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

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2. Veronesi U, Cascinelli N, Mariani L, et al. (2002) Twenty-year follow-up
of a randomized study comparing breast-conserving surgery with radical
mastectomy for early breast cancer. N Engl J Med 347(16):1227–1232.
3. Anderson SJ, Wapnir I, Dignam JJ, et al. (2009) Prognosis after ipsilateral
breast tumor recurrence and locoregional recurrences in patients treated
by breast-conserving therapy in five National Surgical Adjuvant Breast
and Bowel Project protocols of node-negative breast cancer. J Clin Oncol
27(15):2466–2473.
4. Wapnir IL, Anderson SJ, Mamounas EP, et al. (2006) Prognosis after ipsi-
lateral breast tumor recurrence and locoregional recurrences in five National
Surgical Adjuvant Breast and Bowel Project node-positive adjuvant breast
cancer trials. J Clin Oncol 24(13):2028–2037.
5. Morrow M, Jagsi R, Alderman AK, et al. (2009) Surgeon recommenda-
tions and receipt of mastectomy for treatment of breast cancer. JAMA
302(14):1551–1556.
6. Clarke M, Collins R, Darby S, et al. (2005) Effects of radiotherapy and of
differences in the extent of surgery for early breast cancer on local recur-
rence and 15-year survival: An overview of the randomised trials. Lancet
366(9503):2087–2106.
7. Apple SK. (2006) Variability in gross and microscopic pathology reporting
in excisional biopsies of breast cancer tissue. Breast J 12(2):145–149.
8. Molina MA, Snell S, Franceschi D, et al. (2009) Breast specimen orientation.
Ann Surg Oncol 16(2):285–288.
9. Carter D. (1986) Margins of “lumpectomy” for breast cancer. Hum Pathol
17(4):330–332.
10. Guidi AJ, Connolly JL, Harris JR, Schnitt SJ. (1997) The relationship
between shaved margin and inked margin status in breast excision speci-
mens. Cancer 79(8):1568–1573.
11. Wright MJ, Park J, Fey JV, et al. (2007) Perpendicular inked versus tangen-
tial shaved margins in breast-conserving surgery: Does the method matter?
J Am Coll Surg 204(4):541–549.
12. Huston TL, Pigalarga R, Osborne MP, Tousimis E. (2006) The influence of
additional surgical margins on the total specimen volume excised and the
reoperative rate after breast-conserving surgery. Am J Surg 192(4):509–512.
13. Jacobson AF, Asad J, Boolbol SK, et al. (2008) Do additional shaved margins
at the time of lumpectomy eliminate the need for re-excision? Am J Surg
196(4):556–558.
14. Kobbermann A, Unzeitig A, Xie XJ, et al. (2011) Impact of routine cav-
ity shave margins on breast cancer re-excision rates. Ann Surg Oncol
18(5):1349–1355.
15. Marudanayagam R, Singhal R, Tanchel B, et al. (2008) Effect of cavity
shaving on reoperation rate following breast-conserving surgery. Breast J
14(6):570–573.
16. Rizzo M, Iyengar R, Gabram SG, et al. (2010) The effects of additional
tumor cavity sampling at the time of breast-conserving surgery on final mar-
gin status, volume of resection, and pathologist workload. Ann Surg Oncol
17(1):228–234.

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17. Tengher-Barna I, Hequet D, Reboul-Marty J, et al. (2009) Prevalence and
predictive factors for the detection of carcinoma in cavity margin performed
at the time of breast lumpectomy. Mod Pathol 22(2):299–305.
18. Cao D, Lin C, Woo SH, et al. (2005) Separate cavity margin sampling at the
time of initial breast lumpectomy significantly reduces the need for reexci-
sions. Am J Surg Pathol 29(12):1625–1632.
19. Graham RA, Homer MJ, Katz J, et al. (2002) The pancake phenomenon
contributes to the inaccuracy of margin assessment in patients with breast
cancer. Am J Surg 184(2):89–93.
20. Azu M, Abrahamse P, Katz SJ, Jagsi R, Morrow M. (2010) What is an
adequate margin for breast-conserving surgery? Surgeon attitudes and cor-
relates. Ann Surg Oncol 17(2):558–563.
21. Taghian A, Mohiuddin M, Jagsi R, et al. (2005) Current perceptions regar-
ding surgical margin status after breast-conserving therapy: Results of a
survey. Ann Surg 241(4):629–639.
22. Waljee JF, Hu ES, Newman LA, Alderman AK. (2008) Predictors of re-
excision among women undergoing breast-conserving surgery for cancer. Ann
Surg Oncol 15(5):1297–1303.
23. Kurniawan ED, Wong MH, Windle I, et al. (2008) Predictors of surgi-
cal margin status in breast-conserving surgery within a breast screening
program. Ann Surg Oncol 15(9):2542–2449.
24. Lovrics PJ, Cornacchi SD, Farrokhyar F, et al. (2010) Technical factors,
surgeon case volume and positive margin rates after breast conservation
surgery for early-stage breast cancer. Can J Surg 53(5):305–312.
25. Arriagada R, Le MG, Rochard F, Contesso G. (1996) Conservative treatment
versus mastectomy in early breast cancer: Patterns of failure with 15 years of
follow-up data. Institut Gustave-Roussy Breast Cancer Group. J Clin Oncol
14(5):1558–1564.
26. Blichert-Toft M, Rose C, Andersen JA, et al. (1992) Danish randomized
trial comparing breast conservation therapy with mastectomy: Six years of
life-table analysis. Danish Breast Cancer Cooperative Group. J Natl Cancer
Inst Monogr (11):19–25.
27. Poggi MM, Danforth DN, Sciuto LC, et al. (2003) Eighteen-year results in
the treatment of early breast carcinoma with mastectomy versus breast con-
servation therapy: The National Cancer Institute Randomized Trial. Cancer
98(4):697–702.
28. van Dongen JA, Voogd AC, Fentiman IS, et al. (2000) Long-term results of
a randomized trial comparing breast-conserving therapy with mastectomy:
European Organization for Research and Treatment of Cancer 10801 trial.
J Natl Cancer Inst 92(14):1143–1150.
29. Veronesi U, Volterrani F, Luini A, et al. (1990) Quadrantectomy versus
lumpectomy for small size breast cancer. Eur J Cancer 26(6):671–673.
30. Houssami N, Macaskill P, Marinovich ML, et al. (2010) Meta-analysis of the
impact of surgical margins on local recurrence in women with early-stage
invasive breast cancer treated with breast-conserving therapy. Eur J Cancer
46(18):3219–3232.

Margins in Breast Cancer Surgery
83
31. Dillon DA, Guidi AJ, Schnitt SJ. (2010) Pathology of invasive breast cancer.
In: Harris JR, Lippman ME, Morrow M, Osborne CK (eds.), Diseases of the
Breast 4th edn., Wolters Kluwer, Philadelphia, pp. 374–407.
32. Molland JG, Donnellan M, Janu NC, et al. (2004) Infiltrating lobular
carcinoma — A comparison of diagnosis, management and outcome with
infiltrating duct carcinoma. Breast 13(5):389–396.
33. Peiro G, Bornstein BA, Connolly JL, et al. (2000) The influence of infiltrating
lobular carcinoma on the outcome of patients treated with breast-conserving
surgery and radiation therapy. Breast Cancer Res Treat 59(1):49–54.
34. Santiago RJ, Harris EE, Qin L, et al. (2005) Similar long-term results of
breast-conservation treatment for Stage I and II invasive lobular carcinoma
compared with invasive ductal carcinoma of the breast: The University of
Pennsylvania experience. Cancer 103(12):2447–2454.
35. Galimberti V, Maisonneuve P, Rotmensz N, et al. (2011) Influence of mar-
gin status on outcomes in lobular carcinoma: Experience of the European
Institute of Oncology. Ann Surg 253(3):580–584.
36. Harris JR. (1996) Breast-conserving therapy as a model for creating new
knowledge in clinical oncology. Int J Radiat Oncol Biol Phys 35(4):641–648.
37. Holland R, Connolly JL, Gelman R, et al. (1990) The presence of an extensive
intraductal component following a limited excision correlates with prominent
residual disease in the remainder of the breast. J Clin Oncol 8(1):113–118.
38. Bartelink H, Horiot JC, Poortmans P, et al. (2001) Recurrence rates after
treatment of breast cancer with standard radiotherapy with or without addi-
tional radiation. N Engl J Med 345(19):1378–1387.
39. Park CC, Mitsumori M, Nixon A, et al. (2000) Outcome at 8 years after
breast-conserving surgery and radiation therapy for invasive breast cancer:
Influence of margin status and systemic therapy on local recurrence. J Clin
Oncol 18(8):1668–1675.
40. Faverly DR, Burgers L, Bult P, Holland R. (1994) Three dimensional imaging
of mammary ductal carcinoma in situ: Clinical implications. Semin Diagn
Pathol 11(3):193–198.
41. Darvishian F, Hajdu SI, DeRisi DC. (2003) Significance of linear extent of
breast carcinoma at surgical margin. Ann Surg Oncol 10(1):48–51.
42. Holland R, Veling SH, Mravunac M, Hendriks JH. (1985) Histologic mul-
tifocality of Tis, T1-2 breast carcinomas. Implications for clinical trials of
breast-conserving surgery. Cancer 56(5):979–990.
43. Bartelink H, Horiot JC, Poortmans PM, et al. (2007) Impact of a higher
radiation dose on local control and survival in breast-conserving therapy of
early breast cancer: 10-year results of the randomized boost versus no boost
EORTC 22881-10882 trial. J Clin Oncol 25(22):3259–3265.
44. Fisher B, Dignam J, Bryant J, et al. (1996) Five versus more than five years
of tamoxifen therapy for breast cancer patients with negative lymph nodes
and estrogen receptor-positive tumors. J Natl Cancer Inst 88(21):1529–1542.
45. Fisher B, Dignam J, Mamounas EP, et al. (1996) Sequential methotrexate
and fluorouracil for the treatment of node-negative breast cancer patients
with estrogen receptor-negative tumors: Eight-year results from National

84
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Surgical Adjuvant Breast and Bowel Project (NSABP) B-13 and first report
of findings from NSABP B-19 comparing methotrexate and fluorouracil
with conventional cyclophosphamide, methotrexate, and fluorouracil. J Clin
Oncol 14(7):1982–1992.
46. Romond EH, Perez EA, Bryant J, et al. (2005) Trastuzumab plus adju-
vant chemotherapy for operable HER2-positive breast cancer. N Engl J Med
353(16):1673–1684.
47. Mamounas EP, Tang G, Fisher B, et al. (2010) Association between the
21-gene recurrence score assay and risk of locoregional recurrence in node-
negative, estrogen receptor-positive breast cancer: Results from NSABP B-14
and NSABP B-20. J Clin Oncol 28(10):1677–1683.
48. Millar EK, Graham PH, O’Toole SA, et al. (2009) Prediction of local recur-
rence, distant metastases, and death after breast-conserving therapy in early-
stage invasive breast cancer using a five-biomarker panel. J Clin Oncol
27(28):4701–4708.
49. Nguyen PL, Taghian AG, Katz MS, et al. (2008) Breast cancer subtype
approximated by estrogen receptor, progesterone receptor, and HER-2 is
associated with local and distant recurrence after breast-conserving therapy.
J Clin Oncol 26(14):2373–2378.
50. Kyndi M, Sorensen FB, Knudsen H, et al. (2008) Estrogen receptor, pro-
gesterone receptor, HER-2, and response to postmastectomy radiotherapy
in high-risk breast cancer: The Danish Breast Cancer Cooperative Group.
J Clin Oncol 26(9):1419–1426.
51. Fisher B, Brown A, Mamounas E, et al. (1997) Effect of preoperative
chemotherapy on local-regional disease in women with operable breast can-
cer: Findings from National Surgical Adjuvant Breast and Bowel Project
B-18. J Clin Oncol 15(7):2483–2493.
52. van der Hage JA, van de Velde CJ, Julien JP, et al. (2001) Preoperative
chemotherapy in primary operable breast cancer: Results from the European
Organization for Research and Treatment of Cancer trial 10902. J Clin Oncol
19(22):4224–4237.
53. Mieog JS, van der Hage JA, van de Velde CJ. (2007) Preoperative chemother-
apy for women with operable breast cancer. Cochrane Database Syst Rev
(2):CD005002.
54. Wolmark N, Wang J, Mamounas E, et al. (2001) Preoperative chemotherapy
in patients with operable breast cancer: Nine-year results from National Sur-
gical Adjuvant Breast and Bowel Project B-18. J Natl Cancer Inst Monogr
(30):96–102.
55. Hylton N. (2006) MR imaging for assessment of breast cancer response
to neoadjuvant chemotherapy. Magn Reson Imaging Clin N Am 14(3):
383–389, vii.
56. Chen AM, Meric-Bernstam F, Hunt KK, et al. (2004) Breast conservation
after neoadjuvant chemotherapy: The MD Anderson Cancer Center Experi-
ence. J Clin Oncol 22(12):2303–2312.
57. Meyers MO, Klauber-Demore N, Ollila DW, et al. (2011) Impact of breast
cancer molecular subtypes on locoregional recurrence in patients treated

Margins in Breast Cancer Surgery
85
with neoadjuvant chemotherapy for locally advanced breast cancer. Ann Surg
Oncol 18(10):2851–2857.
58. Morrow M, Harris JR. (2007) Practice guideline for breast conservation
therapy in the management of invasive breast cancer. J Am Coll Surg
205:362–376.
59. Kaufmann M, Morrow M, von Minckwitz G, Harris JR. (2010) Locoregional
treatment of primary breast cancer: Consensus recommendations from an
International Expert Panel. Cancer 116(5):1184–1191.
60. Bijker N, Meijnen P, Peterse JL, et al. EORTC Breast Cancer Cooperative
Group; EORTC Radiotherapy Group. (2006) Breast-conserving treatment
with or without radiotherapy in ductal carcinoma-in-situ: Ten-year results
of European Organisation for Research and Treatment of Cancer randomized
phase III trial 10853 — A study by the EORTC Breast Cancer Cooperative
Group and EORTC Radiotherapy Group. J Clin Oncol 24(21):3381–3387.
61. Wapnir IL, Dignam JJ, Fisher B, et al. (2011) Long-term outcomes of inva-
sive ipsilateral breast tumor recurrences after lumpectomy in NSABP B-17
and B-24 randomized clinical trials for DCIS. J Natl Cancer Inst 103(6):
478–488.
62. Cuzick J, Sestak I, Pinder SE, et al. (2011) Effect of tamoxifen and radio-
therapy in women with locally excised ductal carcinoma in situ: Long-term
results from the UK/ANZ DCIS trial. Lancet Oncol 12(1):21–29.
63. Emdin SO, Granstrand B, Ringberg A, et al. (2006) SweDCIS: Radiotherapy
after sector resection for ductal carcinoma in situ of the breast. Results of
a randomised trial in a population offered mammography screening. Acta
Oncol 45(5):536–543.
64. Dunne C, Burke JP, Morrow M, Kell MR. (2009) Effect of margin status on
local recurrence after breast conservation and radiation therapy for ductal
carcinoma in situ. J Clin Oncol 27(10):1615–1620.
65. Dick AW, Sorbero MS, Ahrendt GM, et al. (2011) Comparative effective-
ness of ductal carcinoma in situ management and the roles of margins and
surgeons. J Natl Cancer Inst 103(2):92–104.
66. Aref A, Youssef E,Washington T, et al. (2000) The value of postlumpectomy
mammogram in the management of breast cancer patients presenting with
suspicious microcalcifications. Cancer J Sci Am 6(1):25–27.
67. Gluck BS, Dershaw DD, Liberman L, Deutch BM. (1993) Microcalcifica-
tions on postoperative mammograms as an indicator of adequacy of tumor
excision. Radiology 188(2):469–472.
68. Silverstein MJ, Lagios MD, Groshen S, et al. (1999) The influence of margin
width on local control of ductal carcinoma in situ of the breast. N Engl J
Med 340(19):1455–1461.
69. Hughes LL, Wang M, Page DL, et al. (2009) Local excision alone without
irradiation for ductal carcinoma in situ of the breast: A trial of the Eastern
Cooperative Oncology Group. J Clin Oncol 27(32):5319–5324.

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Chapter 6
RESECTION OF THE TUMOR
Mahmoud El-Tamer
Breast Service, Department of Surgery,
Memorial Sloan-Kettering Cancer Center,
New York, NY 10065, USA
6.1 General Principles and Preoperative Planning
The preliminary objective of an oncoplastic surgical procedure must always
be adequate resection of the primary tumor. The surgeon should not com-
promise that objective. An adequate resection is defined as the complete
removal of the tumor with histologically confirmed negative margins. We
have defined in Chapter 5 what we consider to be evidence-based negative
margins. Surgeons should follow these recommendations or resort to their
departmental or institutional definitions as long as histologically negative
margins are achieved.
Positive margins, however defined, have been associated with a signifi-
cantly higher incidence of recurrence.1,2 Furthermore, some have reported
an association between positive margins, and systemic recurrence and
disease-specific survival.3 All efforts should be directed toward achieving
negative margins from the start, particularly when complex repairs are
planned, or when breast reduction or rotation flaps are used. The aim of
the oncoplastic resection is to maximize the removal of malignant tissue
and minimize the loss of benign tissue, including skin, subcutaneous fat,
breast, pectoralis fascia, and muscle tissue. We recommend excising extra
benign tissue for the purpose of breast reduction or mastopexy only when
indicated.
One of the most important steps in managing a breast cancer is achiev-
ing a diagnosis prior to any surgical intervention. Percutaneous needle aspi-
ration or biopsy is currently the standard of care. Preoperative diagnosis by
needle biopsy can be achieved in more than 90% of patients.4 Preoperative
87

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Principles and Techniques in Oncoplastic Breast Cancer Surgery
needle diagnosis limits the number of operative procedures5 and increases
the sentinel node detection rate.6
Preoperative evaluation of the size and extent of the tumor is crucial
for planning the resection. All available images are reviewed and should
be accessible to the surgeons during the operative procedure as needed.
Mammography, ultrasonography, and magnetic resonance imaging (MRI)
are complementary when defining the extent of the disease. Mammography
has the unique capability of defining the extent of malignant and suspicious
calcifications. When the calcifications are at a distance from the index can-
cer or may not be included in the planned resection, we have felt it more
convenient to use a separate needle or wire for localization, even when
the primary is palpable. As mammograms are performed in the standing
position and under breast compression, of particular concern is that the
calcification may not be in the expected location when the patient is lying
down on the operative table. Mammography and ultrasonography in par-
ticular are helpful in defining the size of the malignant mass.
The role of MRI in evaluating the extent of disease has been heavily
debated over the past few years. MRI has been helpful but occasionally
deceptive in planning resection. MRI has not decreased the re-excision rate
and certainly has not lowered the rate of local recurrence.7 Furthermore,
some clinicians have reported an unnecessary mastectomy rate in 5% to
10% of cases when using MRI for evaluation of the extent of disease. So
far, we have not uniformly relied on MRI to evaluate the extent of disease.
We have limited MRI to patients who fall into the following categories:
(1) Mammographically occult lesions.
(2) Premenopausal women with dense breasts, particularly women younger
than 40 years of age.
(3) Patients considering contralateral prophylactic mastectomy.
(4) High-risk patients, particularly those who are mutation carriers.
The patient is marked preoperatively in the pre-anesthesia care unit. We
prefer to mark the patient while she is standing or in a semi-sitting position.
In patients for whom a major resection is contemplated with mobilization of
the nipple areola complex (NAC), certain landmarks should be defined and
marked preoperatively as described in Chapter 2. We strongly encourage
the breast/general surgeon who has not had any training in mastopexy or
breast reduction to seek the expertise of a plastic surgeon. In cases where
the resection is limited and will not involve any mobilization of the NAC
of the breast, the skin incision may be drawn intraoperatively while the
patient is on the table. We do, however, feel that the lines of Kraissl7,8 are
better defined in the standing position. The areolar edges in fair individuals

Resection of the Tumor
89
or nulliparous women are better visualized before prepping the patient,
particularly when using Betadine as a surgical preparation.
The vast majority of breast conservation procedures are performed
under local anesthesia with sedation. In cases where we have planned a
major resection with repositioning of the NAC, particularly when a breast
reduction or a mastopexy procedure is included, we have resorted to general
anesthesia.
6.2 Resection of the Primary
6.2.1 General Principles
Breast surgery has long been dominated by Halstedian principles. With
the paradigm shift from mastectomy to breast conservation, some sur-
geons have applied the same Halstedian principles to the local excision
of the breast primary; such an approach recommends an en bloc resection
starting with the overlying skin, the breast cancer with the breast tissue
surrounding it, and down to the chest muscles, including the pectoralis
fascia. Such a composite resection was the main approach utilized in the
Milan breast-conserving therapy trial and was labeled “quadrantectomy.”
The National Surgical Adjuvant Breast and Bowel Project (NSABP) trial
recommended a lumpectomy in the form of a wide-local excision without
necessarily including the overlying skin and underlying pectoralis fascia in
every resection. This approach was labeled as lumpectomy. Both studies
have shown the reliability of breast-conservation surgery when compared
with mastectomy with 20 years follow-up. Both trials also demonstrated
a similar rate of local recurrence of the original primary when compared
with mastectomy. The incidence of local recurrence in the NSABP trial
was higher than the Milan trial. The inclusion criteria were different, how-
ever; the Milan trial was limited to T1 tumors whereas the NSABP included
lesions as large as 5 cm in size. Although intuitive, there are enough data to
support that larger resections will result in more deformity without improv-
ing local control. Noh et al. compared 456 patients who underwent a quad-
rantectomy with 351 patients whose surgical procedures were limited to a
lumpectomy. Both groups had similar clinical and pathologic characteris-
tics. Using multivariate analysis, young age (less than 35 years), positive
nodes, and the presence of an extensive intraductal component were the
only predictors of local recurrence. Lumpectomy was not a predictor of
local recurrence; however, it was associated with a higher re-excision rate.
The conclusion was that the extent of surgery did not predict ipsilateral
breast tumor recurrence when adequate surgical margins were achieved.9

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Principles and Techniques in Oncoplastic Breast Cancer Surgery
To avoid a high re-excision rate, we have removed the primary tumor
and excised separate margins. We have focused our surgical resection
on the tumor and appropriate clear margins. We have limited excision
of the overlying skin or underlying pectoralis fascia to tumors that are
close to these structures. Frequently, however, we recommend excision
of the overlying skin to facilitate approximation of breast tissue and
avoid redundant skin, or as part of a mastopexy or breast reduction
procedure.
6.2.2 Technical Aspects
Following completion of the incision, we elevate the skin and subcuta-
neous tissue offthe underlying breast. We use the superficial fascial plane
as if we were performing a mastectomy [Figure 6.1(a)] when the tumor
is quite superficial. If the tumor is deep in the breast tissue, we believe
the surgeon can save a significant amount of tissue and raise the flaps at
the glandular level [Figure 6.1(b)] or even deeper in the breast, particu-
larly in centrally located and deep tumors. One caveat, however: when
one raises the flaps in the breast substance, attention must be directed to
the anterior margins in the specimen. We prefer to excise the overlying
skin if we feel we must include the subcutaneous tissue in the resection
to achieve a sound oncologic procedure. We have noticed that resection
of the subcutaneous tissue from the dermis down has routinely resulted
in a poor cosmetic outcome, with the dermis adhering to the underlying
tissue, resulting in a retracted scar. The flap elevation prior to resection
allows for excellent visualization and planning of breast tissue resection
[Figure 6.1(c)].
We have recently adopted a technique in which we excise the tumor
with 0.5–1.0 cm grossly negative margins. After completion of this limited
lumpectomy, we re-excise the totality of the lumpectomy cavity and submit
each edge of the lumpectomy cavity separately as final margins while ori-
enting the new true margin for the pathologist. We, as well as others, have
recognized a drop in our re-excision rate as a result. Our resection has been
dictated by the location of the tumor and has not compromised the final
cosmetic result. When we combine resection of a tumor with a breast reduc-
tion (see Chapter 8), we usually resect the whole quadrant where the tumor
is located with 2–3 cm grossly negative margins as part of the reductive
procedure.
Some surgeons have advocated the use of intraoperative ultrasound
(US) for guidance.10,11 It is certainly a useful tool as described in the lit-
erature and reported by others. We have not routinely used intraoperative

Resection of the Tumor
91
(a)
(b)
(c)
Figure 6.1.
(a) After completion of the incision, we elevate the skin and subcutaneous
tissue offthe underlying breast following the superficial fascial plane as if we were
performing a mastectomy. (b) If the tumor is deep in the breast tissue, we believe
surgeons can spare a significant amount of tissue and raise the flaps at the glandular
level. (c) Flap elevation prior to resection allows for excellent visualization and planning
of the breast tissue to be excised.

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Principles and Techniques in Oncoplastic Breast Cancer Surgery
US for guidance while excising tumors. With our lumpectomy technique,
positive margins are most frequently due to ductal carcinoma in situ
(DCIS) where ultrasound has a limited role. However, we have used needle
localization liberally in patients in whom the tumor is vaguely palpable.
We have also asked radiologists to aim for the center of the tumor while
localizing a lesion. We have preferred the bracketing technique to a single
needle in the center of the microcalcifications when dealing with a wide
area of microcalcifications. The bracketing technique can help to better
identify the limits of the resection, particularly when the calcifications are
spread more than 3 cm in width (see Case No. 1).
Case No. 1
A 60-year-old patient presented with a new mammographic finding of
7.5-cm microcalcifications. She was interested in BCT. The bracketing
technique was used to delineate the extent of resection in the left breast.
Image 1.1. Left breast medio-lateral oblique.

Resection of the Tumor
93
Image 1.2. Left breast cranio-caudal.
Image 1.3. Left breast preoperative needle localization with bracketing.

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Principles and Techniques in Oncoplastic Breast Cancer Surgery
Image 1.4. Specimen X-ray. The lumpectomy measured 11 cm × 10 cm × 6 cm.
Image 1.5. The patient after left breast lumpectomy and sentinel node biopsy.

Resection of the Tumor
95
Image 1.6. The patient after left breast lumpectomy and sentinel node biopsy with the
arm elevated. Notice the minimal deformity.
Image 1.7. The lateral view showing the scar.
Prior to adopting the technique of excising and submitting the margins
separately, we used to perform a lumpectomy with 1–2 cm grossly negative
margins. Whatever technique the surgeon uses, we strongly recommend
orienting the specimen intraoperatively. Different methods have been used
to orient the specimen, including sutures, hemoclips, and metallic markers.
Some surgeons have even resorted to inking the specimen intraoperatively.
We believe each breast center should develop and adhere to a convenient
method of specimen orientation that is agreed upon by pathologists and
surgeons. With clearly defined margins, we have limited re-excision to the

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Principles and Techniques in Oncoplastic Breast Cancer Surgery
positive margins only. We have reserved whole cavity re-excision to mul-
tifocal disease with multiple positive margins, or to cases referred to us
following lumpectomy with unoriented specimens. Gibson et al. did not
notice any difference in local recurrence following ink-directed re-excision
and whole cavity re-excision for positive margins. Specimen weights after
whole cavity re-excision were nearly 4 times heavier than ink-directed lim-
ited re-excision (23 g versus 83 g). Larger volumes of tissue excision will
clearly negatively impact the cosmetic outcome.12
After completion of removal of the primary, we repair the defect and
close the overlying skin. (See Chapter 7 for the techniques of repair.) We do
not usually insert drains into the breast tissue. In cases where we perform
the resection and complete an axillary node dissection, we may consider
inserting a drain into the breast tissue, particularly when the tumor is
located in the outer quadrant or centrally. The surgical dressing we apply
is limited to steri-strips and a transparent impermeable dressing such as an
Opsite R⃝or a Tegaderm R⃝. We do not wrap patients with Ace bandages; we
have routinely asked the patient to continuously wear a surgical or wireless
sports brassiere continuously for a period of 72–96 hours, however.
In the postoperative period, patients are allowed to shower as of the
first operative day and resume regular daily activity. We recommend that
patients abstain from applying heavy pressure over the operated breast
and refrain from physical activities that result in heavy bouncing of the
breast (such as jogging and heavy cardiovascular exercises) for a period of
6 to 8 weeks. We avoid any mammographic studies in the postoperative
period unless essential, and then we limit the amount of compression to
the bare minimum for fear of disrupting the repair, particularly in women
with fatty breasts. In cases where the patient is returning to the operating
room for re-excision of margins, we repeat the mammogram as necessary
prior to the re-excision to identify residual calcification.
In very few cases with significant disruption of the lymphatic drainage,
we have encountered a significant seroma. The seroma, however, has not
been significant enough to disrupt the repair. In our experience, the
seroma resulted in disruption of the repair in only one patient, neces-
sitating a return to the operating room for evacuation of seroma and
re-approximation of tissue. Most seroma are adequately managed with per-
cutaneous office aspiration as needed.
References
1. Schnitt SJ. (2003) Risk factors for local recurrence in patients with invasive
breast cancer and negative surgical margins of excision. Where are we and
where are we going? Am J Clin Pathol 120(4):485–488.

Resection of the Tumor
97
2. Singletary SE. (2002) Surgical margins in patients with early-stage breast
cancer treated with breast conservation therapy. Am J Surg 184(5):383–393.
3. Meric F, Mirza NQ, Vlastos G, et al. (2003) Positive surgical margins and
ipsilateral breast tumor recurrence predict disease-specific survival after
breast-conserving therapy. Cancer 97(4):926–933.
4. Pocock B, Taback B, Klein L, et al. (2009) Preoperative needle biopsy
as a potential quality measure in breast cancer surgery. Ann Surg Oncol
16(5):1108–1111.
5. Morrow M, Venta L, Stinson T, Bennett C. (2001) Prospective comparison
of stereotactic core biopsy and surgical excision as diagnostic procedures for
breast cancer patients. Ann Surg 233(4):537–541.
6. Julian TB, Land SR, Fourchotte V, et al. (2007) Is sentinel node biopsy
necessary in conservatively treated DCIS? Ann Surg Oncol 14(8):2202–2208.
7. Gray H. (1995) Skin lines. In: Williams PL (ed.), Gray’s Anatomy, 38th edn.
Churchil Livingstone, London, pp. 378–381.
8. Kraissl CJ. (1951) The selection of appropriate lines for elective surgical
incisions. Plast Reconstr Surg (1946) 8(1):1–28.
9. Noh WC, Paik NS, Kim MS, et al. (2005) Ipsilateral breast tumor recur-
rence after breast-conserving therapy: A comparison of quadrantectomy ver-
sus lumpectomy at a single institution. World J Surg 29(8):1001–1006.
10. Buman SJ, Clark DA. (2005) Breast intraoperative ultrasound: Prospective
study in 112 patients with impalpable lesions. ANZ J Surg 75(3):124–127.
11. Ngo C, Pollet AG, Laperrelle J, et al. (2007) Intraoperative ultrasound local-
ization of nonpalpable breast cancers. Ann Surg Oncol 14(9):2485–2489.
12. Gibson GR, Lesnikoski BA, Yoo J, et al. (2001) A comparison of ink-directed
and traditional whole-cavity re-excision for breast lumpectomy specimens
with positive margins. Ann Surg Oncol 8(9):693–704.

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Chapter 7
REPAIR OF BREAST DEFECTS
Mahmoud El-Tamer
Breast Service, Department of Surgery,
Memorial Sloan-Kettering Cancer Center,
New York, NY 10065, USA
The resection, as previously described in Chapter 6, is centered on the
tumor. It has been our practice to excise the primary with 0.5–1.0 cm of
grossly soft tissue and later excise each margin separately. We have noticed
a decrease in our re-excision rate with perhaps a subtle increase in the
volume of resection. With separate excision of margins, it was easier for the
surgeon and the pathologist to clearly agree on the exact margin. We mark
the site of the true margin intraoperatively. This mode of resection and
orientation works well for us at Memorial Sloan-Kettering Cancer Center.
We recommend, however, that you follow your institutional practice. We
do not necessarily perform a full-thickness resection, that is, from skin
down to the pectoralis fascia, on every patient. Following completion of
the resection, we evaluate the mobility of the breast tissue.
When the breast tissue does not have enough mobility over the chest
wall, we then elevate the breast tissue offthe pectoralis fascia in the plane
of the retromammary space.
The defect is evaluated for closure and is approximated along the most
convenient route for the particular quadrant where it is located. The skin
overlying the breast tissue is elevated when the tumor is close to the surface
or when dealing with A or B cup size breasts. In deep-seated tumors, we
resect the lesion, repair the defect, and later assess the need for further
skin elevation.
The resection and repair of defect are planned based on multiple factors:
• The location of the tumor (quadrant and depth)
• The size of the tumor
99

100
Principles and Techniques in Oncoplastic Breast Cancer Surgery
• The size of the breast
• The level of ptosis of the breast
In patients for whom the resection would include less than 25% of the
breast volume, a simple oncoplastic procedure can easily be performed. In
cases in which the patient has a ptotic breast or is interested in reducing the
size of her breast, we would encourage combining the oncologic procedure
with a mastopexy or a breast reduction, accordingly.
7.1 General Principles
The skin incision is performed, and the skin and subcutaneous tissue are
elevated offthe breast for a distance of 2–4 cm circumferentially around
the center of the tumor as indicated in Figure 7.1(a). When the tumor
is very close to the skin or tethering the skin, we recommend excision
of the overlying skin as part of the specimen. If the tumor is very close
to the superficial layer of breast glandular tissue, we elevate the skin in
the mastectomy plane [Figure 7.1(b)]. When the tumor is in the center
of the gland, we elevate the skin at the glandular level [Figure 7.1(c)]. In
cases where the tumor is deep in the center of the breast, we continue the
dissection down in the breast tissue up to 1–2 cm above the tumor, and
then start the resection at that level.
The lesion is excised as per your routine. At the beginning of this chap-
ter, we have summarized our personal technique. We recommend orienting
the specimen by whatever methods the surgeon or the institution deem
appropriate. We cannot, however, overstress the importance of specimen
orientation.
In A and B cup size breasts, we have invariably realized that the resec-
tion is full thickness, that is, down to the pectoralis major fascia, due to
the paucity of breast tissue surrounding the tumor. In larger breasts, we
have limited full-thickness resection depending on the location and size
of the tumor. Following completion of the resection [Figure 7.1(d)], the
sub-glandular space or retromammary bursa is entered. The mobility of
the breast is assessed; the breast tissue is elevated offthe pectoralis fas-
cia using the retromammary plane. In some areas, and particularly in the
center of the breast, there may be no need to undermine the breast tissue
[Figure 7.1(e)]. The breast tissue is rotated or advanced as necessary, and
it is approximated with sutures. We have routinely used absorbable sutures
of 2-0 or 3-0 thickness. The type of rotation/advancement and approxima-
tion vary with the quadrant of the tumor. The main purpose of mobilizing
the breast tissue is to allow the restoration of contour and closure of the
defect. When the defect is left open, a seroma develops in the immediate

Repair of Breast Defects
101
(a)
(b)
(c)
Figure 7.1.
(a) Skin elevation prior to resection. (b) The plane of elevation is in the
subcutaneous tissue as if performing a mastectomy. (c) The level of skin elevation is
at the glandular level. The skin flap thickness varies with the amount of subcutaneous
tissue. (d) This is a patient who underwent a resection of a lateral tumor. The resection
extended from the skin down to the pectoralis muscle. (e) The breast tissue is shown
after its separation from the pectoralis fascia in preparation for a radial closure.

102
Principles and Techniques in Oncoplastic Breast Cancer Surgery
(d)
(e)
Figure 7.1.
(Continued)
postoperative period, therefore giving fullness to the breast. With time,
the seroma resolves and the patient receives radiation therapy, resulting
in shrinkage of the cavity and some deformity of contour. Frequently, the
skin will adhere to the underlying muscle, creating a significant deformity
of the breast. Such deformities are particularly seen following resection

Repair of Breast Defects
103
of inner quadrant lesions. We have also observed that in patients for whom
the lumpectomy cavity is not approximated, the resulting scar is larger and
denser, making follow-up clinical exams and mammograms more difficult
compared with cases in which the lumpectomy defect has been repaired.
In most women, there are some differences in the size and shape of both
breasts. This asymmetry varies from the subtle to the grossly obvious.1
It is quite understandable that following an oncologic procedure, there
will be loss of volume and some differences in breast size and shape. One
hopes, however, that with the plastic aspect of the oncoplastic procedure,
this difference will be minimized. In spite of the size difference, the final
shape of the operated breast will be cosmetically acceptable and frequently
preferable to the contralateral side.
All the described techniques in this section are performed without spe-
cific attempts at mobilization of the nipple. In patients for whom the resec-
tion would require removal of more than 20%–25% of breast volume, we feel
that such a resection needs to be part of a breast reduction, and we reserve
such procedures to C cup size breasts or larger. We prefer to start patients
with A and B cup size breasts who would require removal of more than
25%–30% of the breast on neoadjuvant therapy, if indicated, in an attempt
to reduce the volume of resection to achieve better cosmetic results. Refer
to Chapter 3 for neoadjuvant therapy.
We have generally used 5 types of closures that we will describe inde-
pendently:
• Transverse closure
• Radial closure
• Triangular closure
• Purse-string closure
• Mobilization of surrounding subcutaneous tissue
7.1.1 Transverse Closure
Transverse closure is completed by advancing the upper and lower edges
of the defect toward each other, resulting in a transverse line of closure
[Figures 7.2(a)–(c)]. This type of closure is ideal for the defects located in
the upper hemisphere and the center of the breast. We have avoided using
this type of closure in the lower hemisphere, particularly for defects located
between 4 o′clock and 8 o′clock, as it will invariably result in a downward
traction of the nipple areola complex (NAC). To avoid such traction, one
may have to elevate the NAC offthe glandular flap.
Case Nos. 1 and 2 demonstrate the technique and the postoperative
results in vivo. Case No. 3 shows the result of transverse closure in the
upper inner quadrant.

104
Principles and Techniques in Oncoplastic Breast Cancer Surgery
(a)
(b)
(c)
Figure 7.2.
(a–c) Transverse closure.

Repair of Breast Defects
105
Case Nos. 1 and 2: Patients with transverse closure at 12 o′clock.
Case No. 1
This patient presented with a 2.5-cm tumor in the 12 o′clock axis. She was
scheduled for a needle localization lumpectomy and sentinel node biopsy.
Image 1.1. The patient on the operating room table with needle localization.
Image 1.2. The patient after completion of resection. The dressing in the axilla was
applied over the sentinel node scar.

106
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Image 1.3. The breast flaps elevated offthe pectoralis fascia and overlying skin. The
flaps are prepared for transverse approximation.
Image 1.4. The patient after completion of the breast tissue approximation, prior to
closure of the skin.

Repair of Breast Defects
107
Case No. 2. This patient with size A cup breasts had a 2.5-cm tumor in
the same location as the patient in Case No. 1.
Image 2.1. This patient with similar size and location of tumor seen 7 years postoper-
atively. The patient reported that she preferred the operated breast because it “looked
younger.”
Image 2.2. Same patient as in Image 2.1.

108
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Case No. 3: Transverse repair in the upper inner quadrant (UIQ).
• Images 3.1 and 3.2 show the patient 2 years after lumpectomy and sen-
tinel node biopsy for a T2N0 tumor located in the UIQ. Notice the size
difference of both breasts and the subtle elevation of the inframammary
line with arm elevation. Except for that critical observation, the patient
was very happy with the contour and shape of the operated breast.
Image 3.1
Image 3.2

Repair of Breast Defects
109
7.1.2 Radial Closure
The breast tissue is approximated along a radial line. This kind of repair
can be applied in any quadrant. It is particularly useful in the lower hemi-
sphere of the breast between 3 o′clock and 9 o′clock [Figure 7.3(a–e)]. The
resection is carried out as planned. We frequently shape the resection in
an elliptical form to facilitate closure. After completion of the resection,
the breast tissue is elevated offthe pectoralis major fascia and rotated as
in Figure 7.3(c). Both lateral and medial breast tissue are equally elevated
and rotated when the tumor is located in the lower outer quadrant. For
lesions in the inner lower quadrant, we have found that we frequently tend
to mobilize the lateral flap to a greater extent than the medial flap, mainly
due to the paucity of the breast tissue in the medial flap.
The
breast
tissue
is
approximated
at
multiple
levels,
starting
with the deep layers and finishing with the surface of the breast
[Figure 7.3(c–d)]. The skin is later approximated with subcuticular tech-
nique. In Figure 7.3(e), we have demonstrated a radial incision; this type
of resection and repair could be completed through a transverse or even an
inframammary incision. We certainly resort to a radial incision when we
are planning to excise the skin overlying the tumor as presented in Case
No. 4. Case No. 5 shows the final result of a patient after lumpectomy
and axillary node dissection followed by chemotherapy and radiation for a
T2 N1 palpable lesion located at the 9 o′clock axis of the left breast. The
patient has A cup size breasts.
(a)
(b)
Figure 7.3.
(a–e) Radial closure of defects at 6 o′clock; (f–h) clinical example with
1-year postop.

110
Principles and Techniques in Oncoplastic Breast Cancer Surgery
(c)
(d)
(e)
(f)
(g)
(h)
Figure 7.3.
(Continued)

Repair of Breast Defects
111
Case No. 4
Radial closure, inner lower quadrant. A 54-year-old woman presented with
a palpable mass in the lower inner quadrant of the left breast. The tumor
was close to the skin. We had planned a full-thickness resection of the
skin, breast tissue down to the pectoralis fascia.
Image 4.1. The patient on the operating room table. The ellipse delineates the skin to
be excised. The circle represents the underlying tumor.
Image 4.2. The patient after resection of the skin and the tumor, and elevation of the
glandular flaps, prior to rotation and approximation of the breast tissue.

112
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Image 4.3. The patient 10 days postoperatively. The reaction of the skin to the adhesive
was still apparent. The operated breast is swollen and seems larger than the contralat-
eral side.
Image 4.4. Taken 10 days postoperatively with arm elevation. It is evident that the
patient had loss of volume from the lower hemisphere, and the skin seems flattened
due to the resection of an ellipse of skin.

Repair of Breast Defects
113
Image 4.5. Taken 8 months postoperatively after chemotherapy and completion of
radiation treatment.
Image 4.6. Taken 1 year postoperatively. Note the excellent cosmetic results, symmetry
in shape, and resolution of the flattening of the lower hemisphere.

114
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Image 4.7. Taken 1 year postoperatively as in Image 4.6.
Case No. 5
Radial closure, inner quadrant, left breast, 9 o′clock axis. A 48-year-old
woman presented with a palpable mass in the 9 o′clock axis of the left
breast. The tumor was around 2.4 cm in size and the patient had A cup
size breasts. She underwent a lumpectomy and axillary node dissection.
The defect was repaired along the 9 o′clock axis. The patient received a
full course of chemotherapy and whole breast radiation with boost to the
lumpectomy site.
• Images 5.1 and 5.2: The patient 6 years postoperatively. One clearly
sees the difference in size, with the left breast smaller than the right.
The shape of the left breast is within acceptable limits. The patient was
extremely pleased with the cosmetic appearance of her operated side.
Image 5.1

Repair of Breast Defects
115
Image 5.2
7.1.3 Triangular Closure (Also Known as “Mercedes”
Closure)
This is a combination of a transverse and radial repair. It is particularly
useful in the upper hemisphere as it allows elevation of the NAC through
the transverse segment but avoids displacement or malposition through the
radial component. We have mostly used this type of repair in the upper
outer quadrant to avoid outward deviation of the NAC.
As soon as the resection is completed, the defect is usually conical in
shape. The repair is started by applying a triangular suture at the center
of the defect [Figure 7.4(a)]. By tying that triangular suture, the walls of
the defect are transformed into 3 lines [Figure 7.4(b)]. The breast tissue
is approximated along these lines. The extent of elevation of the NAC
is controlled by the initial triangular suture. Figure 7.5 shows how the
surgeon can increase or decrease the extent of the elevation of the NAC by
changing the position of the triangular suture. The extent of elevation is
usually equal to a perpendicular line from point C to Line AB.
This kind of repair is also feasible through any skin incision. A key to
the success of this repair is an adequate undermining of the overlying skin
and mobilization of the breast tissue, particularly in patients with dense
glandular tissue. Case No. 6 demonstrates the application of this technique
in a patient with an upper outer quadrant lesion.

116
Principles and Techniques in Oncoplastic Breast Cancer Surgery
(a)
(b)
Figure 7.4.
(a)–(b) Triangular repair.
Figure 7.5.
The surgeon can control the extent of NAC elevation by directly tuning
the placement of the sutures at points A and B. The extent of elevation is equal to a
perpendicular line from point C to the line AB.

Repair of Breast Defects
117
Case No. 6
Triangular repair. A 41-year-old patient presented with a palpable mass
in the upper outer quadrant of the right breast. She underwent a lumpec-
tomy and axillary node dissection for a T2N1 breast cancer, followed by
chemotherapy and radiation treatment. The resection involved a signifi-
cant component of the UOQ. The repair was performed in a triangular
fashion; the NAC was slightly elevated. However, it remained along the
nipple line and matched very well with the contralateral side.
Image 6.1. The preoperative mammogram.

118
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Image 6.2. The postoperative mammogram 3 years later. Note the calcification at the
site of the tumor bed that represents the triangular suture. Note also the minimal
scaring at the tumor site following the repair and closure of the defect. In patients in
whom the tumor bed is left open, the scarring is significant and may result in some
difficulty for early detection of any recurrences.
Image 6.3. The patient 3 years postop. Notice the excellent cosmetic result with subtle
elevation of the NAC, and the perfect contour and projection of the operated breast.

Repair of Breast Defects
119
Image 6.4: The patient 3 years postop. Notice the excellent cosmetic result.
Image 6.5: The patient 3 years post-op. Notice the excellent cosmetic result and
projection of the breast.
7.1.4 Purse-String Closure
We initially developed and applied this type of repair to terminal duct exci-
sion. So far, we have exclusively applied this repair to subareolar lesions.
Theoretically, however, it could be applied to different parts of the breast
as well. The NAC is elevated offthe breast tissue, exposing the tissue to
be resected. The thickness of the nipple areola flap directly depends on the

120
Principles and Techniques in Oncoplastic Breast Cancer Surgery
(a)
(b)
(c)
(d)
Figure 7.6.
(a–d) Purse-string repair.
depth of the tumor. Again, when operating around the NAC, the surgeon
has to be cognizant of the blood supply and innervation of that structure
(see Chapter 1). The incision around the nipple areola should not extend
beyond 50% of its circumference, and preferably less. If the diameter of the
nipple areola is restrictive, we recommend extending the incision laterally
or medially or to both sides for better exposure (Figure 7.6).
After elevation of the NAC, the resection is carried out as planned
[Figure 7.6(b)]. This type of repair lends itself to resections that are cir-
cular or conical. It is our experience that in patients with large or fatty
breasts, we may not need to extensively undermine the breast tissue offthe
pectoralis major muscle. It is, however, important to elevate the skin and
subcutaneous tissue offthe breast. This skin elevation should be limited to
the cutaneous part of the incision; further undermining the skin where the
NAC is attached may result in necrosis or denervation of that structure
[Figure 7.6(c)]. We recommend resecting some of the skin above the NAC
when a large resection of tissue under the NAC is required, as the NAC
may appear wrinkled following approximation of the breast tissue. (Refer
to Mastopexy Dome/Bat Wing Repair, Chapter 9.)

Repair of Breast Defects
121
The repair is carried out by applying one or more purse-string sutures
starting with the base of the defect [Figure 7.6(d)]. Case No. 7 shows the
result of the technique applied in a patient with ductal carcinoma in situ.
Case No. 7
Purse-string repair. A 44-year-old woman with ductal carcinoma in situ
in the center of the right breast. The patient underwent resection in the
form of a terminal duct excision. We used the purse-string technique to
repair the defect. The patient received postoperative radiation.
• Images 7.1–7.3 show the patient 4 years postoperatively.
Image 7.1
Image 7.2

122
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Image 7.3
7.1.5 Mobilization of Surrounding Subcutaneous Tissue
This type of repair is only possible when tumors are located around the
periphery of the breast, particularly in the outer hemisphere. The prereq-
uisite for this repair is the availability of contiguous tissue to be mobilized.
The patient must have an excess of fat in the subcutaneous tissue sur-
rounding the breast. The most common tissue we have used has been the
lateral axillary fat pad and the subcutaneous tissue below the inframam-
mary line. The resection is carried out routinely. The lateral axillary fat pad
must be elevated offthe serratus muscle and separated from the overlying
skin. The axillary fat pad is then advanced and sutured to the breast tis-
sue (Figure 7.7). The axillary fat pad may be directly advanced or rotated
into the defect. We tend to minimally raise the breast tissue to avoid any
lateral deviation of the NAC, and we mostly rely on the axillary fat pad to
fill the defect. This technique could be combined with a partial transverse
or radial repair of the glandular tissue. We strongly recommend elevating
the fat pad offthe serratus anterior muscle as the fat pad may retract in

Repair of Breast Defects
123
Figure 7.7.
Mobilization of surrounding tissue.
the postoperative period. Case No. 8 demonstrates the application of this
technique.
Case No. 8
This is a 68-year-old woman who had right breast cancer treated with
breast conservation. While on aromatase inhibitors, she presented with
a left invasive lobular carcinoma estrogen receptor positive and proges-
terone receptor positive tumor, involving a significant segment of the outer
quadrant between 2 o′clock and 4 o′clock. The patient insisted on breast
conservation. She had multiple medical problems and was not a candidate
for neoadjuvant chemotherapy.

124
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Image 8.1. The preoperative mammogram and the extent of resection, estimated pre-
operatively.
Image 8.2. The patient on the operating table with needle localization wires bracketing
the lesion. Note the extent of the axillary fat pad that could be used to repair the defect.

Repair of Breast Defects
125
Image 8.3. The patient mammogram after the needle localization, and the specimen
radiogram showing the extent of resection.
Image 8.4. On the operating table, we approximated the subcutaneous tissue without
repairing the defect. Note the resulting extensive depression and adherence of the skin
to the chest wall.

126
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Image 8.5. The patient after completion of the repair and approximation of the sub-
cutaneous tissue. It is obvious that the repair has filled the defect preventing the
depression of the skin and restored the contours of the breast. Also note the loss of the
lateral fat pad that has been mobilized to repair the defect.
Image 8.6. The patient in the postoperative period. The right breast shows the effect
of prior radiation. The left breast contours are maintained.

Repair of Breast Defects
127
Image 8.7. The patient in the postoperative period as in Image 8.6.
These techniques are simple easy to learn and apply. Regardless of the
technique you use, we recommend the following important steps:
• Orient the specimen to facilitate limited re-excision as needed, thus
avoiding re-excision of the totality of the cavity.
• Apply clips to the wall of the defect prior to initiating the repair.
• Document the steps used to repair the defect in the operative note. The
operative note will be a useful document when patient returns to the
operating room for re-excision of margins.
References
1. Bostwick J. (1983) Correction of Breast Asymmetries. Aesthetic and Recon-
structive Breast Surgery. Mosby Company, St. Louis, Toronto, London,
p. 252.

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Chapter 8
ONCOPLASTIC BREAST REDUCTION
Tara L. Huston,∗Christine H. Rohde,∗Mahmoud El-Tamer,†
and Jeffrey Ascherman∗
∗Division of Plastic Surgery,
New York-Presbyterian Hospital/Columbia University Medical Center,
New York, NY, USA
†Breast Service, Department of Surgery,
Memorial Sloan-Kettering Cancer Center,
New York, NY, USA
8.1 Introduction
Improved survival, coupled with enhanced patient expectations, created the
impetus for better aesthetic results in breast-conservation therapy (BCT).
This driving force has encouraged breast surgeons and plastic surgeons
to work together to design operations that are oncologically sound and
maximize the cosmetic outcome.1
Over the past 2 decades, there has been an increase in the number of
women with breast cancer who are treated with BCT. BCT is a combina-
tion of local tumor resection and breast radiation therapy, which allows
a woman to keep her breast. It has an equivalent disease-free survival
when compared to traditional mastectomy. This increase in BCT is a
result of increased screening and earlier mammography, and a correspond-
ing increase in small, early-stage breast cancers. Also, it is important to
note the increased use of neoadjuvant chemotherapy (NCT), which drasti-
cally decreases tumor size, thus permitting breast-conserving procedures.
Lastly, the desire of many women to preserve their breast for psychological
reasons, regardless of cosmetic outcome, has led to greater use of BCT.
It is well established that local control of breast cancer may affect
survival and that clear margins are warranted when breast preserva-
tion is undertaken. From the National Surgical Adjuvant Breast and
129