥1 mm).
• Younger patients have an increased rate of local recurrence after breast-conserving surgery.
Conversely, older patients have a lower rate of local recurrence.

Breast-conserving surgery: the balance between good cosmesis and local control
67
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• Tumour grade, EIC and LVI have a limited influence on the rate of local recurrence. Patients
with these factors should not be denied breast-conserving surgery, providing the cancer can be
excised to clear margins.
• There is a direct correlation between cosmetic outcome after breast-conserving surgery and
psychological morbidity, with better cosmetic outcomes being associated with less anxiety and
depression and better body image and self-esteem.
• The most important factor influencing cosmetic outcome after breast-conserving surgery is the
percentage volume of breast excised. Removing more than 10% of the breast volume dramatically
increases the number of women having a poor cosmetic outcome.
• Patients who develop local recurrence after breast-conserving surgery, particularly in the first
5 years, are at increased risk of having systemic relapse.
• Isolated local recurrences after breast-conserving surgery are usually treated by mastectomy,
although re-excision is possible, particularly if the recurrence develops more than 5 years after
treatment or the patient has not received radiotherapy to the breast.
• Prolonging hormonal therapy beyond 5 years in postmenopausal women with hormone receptor-
positive breast cancer reduces the rate of subsequent ‘in-breast recurrence’ and the rate of
contralateral breast cancer development.

Chapter 4
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37. Pierce L, Levin A, Rebbeck T, et al. Ten-year outcome
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40. Haffty BG, Fischer D, Rose M, et al. Prognostic fac-
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44. Eberlein TG, Connolly JN, Schnitt JS, et  al.
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of differences in prognosis, recurrence patterns and
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51. Solin LJ, Fowble BL, Schultz DJ, et  al. The sig-
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54. Schmidt-Ullrich R, Wazer DE, DiPetrillo T, et  al.
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control rates: a case for aggressive therapy to the tu-
mour bearing quadrant. Int J Radiat Oncol Biol Phys
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55. Vallasiadou K, Young OE, Dixon JM. Current prac-
tices in breast conservation surgery: results of a
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Premenopausal breast cancer patients treated with
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71
5
R. Douglas Macmillan
Techniques of mastectomy: tips and pitfalls
Introduction
Mastectomy is used to treat approximately 35%
of all breast cancers. The procedure can be accom-
plished using one of a wide variety of techniques,
depending on the clinical setting. Any mastectomy
should be sensitive to the aims and principles of
­oncoplastic breast surgery, namely that optimal
treatment of the malignancy should be achieved
with minimal impact on quality of life.
Techniques of mastectomy are largely not evidence
based. A few small trials exist but much of what is
described in this chapter is based on reports of case se-
ries, expert opinion and personal preference. It is not
intended to be prescriptive or dogmatic but merely a
description of an approach to a commonly performed
operation. Factors such as breast size, physical ac-
tivities, preference for certain clothes (necklines) and
expectations are all important discussion points that
may influence choice of technique in many situations.
General considerations
The patient may have risk factors for poor wound
healing, which include:
• smoking;
• obesity;
• diabetes;
• poor skin quality;
• previous radiotherapy;
• previous surgery to the breast;
• severe comorbidities.
Of these, smoking is the most commonly encoun-
tered factor that can be improved to optimise out-
come within the timescale of the urgent case. This
and other factors may affect technique selection.
Smoking
There are more than 4000 chemicals present in ciga-
rette smoke, including nicotine and carbon monox-
ide.1 One effect of nicotine is to cause vasoconstriction
of the dermal–subcutaneous vascular plexus. This has
important consequences, as mastectomy flaps rely on
this plexus for survival.2 As well as inducing a hypoxic
state and causing vasoconstriction, smoking can lead
to increased platelet aggregation, which results in the
formation of tiny thromboses in capillaries. This is
detrimental to wound healing, which relies heavily on
blood flow in newly formed capillaries. Smokers have
higher levels of fibrinogen and haemoglobin, which
increase blood viscosity, which further increases the
likelihood of blood clotting, and blood velocity can
be reduced by up to 42% in smokers.3 The combi-
nation of decreased oxygen delivery to tissues and
the thrombogenic effects of smoking, together with
increased viscosity and reduced velocity, explain why
wound healing in smokers is significantly impaired.
The link between smoking and wound healing was
first documented in the 1970s. One study of 425 pa-
tients undergoing mastectomy and breast-conserving
surgery identified smoking as an independent pre-
dictor for wound infection and skin necrosis regard-
less of the number of cigarettes smoked.4

Chapter 5
72
Another study of 716 patients having free trans-
verse rectus abdominis myocutaneous (TRAM) flaps
showed mastectomy flap necrosis, abdominal flap
necrosis and abdominal hernias were significantly
higher in smokers.5 This study did demonstrate a
dose effect with smokers who had a history of more
than a pack a day for 10 years being at increased
risk of developing problems compared with smokers
who had smoked for a smaller number of pack years
(55.8% vs. 23.8%). One observation in this study
was that delayed breast reconstruction in smok-
ers was associated with a significantly lower rate
of wound complications compared with immedi-
ate breast reconstruction in smokers. The risk of
wound complications in delayed reconstructions
in smokers was similar to the rate in non-smokers.
Complications were also less common in women who
stopped smoking 4 or more weeks before surgery.
There was one small study of 108 patients investi-
gating smoking cessation prior to surgery that was
a randomised clinical trial with 40 patients in the
control group and 68 patients in the interventional
group.6 Patients assigned to intervention were given
counselling and nicotine replacement therapy. This
study showed a significant reduction in complica-
tions in the intervention group, with a reduction in
both wound-related complications and the need for
secondary surgery.
In this study patients stopped smoking 6–8 weeks
before surgery and did not smoke for 10 days after
the operation. In the literature there is no consensus
on the optimal duration of preoperative smoking ces-
sation but there is evidence from a variety of studies
that there are potential benefits from even a brief pe-
riod of abstention. Part of the problem is that the ma-
jority of studies are retrospective and have inherent
weaknesses in their design.
Considerations for simple
mastectomy
In addition to general considerations, four ques-
tions should be answered:
1. Is it necessary/desirable to excise skin overlying
the cancer?
In principle, skin only requires to be excised if
the cancer is involving the skin or is so close that a
clear margin cannot clearly be achieved around the
­cancer ­without skin resection.
2. Is there likely to be a lateral dog ear/redundant
tissue?
The all too frequently seen but completely avoidable
complication of mastectomy is redundant tissue, also
known as a dog ear, which is unsightly, causes diffi-
culty with bra fitting and often chafes on the prosthe-
sis, arm or bra (Fig. 5.1).
3. Would the patient benefit from a contralateral
breast reduction?
This is a simple and very effective option to enable
women with a heavy breast to wear a lighter pros-
thesis and feel less unbalanced (Fig. 5.2a). In some
cases a woman may choose a bilateral mastectomy
to achieve better overall symmetry.
4. Is a delayed breast reconstruction planned?
The scar should be sympathetic to the method of
delayed reconstruction planned. In most cases a low
scar is best (as in Fig. 5.2a). It allows a flap-based
reconstruction to be set at the inframammary fold,
with the upper scar low enough to be hidden in low-
neckline clothes (Fig. 5.2b).
Planning a mastectomy
• Examine the patient sitting up to assess lateral
tissue and plan the likely lateral end of scar. The
predicted lateral extent of the incision can be
marked.
• The extent of the scar is important if radiotherapy
is planned as the whole scar will be covered and
can result in large volumes of tissue being treated
if the scar extends a long distance posteriorly.
Figure 5.1  •  Poor result from mastectomy.

Techniques of mastectomy: tips and pitfalls
73
• Mark any skin that needs to be removed over
the cancer.
• Decide if a second incision is required for
sentinel node biopsy (usually not necessary).
Technique
Most scars can be based around the inframammary
fold (IMF). The incision pattern is drawn in the-
atre initially with a line at or just below the IMF
(in women with any intertrigo the scar should be
placed below this). Then with repeated upward and
downward movement of the breast the planned
transposition of this line on the breast skin can
be marked (Fig. 5.3). In most cases the upper inci-
sion line passes a little above the areola. Attention
should be paid to the degree of tension applied to
the upward or downward breast movement as this
represents the tension that will be exerted on the
wound on closure. The upper and lower incision
lines should be planned so that they meet comfort-
ably but without excess laxity. Incisions should be
planned to avoid any dog ear. To achieve this it is
often best to continue the incision along the bra
line laterally, curving up slightly until the upper and
lower lines meet (Fig. 5.4) or, if there is doubt about
how to fashion the lateral end, stop the incision at
the lateral edge of the breast and fashion it once the
mastectomy is complete, before closure (see com-
ments regarding dog ear below). Transverse mastec-
tomy scars are commonly used but rarely, if ever,
can be closed without significant excess of tissue,
particularly laterally. It is beholden on all surgeons
to be familiar with a range of mastectomy incisions
and given that there are always better alternatives,
transverse mastectomy scars should be avoided.
Inferior broad-based flaps can be designed to allow
skin excisions in the upper pole. In breasts with a
high nipple position or in cases where skin ­excision
in the upper pole is desired, the lower incision line
Figure 5.2  •  (a) A low mastectomy scar with contralateral reduction. (b) Delayed reconstruction with LD flap.
a
b
Figure 5.3  •  Drawing of IMF-based incision.
Figure 5.4  •  IMF-based incision with lateral extension.

Chapter 5
74
can be adjusted to preserve skin on the lower flap.
Such modifications to the inferior skin flap should
be broad based. Other scar patterns to consider in
such situations include the Wise pattern or dome-
shaped scar (Fig. 5.5).
Lighting
A headlight is valuable and should be part of the
equipment available for any breast operation.
Retraction
Care should be taken with the edges of the mastec-
tomy flaps. Sharp hooks or tissue forceps applied to
dermis cause less trauma to mastectomy flaps than
blunt retractors.
Identifying the ‘plane’
Some would contest its existence, but there is a
­readily identifiable plane between the breast and
subcutaneous fat that defines the dissection. That
is not to say that it is obvious in every case and it
may be quite irregular. The thickness of fat on mas-
tectomy flaps varies between patients and increases
further the distance from the nipple. Importantly,
however, the subcutaneous vessels (extensions of
the intercostal perforators) lie superficial to this
plane. The plane can be defined by hydrodissection
infiltrating saline (I use 1 in 1 million – others use 1
in 500 000)/adrenaline using a spinal needle, Verres
needle or blunt infiltration cannula attached to a
50-mL syringe or a pressure bag (100–150 mmHg)
of saline/adrenaline solution. The plane is identified
as a white line after performing a skin incision be-
fore the flaps are lifted and retracted. With ­opposing
retraction on skin and breast and light initial
­dissection, tissues are seen to separate at the level
of the plane. Dissection then chases this white line
with continued opposing retraction (with skin hook
retraction on the upper flap, skin kept as straight
as possible), cutting on its superficial surface. This
produces a flap of uniform thickness that will be
thicker in fatter women and thinner in others.
Surgical tools
My preference is to use a hand-held diathermy on a
fulgurate setting throughout. If using hydrodissec-
tion, scissors or a knife can be used as the plane
is bloodless. Different surgeons have different pref-
erences. Blood loss should be less than 100 mL if
diathermy is used. Some prefer scissors or the knife
because of concern of the ‘burn’ that results from
diathermy dissection; blood loss is generally greater
with scissors or the knife.
Preserving the intercostal perforators
These represent the main blood supply to the mas-
tectomy flaps once the breast tissue is removed.
Their preservation is important, not just for the pre-
vention of flap necrosis and wound problems, but
also to maximise the longer-term quality of the skin.
The largest tend to originate at the second or third
intercostal space. These are usually encountered
early in the dissection just superior to the areola
and can be seen (especially in thin women) and pre-
served during dissection upwards and medially.
Issues regarding posterior margin
Strong opinions are often expressed regarding
whether or not to excise the pectoral fascia and when
to excise some muscle. The posterior plane or breast
plate is very well defined, certainly in the middle and
upper part of the breast. In these areas there is no
need and no clinical evidence to support removal of
the pectoral fascia. For mastectomy, preservation of
the fascia is only an issue if the cancer lies posterior
in the breast. If this is the case and there is any doubt
about adherence to muscle, then a portion of pec-
toral muscle can also be taken. In such situations a
wide margin of muscle excision avoids the situation
where a margin is reported as histologically involved
or close (often due to its contraction following fixa-
tion), at no additional cost in terms of morbidity.
Inframammary fold
With a simple mastectomy this is normally excised,
avoiding a ridge and producing a flat surface.
Figure 5.5  •  Dome-type mastectomy scar to allow
excision of upper pole skin.

Techniques of mastectomy: tips and pitfalls
75
The anterior fat over the shoulder
This is often prominent and yet not part of the breast.
If not contoured, it can produce a bulge in the upper
outer aspect of the mastectomy site. Undermining
the upper flap towards the shoulder often releases
this fat pad so that it is more evenly distributed.
A flat surface
After mastectomy, before closure, the chest wall
should be palpated with the flat of the hand to make
sure there are no ridges or prominent irregularities.
If so, these can be contoured prior to closure. There
is some evidence that suturing the mastectomy flaps
to the chest wall, so-called ‘quilting’, reduces se-
roma formation.
Suturing
Interrupted deep dermal sutures to approximate
skin edges and gather any discrepancy between up-
per and lower flaps are advisable prior to a subcutic-
ular suture. My preference is to use 3/0 absorbable
suture throughout.
Managing the potential dog ear
Several techniques have been described for this.
First and foremost, however, do not use incisions –
such as a transverse mastectomy scar – which pro-
duces a ‘dog ear’ or ‘angel wings’ in the majority of
patients in whom it is used. One approach to reduce
‘dog ears’ is as follows. If the patient is fairly thin,
a flat lateral chest wall can be achieved by using an
IMF scar as described above. In women with excess
lateral tissue, it is often useful to complete the mas-
tectomy with minimal extension of the scar laterally
and then tidy this part of the scar. The easiest way
to do this is to close the skin with temporary place-
ment of skin staples. This then allows variations of
lateral scar closure to be visualised before commit-
ment to any particular one. The staples can be re-
moved and replaced as many times as necessary to
get the best and shortest scar. Final wound closure is
with two layers of absorbable deep and superficial
subcuticular absorbable sutures. Some lateral laxity
can be accommodated by gathering the upper flap.
The three most useful techniques for lateral scar
design in my experience are lateral extensions of
the IMF scar, liposuction and the fishtail technique
(Fig.  5.6). When performing fishtailing use staples
to approximate the wound edges and take the lat-
eral end of the transverse incision and move it and
staple it medially to flatten out the lateral end of
the wound to leave two smaller dog ears. Mark out
incisions to excise these dog ears and then excise
or de-epithelialise these (to preserve blood supply
at the ‘T’ where the three wounds meet) to produce
the fishtail pattern. Ensure that the wound is flat,
if necessary by using liposuction. Liposuction is a
useful adjunctive technique in many mastectomies.
Cases in which difficulty with the lateral tissue is
predicted preoperatively can be performed either
with the patient on their side (ideally) or with some
degree of rotation. Women with excess lateral tis-
sue can be challenging cases, and should be man-
aged by those familiar with a range of flap-based
surgery as well as liposuction, and be planned pre-
operatively. Glue provides a dressing that does not
need to be changed, is waterproof (so patients can
shower next day) and rarely produces skin reaction,
so minimising further trauma to the skin surface
around the flap edges.
Goldilocks mastectomy
Although it has been tradition to excise the excess
skin over the breast during a mastectomy to leave
a flat chest wall, other options may be considered.
Skin that would normally be discarded may be de-
epithelialised, shaped and buried to improve the
cosmetic result. This may avoid the concave ap-
pearance that often results from mastectomy and
in some cases can produce a small breast mound.
Skin incisions are marked as normal but the skin
between the upper and lower incisions is de-
epithelialised. The de-epithelialised lower flap is then
buried under the upper mastectomy flap. The amount
Figure 5.6  •  Fishtail scar with contralateral reduction
(correction of case in Fig. 5.1).

Chapter 5
76
of tissue that can be preserved and used in this
way will vary considerably, depending on risk fac-
tors for tissue viability and the amount of skin
required to be removed for oncological reasons.
Care is required in wound closure to maintain the
superficial vasculature (Fig. 5.7a–c).
Bilateral simple mastectomy
Ideally these should be symmetrical. Bilateral IMF-
based scars work well. It is important to leave a skin
bridge in the midline and not have a continuous scar
across the chest.
Undesirable scar patterns
High transverse and most diagonal scars should be
historical other than in salvage situations, likewise
any scar that does not leave a flat surface with a
contoured lateral chest wall. Transverse scars rarely
leave a satisfactory result without fishtailing at the
lateral end and are not recommended.
Considerations for
mastectomy with immediate
reconstruction
Of the general issues listed above, smoking is a par-
ticular concern and the major risk factor for flap
necrosis and wound problems with skin-sparing
mastectomy.7 The following questions should be
considered:
1. Is it necessary/desirable to excise skin overlying
the cancer?
In general terms, the same principles apply as described
above. However, immediate breast reconstruction is en-
hanced by preserving most (if not all) of the breast skin.
Studies assessing the safety of this procedure relative to
rates of local recurrence are summarised in Table 5.1.
Although there are several that report acceptable recur-
rence rates, no large randomised trial data are avail-
able. It seems sensible to apply the same principles as
one would for simple mastectomy. In other words, if
the cancer is close to skin such that a healthy margin of
normal tissue cannot easily be excised around it, then
the ­overlying skin should be resected. An important
Figure 5.7  •  Goldilocks mastectomy. (a) Preoperative markings. (b) Final outcome. (c) Bilateral Goldilocks mastectomy.
a
b
c

Techniques of mastectomy: tips and pitfalls
77
principle of oncoplastic surgery is that treatment must
not be compromised for the sake of cosmesis. Different
designs of skin-sparing mastectomy can allow skin ex-
cisions at any site.
2. Is overall reduction or augmentation planned?
This will obviously influence the scar pattern
planned to facilitate the adjustment and obtain op-
timal symmetry of scars.
3. What scar design will give the optimum balance
of access and aesthetic result?
Access to perform the mastectomy adequately
cannot be compromised. Familiarity with a range
of different options will enable the best outcome.
Designs will vary according to method of recon-
struction, as described below.
4. Is the nipple–areola complex to be excised?
This is increasingly considered an option in small
breasts, particularly for prophylactic mastectomy
but also in cancer cases.8–16 Scar placement in this
setting should allow good access to the breast and
the nipple itself.
Planning a mastectomy with
reconstruction
Examine and mark up with the patient standing.
Different techniques are best described according to
whether tissue-based or implant-based reconstruc-
tion is being performed.
Tissue-based reconstruction
Circumareolar
This is perhaps the most commonly employed tech-
nique. It gives excellent access to all but very large
breasts. It can be extended easily by a lateral or inferior
extension or by widening the circular skin excision. The
resulting defect is replaced with skin from the flap, often
with nipple reconstruction at the same time (Fig. 5.8).
Wise pattern
This is another commonly employed technique that
can be used for any ptotic breast. The design is more
conservative than would be used for a standard breast
reduction, and is often best planned as very conserva-
tive, with adjustment of the vertical limbs at the time
of closure according to viability and tension. A vul-
nerable part of this design is the lateral part of the in-
verted ‘T’. A recent modification is to de-epithelialise
the lower mastectomy flap as for a ‘Goldilocks’ mas-
tectomy so the vulnerable part of the T incision is
placed directly over the de-epithelialised lower flap
of the mastectomy scar. With division of the lateral
thoracic vessels as part of the mastectomy, this often
ends up as the most ischaemic part of the mastec-
tomy flap. Designing an inverted ‘V’ component to
Authors
Year of
publication
Number
of patients
Local recurrence
rate/annum (%)
Follow-up
(months)
Newman et al.8
1998
372
1.5
50
Kroll et al.9
1999
114
1.2
72
Medina-Franco et al.10
2002
173
0.7
73
Spiegel and Butler11
2003
221
0.5
118
Carlson et al.12
2003
565
1.0
65
Gerber et al.13
2003
112
1.0
65
Greenway et al.14
2005
225
0.4
49
Meretoja et al.15
2007
146
0.6
51
Petit et al.16
2009
1001
0.8
20
Table 5.1  •  Case series of over 100 patients reporting local recurrence rates after skin-sparing mastectomy
Figure 5.8  •  Circumareolar mastectomy with immediate
LD flap and nipple reconstruction.

Chapter 5
78
the lower incision that will release tension at the ‘T’
junction is often prudent (Fig. 5.9). Preservation of
a larger section of lower flap skin until the time of
closure enables the option of wider skin excision
if viability is a concern or, as outlined above, de-
epithelialisation and double-breasting of the scar.
Dome
This allows excision of an aesthetic unit of the
breast of variable size. It also allows the flap to be
inserted directly into the IMF. It is a very ‘safe’ de-
sign for higher risk cases.
Vertical
This is only really suitable for small breasts.
Implant reconstruction
Wise pattern
This is probably the best option for the large breast
and possibly any breast with some ptosis. It gives
excellent access to the breast. It is particularly use-
ful when a lower de-epithelialised flap is being used
to create a partial submuscular/partial subdermal
pocket (Fig. 5.10a,b). This has become a standard
approach when available. A de-epithelialised lower
flap can also be combined with the use of a dermal
matrix for breast reconstruction and can provide
complete cover of the dermal matrix, particularly
in the vulnerable area where all three scars meet.
Vertical
This is a good option in small breasts when a total
submuscular pocket is planned. Shortening of the
scar is rarely possible to any significant degree. This
can sometimes be combined with a de-epithelialised
vertical mastopexy scar to allow repositioning of
the nipple/areola.
IMF
A more technically demanding approach, but a scar
based on the outer half/third of the IMF is very suited
to one-stage implant reconstruction with subcutaneous
mastectomy. This is similarly the case for the lateral
skin crease or lateral breast curvature scar (Fig. 5.11).
Short transverse
This is sometimes a good option when a patient has
a small areola that can be excised as a circumareolar
incision but closed transversely.
Is a second incision required for
sentinel lymph node biopsy?
This is often prudent with skin-sparing mastectomy
to allow a timely search for blue nodes and limit
Figure 5.9  •  Preservation of inverted ‘V’ on lower flap in
Wise pattern mastectomy with implant reconstruction.
Figure 5.10  •  (a) Drawing of a Wise pattern mastectomy.
(b) Intraoperative demonstration of implant placed in
a partial submuscular (pectoralis major and serratus
anterior)/partial subdermal pocket before skin closure.
a
b

Techniques of mastectomy: tips and pitfalls
79
the degree with which skin flaps are retracted, with
small distal incisions to access the axilla. It can also
be valuable if a latissimus dorsi flap is being used
for the breast reconstruction.
Undesirable scar patterns
• Hemicircumareoalar. This allows very restricted
and, in my opinion, difficult access to the breast
in all but very small breasts and compromises
nipple blood supply.
• Any long transverse/oblique scar. These really
have no role in immediate reconstruction.
• Purse-string. This is intuitive, but creates
ischaemia at the skin edge, can result in a
central sinus, stretches to produce an unsightly
scar, and results in a scar that presents
difficulties for nipple reconstruction and
tattooing.
Technique
Preoperative marking
Mark with the patient standing. Put a mark on
the midline and draw a dashed line around the
circumference of the breast. For the periphery
above the IMF take the weight of the breast and
move it towards each periphery to enable the edge
of the breast to be seen and marked. In practice
this becomes most useful when a mastectomy is
performed with the patient on their side simul-
taneous to raising a latissimus dorsi (LD) flap.
Other markings will depend on the scar pattern
to be used.
Circumareolar incisions can be marked pre- or in-
traoperatively. In women with a large areola some
areola can be preserved.
For Wise and vertical patterns the breast me-
ridian is drawn and patients marked up as for
a reduction or mastopexy but with more con-
servative vertical incision lines (Fig.  5.10a). In
Wise pattern mastectomy the vertical compo-
nents are usually 10 cm in length from apex to
horizontal incision. They often hug the areola
margin. They can always be trimmed if neces-
sary on closure and the ‘T’ junction modified as
described above.
Dome-shaped incisions are based on the IMF. The
base width can be varied. The apex of the dome is
on the breast meridian and can be extended to the
required height.
IMF incisions start medially at a line drawn ver-
tically from the medial edge of the areola and ex-
tend laterally along the IMF/lateral breast curvature
(usually 6–8 cm).
In a similar fashion to simple mastectomy, the
plane is often best identified using opposing trac-
tion on the wound before skin hooks or similar
retractors are applied. For incisions where access
is limited, hydrodissection an adrenaline/saline
solution injected using a blunt infiltration can-
nula is very useful. A bloodless field is essential
to allow visualisation of the plane of dissection
throughout and preservation of the perforators.
If access is really felt to be compromising the dis-
section, then the incision should be extended.
For IMF incisions the mastectomy is usually best
achieved by dissecting the subcutaneous plane
with half open scissors. This is quick, usually
bloodless and avoids excess retraction. Once the
subcutaneous plane is dissected, the submammary
plane is dissected with cautery. The peripheral
attachments can then be dissected under di-
rect ­vision. For subcutaneous mastectomies, the
­nipple/areola is preserved by first bluntly dissect-
ing the subareolar plane with scissors. The ducts
are then divided close to the nipple base. With
the nipple inverted any remaining ducts can be
trimmed from the nipple ‘core’.
Inframammary fold
This should be preserved.
Figure 5.11  •  Lateral skin crease scar.

Chapter 5
80
Pectoral fascia
It is an advantage to preserve this if an implant re-
construction is being performed as it adds reinforce-
ment to a submuscular pocket.
Wound closure
The use of deep dermal interrupted sutures before
subcuticular closure maximises wound quality.
Wound edges should be ‘freshened’, particularly if
traumatised by retraction during operation. Often
wounds can be double-breasted, with the small re-
inforcing de-epithelialised segment.
Skin stapler
This is particularly useful in Wise pattern mastec-
tomy or any mastectomy where a skin-bearing flap
is being inserted. The shape can be visualised and
flaps trimmed as appropriate. Staples are always
removed and wound closure should be with absorb-
able subcuticular sutures.
Glue
This produces a waterproof dressing that does not
need re-dressing.
Over-dressing
If a support over-dressing (e.g. gauze and
Elastoplast) is used this should be lightly ap-
plied so as not to compromise mastectomy flap
blood flow. Steri-strips, if used, should be wide
0.5- or 1-inch and placed parallel to the wound,
not at 90° to the skin incision, as they can cause
blistering.
Flap necrosis
Using the principles and techniques described
this should be a rarity (1% or 2% of cases). The
main reasons for it are smoking, poor technique
selection, poor execution of dissection, failure
to preserve the intercostal perforators and too
much tension of wound edges. In the circum-
stances where flap necrosis is encountered, early
surgical debridement may allow direct re-closure
and usually results in a satisfactory outcome
(Fig. 5.12a,b). Occasionally a small skin graft is
required.
Radical mastectomy
This still has a role to control locally advanced dis-
ease. Formal removal of all of the pectoralis major
muscle is, however, rarely required and partial exci-
sions removing the area of muscle involved with a
margin of normal muscle are usually sufficient. In
escalating order, the following options for wound
closure should be considered:
• abdominal advancement flap;
• split-skin graft;
• lateral chest wall perforator flap;
• LD flap;
• deep inferior epigastric perforator/transverse
rectus abdominis myocutaneous flap.
All have a potential role depending on the size of
defect, patient fitness and suitability of donor sites.
Figure 5.12  •  (a) Skin necrosis after circumareolar
mastectomy and LD flap in a heavy smoker. (b)
Appearance a few weeks after early (next day)
debridement and primary re-closure.
a
b

Techniques of mastectomy: tips and pitfalls
81
References
1. Krueger JK, Rohrich RJ. Clearing the smoke: the sci-
entific rationale for tobacco abstention with plastic
surgery. Plast Reconstr Surg 2001;108(4):1063–73.
2. Chang LD, Buncke G, Slezak S, et al. Cigarette smok-
ing, plastic surgery and microsurgery. J Reconstr
Microsurg 1996;12(7):467–74.
3. Sarin CL, Austin JC, Nickel WO. Effects of
smoking on digital blood flow velocity. JAMA
1974;229(10):1327.
4. Sorensen LT, Horby J, Friis E, et  al. Smoking
as a risk factor for wound healing and infec-
tion in breast cancer surgery. Eur J Surg Oncol
2002;28(8):815–20.
5. Chang DW, Reece GP, Wang B, et al. Effect of smok-
ing on complications in patients undergoing free
TRAM flap breast reconstruction. Plast Reconstr
Surg 2000;105(7):2374–80.
6. Moller WM, Villebro N, Pederson T, et al. Effect of
preoperative smoking intervention on postoperative
complications: a randomised clinical trial. Lancet
2002;359(9301):114–7.
7. Woerdeman LAE, Hage JJ, Hofland MMI, et  al.
A prospective assessment of surgical risk factors
in 400 cases of skin-sparing mastectomy and im-
mediate breast reconstruction with implants to
establish selection criteria. Plast Reconstr Surg
2007;119:455–63.
8. Newman LA, Kuerer HM, Hunt KK, et  al.
Presentation, treatment, and outcome of local re-
currence after skin-sparing mastectomy and im-
mediate breast reconstruction. Ann Surg Oncol
1998;5:620–6.
9. Kroll SS, Khoo A, Singletary SE, et al. Local recur-
rence risk after skin-sparing and conventional mas-
tectomy: a 6-year follow-up. Plast Reconstr Surg
1999;104:421–5.
10. Medina-Franco H, Vasconez LO, Fix RJ, et  al.
Factors associated with local recurrence after
skin-sparing mastectomy and immediate breast re-
construction for invasive breast cancer. Ann Surg
2002;235:814–9.
11. Spiegel AJ, Butler CE. Recurrence following treat-
ment of ductal carcinoma in situ with skin-sparing
mastectomy and immediate breast reconstruction.
Plast Reconstr Surg 2003;111:706–11.
12. Carlson GW, Styblo TM, Lyles RH, et  al. Local
recurrence after skin-sparing mastectomy: tumor
biology or surgical conservatism? Ann Surg Oncol
2003;10:108–12.
13. Gerber B, Krause A, Reimer T, et al. Skin-sparing
mastectomy with conservation of the nipple–areola
complex and autologous reconstruction is an onco-
logically safe procedure. Ann Surg 2003;238:120–7.
14. Greenway RM, Schlossberg L, Dooley WC. Fifteen-
year series of skin-sparing mastectomy for stage 0 to
2 breast cancer. Am J Surg 2005;190:933–8.
15. Meretoja TJ, von Smitten KAJ, Leidenius MHK,
et al. Local recurrence of stage 1 and 2 breast cancer
after skin-sparing mastectomy and immediate breast
reconstruction in a 15 year series. Eur J Surg Oncol
2007;33:1142–5.
16. Petit J-Y, Veronesi U, Orecchia R, et  al. Nipple
sparing mastectomy with nipple areola intraopera-
tive radiotherapy: one thousand and one cases of
a five years experience at the European Institute of
Oncology of Milan (EIO). Breast Cancer Res Treat
2009;117:333–8.
Key points
Mastectomy
• A flat, even chest wall should be achievable in all patients.
• The aim should be to avoid so-called ‘dog ears’ by using an incision that avoids these and in
particular avoiding transverse incisions.
• The technique should be sympathetic to a delayed reconstruction if planned.
Mastectomy with reconstruction
• Many techniques are available.
• The technique should be appropriate to the method of reconstruction.
• The technique should not compromise on access or cancer excision.

82
6
Richard M. Rainsbury
Krishna B. Clough
Gabriel J. Kaufman
Claude Nos
J. Michael Dixon
Oncoplastic procedures to allow breast
conservation and a satisfactory cosmetic outcome
Part 1
Volume replacement techniques
to improve cosmetic outcomes
after breast-conserving surgery
Richard M. Rainsbury
Introduction
Breast-conserving surgery (BCS) combined with
­radiotherapy has become the treatment of choice
for the majority of women presenting with primary
breast cancer over the last 20 years.
The risk of LR is related to a number of factors,
­including positive margins, tumour grade, extent
of in situ component, lymphovascular invasion
and age. Whole-breast section analysis techniques
have been used to show the likelihood of complete
­excision of unicentric carcinomas using different
margins of excision (see Chapters 4 and 15).
Local recurrence and
cosmetic outcome
The margins of clearance and to a lesser degree
the extent of local excision during BCS are strong
­predictors of subsequent LR.6
The extent of local excision remains a contro-
versial issue in BCS. The wider the margin of
­clearance, the less the risk of incomplete excision
and thus potentially of LR (Table  6.1), but the
greater the amount of tissue removed, the higher
the risk of ­visible deformity leading to an unac-
ceptable ­cosmetic ­result. This clash of interests8 is
most ­evident when attempting BCS in patients with
smaller breast–­tumour ratios, for example when
planning BCS for a 10-mm tumour in a 200-g breast
or a 5-cm tumour in a 700-g breast.
The chances of a poor cosmetic outcome are in-
creased still further when the tumour is in a central,
medial or inferior location.9,10 Cosmetic failure is
more common than generally appreciated, ­occurring
A number of prospective randomised trials
have compared BCS with mastectomy, showing a
survival rate that is unrelated to the type of surgery
performed,1–4 although local recurrence (LR) rates
may be higher when the breast is conserved.1
Holland et al.5 showed that a margin of 2 cm
would eradicate all microscopic disease in about
60% of cases compared with a margin of 4 cm,
which increases this figure to about 90%.

Oncoplastic procedures to allow breast conservation
83
in up to 50% of patients after BCS.11–15 A number
of factors are responsible, including ­volume loss
of more than 10–20% leading to retraction and
­asymmetry, nipple–areola displacement or distor-
tion, the use of ugly and inappropriate incisions, and
the ­local effects of radiotherapy. Volume loss under-
lies many of the most visible and distressing exam-
ples of poor cosmetic outcome and the effects may
be compounded by associated displacement of the
nipple–areola complex (NAC). Poor surgical tech-
nique leading to postoperative haematoma, ­infection
or breast tissue and fat necrosis will ­increase the
amount of scarring and retraction, and add to the
risks of deformity. Moreover, the use of suction
drains, inappropriate incisions and en bloc resec-
tions can worsen the cosmetic result still further.
Role of oncoplastic surgery
The interrelationship between breast–tumour ratio,
volume loss, cosmetic outcome and margins of clear-
ance is complex, and the widespread popularity of
BCS has focused attention on new oncoplastic tech-
niques that can avoid unacceptable cosmetic results.
Until now, surgical options have been limited to BCS
or mastectomy, the choice depending on fairly well-
defined indications and factors. Oncoplastic tech-
niques provide a ‘third option’ that avoids the need
for mastectomy in selected patients and can influence
the outcome of BCS in three respects:
1. Oncoplastic techniques allow wider excision
of breast cancers without risking major local
deformity.
2. The use of oncoplastic techniques to prevent
­deformity can extend the scope of BCS to
include patients with 3–5 cm tumours, without
compromising the adequacy of resection or the
cosmetic outcome.
3. Volume replacement can be used after previous
BCS and radiotherapy to correct unacceptable
deformity16 and may prevent the need for mas-
tectomy in some cases of local recurrence when
further local excision would result in consider-
able volume loss.
Choice of oncoplastic
technique
The choice of technique depends on a number of
­factors, including the extent of resection, position of
the tumour, timing of surgery, experience of the sur-
geon and expectations of the patient. Reconstruction
at the same time as resection (breast-sparing recon-
struction) is gaining in popularity. As a general rule, it
is much easier to prevent than to correct a deformity
that has developed as the sequela of previous ­surgery.
Immediate reconstruction at the time of mastectomy
is associated with clear surgical,17 financial18,19 and
psychological20 benefits, and similar benefits are seen
in patients undergoing immediate breast-sparing re-
construction after partial mastectomy.
Resection defects can be reconstructed in one
of two ways: (i) by volume replacement, import-
ing ­volume from elsewhere to replace the amount
of ­tissue resected; or (ii) by volume displacement,
­recruiting and transposing local dermoglandular
flaps into the resection site. Volume replacement
techniques can restore the shape and size of the
breast, achieving symmetry and excellent cosmetic
results without the need for contralateral surgery.
However, these techniques require additional the-
atre time and may be complicated by donor-site
morbidity, flap loss and an extended convalescence.
In contrast, volume displacement techniques ­require
less extensive surgery, can limit scars on the breast
and limit donor-site problems. These procedures
may be complicated by necrosis of the dermoglan-
dular flaps and contralateral surgery is usually
required to restore symmetry as volume loss is in-
evitable (Table 6.2).
A number of factors need to be considered when
making the choice between volume replacement
and volume displacement. Volume replacement is
­particularly suitable for patients who wish to avoid
volume loss and contralateral surgery after extensive
local resections. They must be prepared to accept a
donor-site scar and be made aware of the possibility

Quadrant­
­ectomy
Wide local
excision
Margin (cm)
2–4
1–2
Clearance (%)*
<90
<58
Recurrence (%)†
2
7
Cosmesis
Fair
Good
Table 6.1  •  Technique-related outcomes of breast-
conserving surgery
* Holland et al.5
†Veronesi et al.7

Chapter 6
84
of complications that may result in prolonged conva-
lescence. Volume replacement is equally well suited
to immediate and delayed reconstruction and is the
method of choice for correcting severe deformity af-
ter previous breast irradiation.
Volume displacement techniques are particularly
useful for patients with large ptotic breasts who
gain benefit from a ‘therapeutic’ reduction mam-
maplasty that incorporates wide removal of the
tumour. Volume displacement is less reliable in ir-
radiated breasts, and patients need to be warned
about the risk of asymmetry that may require si-
multaneous or subsequent contralateral surgery.
Volume replacement
techniques
Several different approaches to volume replacement
have been developed over the last 10 years, includ-
ing myocutaneous, myosubcutaneous, perforator
and adipose tissue flaps, lipomodelling and im-
plants. Autologous latissimus dorsi (LD) flaps are
the most popular option because of their versatility
and reliability.
The myocutaneous LD flap carries a skin paddle
that can be used to replace skin which has been
­resected at the time of BCS or as a result of contrac-
ture and scarring following previous resection and
radiotherapy16 (Fig. 6.1). Although the skin paddle
adds to the replacement volume, it can lead to an
ugly ‘patch’ effect because of the difference in ­colour
between the donor skin and the skin of the native
breast.
Transverse
rectus
abdominis
myocutaneous
(TRAM) and deep inferior epigastric perforator
(DIEP) flaps are used much less frequently, as the
greater risk of these procedures renders them a less
attractive choice than LD flaps in this particular
situation. Moreover, fat necrosis is a more common
A myosubcutaneous LD miniflap21 circumvents
this problem by harvesting the flap in a plane deep
to Scarpa's fascia. This produces a bulky flap
without a skin island and includes a layer of fat on
its superficial surface that is used to reconstruct
defects following wide excision with preservation of
the overlying skin (Fig. 6.2).

Volume
replacement
Volume
displacement
Symmetry
Good
Variable
Scars
Breast + back
Periareolar
inverted-T
Problems
Donor scar
Seroma flap loss
Parenchymal
necrosis
Nipple necrosis
Volume loss
Theatre time
(hours)
2–3
1–2 (per side)
Convalescence
(weeks)
4–6
1–2
Timing
Immediate or
delayed
Immediate > delayed
Mammographic
surveillance
Possibly enhanced
Unaffected
Table 6.2  •  Comparison of techniques for breast-
conserving reconstruction
Figure 6.1  •  Latissimus dorsi myocutaneous miniflap.

Oncoplastic procedures to allow breast conservation
85
complication of abdominal flaps, creating the po-
tential for diagnostic confusion on follow-up.
Perforator flaps22,23 based on thoracodorsal ­artery
perforators (‘TDAP flaps’) and lateral intercos-
tal artery perforators (‘LICAP flaps’) are gaining
popularity. They provide skin and subcutaneous
fat for volume replacement, are relatively quick to
perform, and appear to be associated with a faster
recovery and less morbidity than LD flaps. As the
LD is relatively undisturbed, the LD muscle can be
used for breast reconstruction if a mastectomy is
required for a subsequent local recurrence. TDAP
flaps are most suitable for lateral and upper pole
­defects, while LICAP flaps can be used to recon-
struct small to medium-sized lateral pole defects.
Neither flap can be transposed sufficiently to recon-
struct medial pole defects, which are more suitable
for reconstruction by an LD miniflap that has been
fully mobilised ­following divison of the tendon, all
the serratus anterior branches of the vessels and all
remaining fascial attachments to terres major. Other
flaps, such as the lateral thoracic adipose tissue flap,
have been described24 but their clinical utility is
unclear.
Lipomodelling techniques25 have been used to cor-
rect rather than to prevent deformity after BCS.26
Stem cells harvested from fat are injected around
the defect, into underlying pectoralis muscle and
overlying subcutaneous fat, avoiding the breast pa-
renchyma. This helps to avoid the confusing mam-
mographic images resulting from areas of calcified
fat necrosis in the vicinity of the tumour bed. The
theoretical risk of tumour induction by injected
stem cells remains a concern, and has led to the
somewhat cautious introduction of this innovative
technique into clinical practice.26 Some surgeons
have started to use lipomodelling at the same time
as wide local excision but no long-term results of
this technique have yet been reported.
Non-autologous volume replacement with saline
or silicone implants has been tried with mixed suc-
cess.27,28 Implants can be placed directly into the re-
section defect or under pectoralis major. They cannot
be moulded to fit the resection defect and they form
localised capsules, particularly in irradiated tissues.
This may interfere with clinical examination and
also mammographic surveillance, although there are
techniques to allow mammaplasty in breasts with
implants and magnetic resonance imaging (MRI) fol-
low-up is an option in such patients. If using implants,
low height and low projection implants placed low
in the treated breast combined with lipomodelling
gives the best results. If there is deformity and sig-
nificant nipple deviation then a myocutaneous flap
is preferred. Autologous tissue transfer is usually the
best option for most patients and results in a lifelike
breast of normal shape and size.
A number of innovative surgical procedures have
evolved that facilitate volume replacement at the
time of BCS or at a later date:
1. Resection through a radial incision and LD
harvest through an axillary incision.29
This was the original description by Noguchi
et al. of the use of LD myocutaneous flaps to
reconstruct resection defects during BCS in small-
breasted Japanese patients. Radial incisions are not
the incisions of choice.
Figure 6.2  •  Latissimus dorsi myosubcutaneous miniflap.

Chapter 6
86
2. Conventional LD myocutaneous flap harvest for
correction of major resection defects.16
3. Resection through a circumferential incision and
endoscopic LD flap harvest and reconstruction
through an axillary incision.30
4. Resection, LD harvest and reconstruction
through a single lateral incision.21
Indications for volume
replacement
Volume replacement should always be considered
when adequate local tumour excision leads to an
unacceptable degree of local deformity in those pa-
tients who wish to avoid mastectomy or contralat-
eral surgery.
Breast conservation with or without reconstruc-
tion was formerly reserved for patients with unifo-
cal tumours, but the much wider excision achieved
in patients undergoing immediate volume replace-
ment allows resection of multifocal disease with
clear margins and excellent local control.33 Volume
replacement may be inappropriate in those with
more widespread disease or locally advanced T4
tumours. Likewise, LD volume replacement is
­hazardous in patients with a history suggesting
damage to the thoracodorsal pedicle or to the LD
muscle, and ­alternative methods should be con-
sidered (Box  6.1). Patients should be informed
that using LD for breast conservation precludes its
­subsequent use for later breast reconstruction. If a
mastectomy is required to treat recurrent disease,
the options include a variety of free flaps or subpec-
toral implant-based reconstruction.
Timing of procedures
Ideally, reconstruction of the partial mastectomy
defect should be performed immediately or within
a few  weeks of the tumour resection in order to
prevent deformity rather than to correct defor-
mity months or years later. The emergence of the
multiskilled ‘oncoplastic’ breast surgeon will in
future help to circumvent the current problems en-
countered when organising a ‘two-team’ approach
involving breast and plastic surgeons. Moreover,
immediate reconstruction is associated with fewer
technical problems and complications than delayed
procedures. Delayed reconstruction may be com-
promised by previous radiotherapy, leading to re-
duced tissue viability and an increased risk of fat
necrosis, infection and delayed wound healing.
Immediate reconstruction can be carried out as
a one-stage procedure,21,34 which involves simul-
taneous resection and correction of the resulting
defect. This requires perioperative confirmation
of complete tumour excision using frozen-section
techniques. As an alternative, the procedure can be
split into two steps.35 The first step involves excising
the cancer and performing a sentinel node biopsy if
the nodes are clinically and radiologically normal
and the second step includes axillary dissection if
required, flap harvest and reconstruction, and is
carried out a few days later after confirmation of
clear tumour resection margins. Patients undergo-
ing a one-stage procedure must be informed that a
mastectomy with or without reconstruction may be
required if subsequent histopathological analysis
confirms incomplete tumour excision.
Resection of more than 20% of breast volume,
particularly from central, medial or inferior locations,
significantly increases the likelihood of a significant
and unsightly local deformity,31 which results in
psychological morbidity.32 In these patients, volume
replacement can extend the role of BCS and avoid
mastectomy when resecting up to 70% of the
breast.
Indications
Breast of any size
Resection of 10–50% breast volume
Specimen weight typically 150–350 g
Correcting deformity after breast-conserving surgery
When mastectomy declined
When full reconstruction declined
When contralateral surgery declined
When radiotherapy planned after mastectomy
Contraindications
Multicentric tumours
T4 tumours
Diffuse malignant microcalcification
Comorbidity
Previous division of vascular pedicle
Previous ipsilateral thoracotomy
Box 6.1  •  Selection of patients for volume replacement

Oncoplastic procedures to allow breast conservation
87
Volume replacement with
latissimus dorsi miniflaps
There are many similarities between the differ-
ent surgical approaches used in breast-conserving
­reconstruction and these can be best illustrated by
summarising the main steps involved in LD miniflap
reconstruction, which has been described in detail
elsewhere.36,37 This procedure involves the use of
a myosubcutaneous flap of LD for immediate re-
construction of a partial mastectomy defect, most
commonly in the central zone but also in the upper
outer and upper inner quadrants of the breast. The
term ‘miniflap’ is somewhat misleading, as the flap
needs to be of sufficient volume to replace resection
defects resulting from the excision of 150–350 g of
breast tissue. Moreover, the miniflap needs to be
bulky enough to allow for a small degree of postop-
erative flap atrophy.
When planning immediate volume replacement,
the patient needs to be fully informed about the na-
ture of the procedure and the possibility that a sub-
sequent total mastectomy may be required if partial
mastectomy results in incomplete excision. Careful
preoperative mark-up of the tumour, the margins of
resection and the line of incision are essential. The
operation allows simultaneous partial mastectomy,
axillary dissection, mobilisation of part of LD (the
miniflap) and reconstruction of the resection defect
through a single lateral incision. The procedure is
greatly simplified by high-quality equipment, which
is essential when developing the narrow optical
spaces behind the breast and on the superficial and
deep surfaces of the miniflap.
The operation involves tumour resection, axillary
dissection, flap harvest and reconstruction. First,
the tumour is resected in a subcutaneous plane by
separating the skin envelope overlying the tumour-
bearing quadrant from the underlying breast disc
by sharp dissection, using the preoperative skin
marks to determine the exact extent of dissection.
By developing a mirror-image retromammary space
deep to pectoralis fascia, the mobilised tumour-
bearing quadrant is gripped firmly between fingers
and thumb and resected with a generous margin
of normal breast tissue. Four biopsies taken from
opposite poles of the resection defect are sent for
frozen-­section analysis to allow intraoperative as-
sessment of completeness of excision. The cavity
wall is inked in situ with methylene blue to identify
the inner ­surface, and then can be re-excised in its
entirety if considered necessary. Further bed biop-
sies can also be examined after re-excising the ­cavity
wall if frozen-section examination of the initial bi-
opsies shows incomplete excision. A mastectomy is
performed if these further bed biopsies fail to con-
firm complete excision. Next, appropriate axillary
surgery (sentinel node or axillary dissection) is car-
ried out and the vascular pedicle is prepared.
The third step involves mobilisation of the LD
miniflap by developing superficial and deep peri-
muscular spaces that mirror each other. The myo-
subcutaneous flap carries a layer of fat on its
superficial surface to increase its volume and this
is achieved by developing the superficial pocket just
deep to Scarpa's fascia. Division of the miniflap
around the perimeter of the dissection pocket and
division of the tendon of the LD near its insertion
ensures unrestricted transposition of the miniflap
into the resection defect. Finally, reconstruction
of the resection defect is completed by careful use
of sutures to model the flap, before fixing it to the
­cavity walls.
Perioperative outcomes
The time required for breast-conserving immedi-
ate reconstruction with a miniflap lies somewhere
between BCS alone and total mastectomy com-
bined with immediate LD reconstruction. Early
postoperative complications include infection, flap
necrosis, haematoma formation and transient bra-
chial plexopathy,34 although postoperative stay and
disability are similar to other types of BCS. Breast
oedema is common, particularly after extensive
­resection, but usually settles within 6–8  weeks. It
may be caused by division of multiple afferent lym-
phatic pathways during retromammary dissection.
Donor-site seroma formation occurs in almost all
patients, and can be reduced by ‘quilting’ or delay-
ing drain removal. Flap necrosis is rare, and can
be avoided by gentle resection and handling of the
pedicle and by taking care to prevent traction and
twisting injuries during transposition and fixation
of the flap after tendon division.
Late sequelae of volume replacement include
lateral retraction of the flap, leading to distortion
and hollowing of the resection site, and flap atro-
phy. Flap retraction can be avoided by division and
fixation of the tendon and careful suture of the flap

Chapter 6
88
into the resection defect. Detectable flap atrophy
occurs in a minority of patients followed for up to
10 years.38 It can be counteracted by over-replacement
of the resected volume with a fully innervated flap
that has been harvested with a generous layer of
subcutaneous fat, by using a myocutaneous flap or
by later lipofilling.16
Frozen-section analysis of bed biopsies has been
found to correlate closely with the adequacy of
excision determined by formal histopathology.33
Moreover, the use of LD miniflap reconstruction
leads to a significant fall in the number of incom-
plete excisions compared with BCS alone24 without
compromising the cosmetic outcome. Sensory loss
following miniflap reconstruction is minimal com-
pared with the loss following total mastectomy.39
The sensory innervation of the breast and NAC is
largely intact, except over the resected quadrant.
Finally, volume replacement preserves symmetry,
avoiding the need for alterations to the contralateral
breast in almost all patients (Fig. 6.3).
Mammographic surveillance
The mammographic appearance of the partially
­reconstructed breast compares favourably with the
appearances after routine BCS. Symmetry is pre-
served and the fibres of the isodense flap may be
detectable, often associated with a variable zone of
radiolucency that corresponds to the layer of sur-
face fat. Flaps may be indistinguishable from the
surrounding breast tissue, and important radiologi-
cal characteristics such as skin thickening, stellate
lesions and microcalcifications are easily visualised
after flap transfer. Volume replacement does not
compromise the early detection of LR,40 which typi-
cally develops at the junctional zone between muscle
and breast parenchyma. The appearance of miniflap
on mammograms contrasts with the radiodense dis-
torting stellate scars that are a common source of
diagnostic confusion following conventional BCS.
Lastly, very few patients develop clinically detect-
able flap atrophy, with the majority of flaps remain-
ing bulky and functional throughout the period of
follow-up.
Future prospects
The role of breast-conserving volume replacement
is set to increase as more precise, image-guided
­resection of specific zones of breast tissue becomes
possible. Increasingly sophisticated ­imaging tech-
niques, such as high-frequency ultrasound and
contrast-enhanced dynamic magnetic resonance
imaging,41 may in future enable exact delinea-
tion and excision of all malignant and premalig-
nant changes. Endoscopically assisted techniques42
may increase the ability to harvest more bulky
­myosubcutaneous flaps, allowing the reconstruc-
tion of more extensive resection defects. This will
require the further development of novel ­techniques
for endoscopic dissection,30 including the use of
balloon-assisted techniques42,43 and ­carbon diox-
ide insufflation to maintain the epimuscular opti-
cal cavities. Current progress is hampered by the
use of non-flexible straight endoscopes to carry
out dissection over the rigid convex surface of the
chest wall.
Figure 6.3  •  (a) Latissimus dorsi myocutaneous miniflap. (b) Latissimus dorsi myosubcutaneous miniflap.
a
b

Oncoplastic procedures to allow breast conservation
89
Deformities following breast-
conserving surgery
Until recently, little attention has been paid to the
cosmetic sequelae of BCS, as most patients are re-
lieved not to lose their breast and many surgeons are
unfamiliar with the plastic surgery techniques that
can eliminate postoperative deformities. Moreover,
there has been a tendency to recommend delayed
reconstructive surgery some time after completion
of radiotherapy. Although this is possible, partial
reconstruction of the breast after surgery and ra-
diotherapy is technically challenging and requires
sophisticated techniques, with cosmetic results that
are often disappointing.
In order to better assess the surgical approach
for these patients, a classification of the cosmetic
sequelae after BCS has been published by Clough
et al.44,45 This simple classification defines three
groups of patients based on clinical examina-
tion (Fig.  6.4). The advantage of this classifica-
tion is that it is a valuable guide for choosing the
­optimal reconstructive technique, but it is also a
good predictor of the final cosmetic result after
surgery.
For type I deformities, a contralateral mamma-
plasty is performed to restore symmetry, avoiding
any surgery on the irradiated breast. This is a simple
and reliable approach, the irradiated breast serving
as the model for a contralateral breast lift or breast
reduction. Type II sequelae are almost always
postoperative and are the most difficult to treat.
A wide range of techniques can be used to ­repair
these ­defects, from recentralisation of the nipple
to the insetting of a flap to reconstruct a missing
quadrant. Type III sequelae require ­treatment by
mastectomy and immediate reconstruction with a
myocutaneous flap.
Poor remodelling is one of the reasons for an
ugly deformity after lumpectomy or quadrantec-
tomy.46,47 Some surgeons perform no remodelling
Figure 6.4  •  Deformities after conservative treatment
of breast cancer. (a) Type I: a symmetrical breast with no
deformity of the treated breast. (b) Type II: deformity of the
treated breast, compatible with partial reconstruction and
breast conservation. (c) Type III: major deformity of the
breast requiring mastectomy. Reproduced from Clough KB,
Claude N, Fitoussi A et al. Oncoplastic conservative surgery
for breast cancer. In: Operative techniques in plastic and
reconstructive surgery. Philadelphia: WB Saunders, 1999;
pp. 50–60. With permission from Elsevier.
a
b
c
•   Type I deformities: patients have a treated
breast with a normal appearance but there is
asymmetry between the two breasts.

• Type II deformities: patients have a deformity
of the treated breast. This deformity can be
corrected by partial breast reconstruction
and breast conservation, with the
irradiated breast tissue being spared in the
reconstruction.

• Type III deformities: patients have a major
distortion of the treated breast, or diffuse
painful fibrosis. These sequelae are so
severe that only a mastectomy can be
considered.44

Chapter 6
90
at all, leaving an empty defect and relying on a
postoperative haematoma to fill the dead space.
This may produce acceptable results in the short
term but breast retraction of larger defects invari-
ably occurs with longer follow-up, leading to major
deformities that are increased by postoperative
radiotherapy.10,44,48,49
Conclusion
Breast-conserving partial breast reconstruction
extends the role of BCS by enabling complete
­excision of a greater range of tumours without
compromising cosmesis, postoperative surveillance
or symmetry. Volume replacement and displace-
ment techniques are likely to become increasingly
popular as an alternative to mastectomy in patients
with small breast–tumour ratios and localised dis-
ease who wish to avoid more major surgery and the
use of implants. Further experience of these tech-
niques will lead to a better understanding of their
role in the surgical management of primary breast
cancer and in the management of local relapse and
cosmetic deformity after previous breast-conserving
procedures.
Reshaping of the breast is required after any
tumour excision in order to recreate a normal
breast shape in one operative procedure. In most
cases this can be achieved with a simple unilateral
approach, mobilising glandular flaps to close
the defect or by recentralising the NAC. In other
cases, a bilateral approach incorporating a bilateral
mammaplasty will be the only way to perform a
wide excision with no deformity.50 This graded
approach to breast reshaping is discussed below.
Key points
• Local recurrence following BCS is related to margin involvement that is less when wider excisions
are performed.
• Deformity following wide local excision even for large cancers can be avoided by breast-sparing
reconstruction using volume replacement or volume displacement.
• Volume replacement is most suitable for patients with small or medium-sized breasts who wish to
avoid contralateral surgery. It can also be used for the correction of deformity following previous
BCS.
• Breast-conserving reconstruction may be carried out as a one-stage or two-stage procedure.
• The type of breast-sparing reconstruction selected will be determined by the site and extent of
resection, and by the patient's size, morphology and personal preference.
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