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

Oncoplastic Breast Reduction
131
surgery is indicated for patients who are able to reduce the volume of their
breasts in excess of 20% to 25%. It is also a useful tool for difficult tumor
locations, such as the inner quadrants, centrally, and along the inframam-
mary fold (IMF) where small resections without local tissue rearrangement
may be deforming.
It is estimated that up to 40% of women treated with BCT begin with a
breast size that could be categorized as macromastia.12 Even though there
is a seemingly ideal breast-to-tumor ratio in these women, this population
tends to suffer more complications. The cosmesis is often unsatisfactory as
irradiating a large, ptotic breast can lead to a heterogeneous dose distri-
bution. This is a result of repeated positioning over a prolonged course of
treatment.13 Breast size does affect cosmetic outcome, with larger-breasted
women faring worse. In addition, attempting surgical correction of irradi-
ated tissue to correct the cosmetic issue is fraught with complications. For
these women with macromastia, the combined oncoplastic approach has
the benefit of relieving symptoms, as well as treating the cancer.14
In summary, using the oncoplastic approach of reduction mammaplasty
can make it easier to obtain the desired oncologic and cosmetic outcomes.
It affords the surgeons a large incision, with possible access to the axilla,
thus possibly preventing a second incision. It prophylaxes against cosmetic
sequelae, such as breast asymmetry, and may even relieve symptoms of
macromastia in certain patients. Smaller breast size may also translate
to improved radiation therapy (RT) efficiency. Also, the reduction allows
tissue sampling of the contralateral breast and provides a theoretical risk
reduction through removal of excess breast parenchyma. Occult breast can-
cers have been reported in up to 4% of contralateral symmetrizing reduc-
tion specimens in patients undergoing breast reconstruction.15
It is important that the ablative surgeon understands the concepts of
breast aesthetics, volume, and symmetry, and be cognizant of when pre-
operative referral to a plastic surgeon might be beneficial. In turn, it is
critical that the reconstructive surgeon understands the tenets of oncologic
surgery and is able to devise an operative plan that does not violate them.
Communication between the ablative and reconstructive surgeon is vital.
8.3 Patient Selection and Preoperative Breast Evaluation
Patient selection depends on a number of factors, the most important of
which are a patient’s desire for a smaller breast and the cancer surgeon’s
concern about creating a cosmetic deformity while obtaining adequate spec-
imen size. The ideal candidate is a patient who has symptoms of macromas-
tia, such as chronic headaches, back pain, neck pain, shoulder grooving, or

132
Principles and Techniques in Oncoplastic Breast Cancer Surgery
intertriginous rashes, and who requires a large-volume resection, although
any patient with moderate-to-large–sized breasts can be considered. The
goal is to provide a survival rate comparable to standard BCT, a good
aesthetic outcome, and enhanced patient satisfaction.16 In plastic surgery
practices, women who have had breast reduction tend to express higher pat-
ient satisfaction as the reduction in breast volume and weight allows them
to wear new clothing and embark upon new activities hitherto impossible.
The use of reduction mammaplasty has been ongoing for almost
200 years. It is only recently that we have combined the procedure with
ablative breast surgery. Surgeons have performed reduction mammaplasty
since the 1840s, which then consisted of removal of excess breast
parenchyma and skin via the IMF.17 The classic goals of breast reduc-
tion are to improve symptomatology, decrease the volume of breast tissue
without impairing vascular and nerve supply to the nipple areola complex
(NAC), reposition the NAC to an anatomically correct position, create a
better breast shape, provide parenchymal support for a long-lasting result,
and discard excess skin and minimize scarring.18
After the patient makes the decision to undergo breast reconstruction
after lumpectomy, the surgical team must contemplate the time course.
Immediate reconstruction is psychologically and aesthetically preferable.
In some patients, however, delay may be prudent. Younger patients with
extensive ductal carcinoma in situ (DCIS) are not good candidates for a
1-stage approach as there is a high rate of positive margins. Reconstruction
in these women should be deferred until confirmation of negative margins.
This is one group of patients who should be counseled preoperatively about
a 2-stage procedure.16
There are 2 breasts involved in the decision-making process, and the
treatment plan must take this into account. It is agreed upon that in the
vast majority of cases, immediate breast reconstruction can be undertaken
on the breast that has just undergone a resection. The cases in which a
delay is preferable were just mentioned. Symmetry is crucial in obtaining
a good cosmetic outcome. Many surgeons will reduce or symmetrize the
contralateral breast at the first procedure in order to spare the patient a
second operation. However, it is impossible to know the final size of the
ipsilateral breast following cancer ablation; therefore, the size and shape
of the contralateral breast is an educated approximation. Fitoussi et al.
actually demonstrated a shift from synchronous reconstruction in the early
years to delayed contralateral symmetrizing reduction in the later years of
their 540-case study.19
Patient counseling is an integral part of the preoperative work-up. With
a traditional lumpectomy, positive margins on final pathology often war-
rant a re-excision of the resection cavity. After an oncoplastic reduction,

Oncoplastic Breast Reduction
133
the “cavity” out of which the specimen was removed no longer exists as it
did at resection. During the reduction mammaplasty procedure, its geom-
etry is altered significantly so that margins cannot be identified. As such,
if the margins are positive following an oncoplastic reduction, a total mas-
tectomy may be the necessary next step. Encouragingly, however, a larger
volume of breast tissue can be removed with the oncoplastic procedure,
thus making the theoretical risk of positive margins smaller. Additionally,
patients must understand that nipple complications from the ablation,
reduction, and subsequent radiation are possible. This may mean decreased
sensation, and partial or total thickness skin loss, as well as wound-healing
issues (see Case No. 2, Image 2.4).
8.4 History and Physical
A detailed history and physical are necessary. In the history, it is important
to elicit issues pertaining to macromastia, such as chronic headaches, back
pain, neck pain, shoulder grooving, or intertriginous rashes, as well as a
personal and family history of breast surgery, cancers, connective tissue
diseases, and radiation to the thorax. A history of smoking predisposes to
increased flap necrosis, and efforts must be taken to help the patient quit
immediately if she is currently smoking.
On examination, height and weight should be measured, and a body
mass index can then be calculated. There should be emphasis on breast
size, shape, prior scars, degree of ptosis, and position of the lesion. The
most commonly used system to classify breast ptosis includes 3 grades:
grade 1 is mild, with the nipple at the IMF; grade 2 is moderate, with the
nipple below the IMF, but with lower-pole tissue below the nipple; grade
3 is severe, with the nipple well below the IMF and no lower-pole tissue
below it. Pseudoptosis is actually inferior pole ptosis with the nipple at or
above the IMF, which is often seen in postpartum breast atrophy. Measure-
ments may be taken of the breast width, sternal notch-to-nipple distance,
nipple-to-inframammary–fold distance, and NAC width (see Chapter 2).
Asymmetries should be documented and pointed out to the patient. Pre-
operative photographs may also be taken at this time.
8.5 Types of Breast Reduction
A team approach is crucial for the success of excising a breast lesion in com-
bination with a breast reduction. The breast and plastic surgeon should
clearly communicate preoperatively to define the areas to be excised, thus

134
Principles and Techniques in Oncoplastic Breast Cancer Surgery
allowing the plastic surgeons to design their reduction techniques. A good
result requires a thorough knowledge of basic mammaplasty techniques.
The choice of incision and pedicle depend on a number of factors. The
most important determinant is the tumor location; however, one must also
consider the location of previous scars/needle biopsy sites, and whether
these need to be excised, as well as the need for access to the axilla. Exci-
sion of the skin overlying the tumor and its extent, although not always
needed, has to be taken into consideration and clearly defined preopera-
tively. Surgeon comfort with the various types of reduction mammaplasties
is a factor as well. When designing the operation, consideration must also
be given to the potential for radiation and how this may alter the eventual
size of the breast. Radiation can lead to chronic edema, as well as involu-
tion or shrinkage of the remaining breast tissue. The combined approach
of excising a tumor and reducing the breast is applicable to patients who
present without any prior surgical intervention or after an attempt at breast
conservation with positive margins.
8.6 Relevant Anatomy
The blood supply to the breast comes primarily from the internal tho-
racic artery through its anterior perforators, as well as the lateral thoracic
artery, thoracoacromial artery, and the lateral perforators of the inter-
costal arteries. The NAC receives contributions from all of those vessels
(see Chapter 1).
Nerve supply to the NAC arises from the anterior and lateral perforat-
ing branches of the third, fourth, and fifth intercostal nerves. The fourth
intercostal branch is thought to be the primary sensory contributor. In
order to maintain sensibility of the NAC, it is important to avoid violation
of the pectoralis fascia along the deep lateral resection margin. Interest-
ingly, some women have increased sensitivity postoperatively, possibly from
reduced traction on the nerve with a lighter postoperative breast. Medi-
ally, the nerve branches lie more superficially. Therefore, maintenance of
the dermoparenchymal relationship anteromedially, which is done with the
superomedial pedicle, may help to decrease the potential for injury to these
superficial nerves during pedicle dissection and rotation (see Chapter 1).
Breast dimensions and degrees of ptosis, recorded in the history and
physical, can also assist in making the decision regarding which type of
surgery to perform. In the 1950s Penn defined breast aesthetics by studying
150 healthy women, 20 of whom had “perfect” breasts. He found that
an equilateral triangle existed between the suprasternal notch and both
nipples whose limbs are approximately 21 cm in length. He also found this

Oncoplastic Breast Reduction
135
to be the distance from the mid-clavicular line to the nipple. In this study,
the average nipple-to-IMF distance was 6.9 cm.20 Although these are not
absolutes, as patients and their breasts come in all shapes and sizes, the
symmetry is a useful guide to keep in mind (see Chapter 2).
8.7 Technical Considerations
The first and key goal of this oncoplastic approach is to achieve the
most complete and appropriate resection of the cancer with histologically
negative margins. It has been well documented that a positive margin is
associated with significantly higher incidence of local recurrence.21,22
Knowledge of margin status is important prior to embarking on an
immediate reconstruction. Intraoperative assessments of the margins are
advisable when the breast surgeon is not confident about the extent of
resection. We recommend gross examination of the specimen, and the sur-
geon can also consider radiologic imaging. Specimen mammogram with
two 90-degree images is quite helpful for assessment of microcalcifications.
Currently, some surgeons have noticed a drop in their re-excision rate with
intraoperative ultrasound, particularly with solid masses.23,24
Histologic evaluation is also helpful in cases involving large tumors.
Frozen sections with touch preparation are one of the most accepted cur-
rent methods of intraoperative histologic assessment of margins. Newer
technologies are currently being evaluated, such as Spectroscopy or
the MarginProbe (Dune Medical Devices, Caesarea, Israel), which is a
recently developed device for real-time intraoperative margin assessment.25
Pleijhuis et al. have described the current modalities and future directions
in assessing surgical margins.26 It is well known that local recurrence is
proportional to the size of the tumor, as well as the positive or negative
margin status at the initial resection.27 Clear margins may be difficult to
confirm at the initial operation for women with infiltrating lobular cancer
or in multicentric or multifocal DCIS. The breast surgeon has to achieve
a histologically negative margin. The definition of a histologically negative
margin has been extensively debated in the literature. Chapter 5 in this
book has an extensive review of the literature and presents an evidence-
based recommendation. Each surgeon or institution has specific guidelines
as to what constitutes an appropriate margin, and we recommend they be
followed.
It has often been our practice, particularly following a major oncoplastic
approach, to mark the margins of resection with hemoclips. The clips will
be used by the radiation oncologist as a guide for RT, particularly for the
appropriate delivery of a boost dose.

136
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Once the preoperative evaluation is complete and the timing has been
selected, there are 2 major decisions to make when designing a breast
reduction. The first is the location and size of the incision, and the second
is the origin of the dermoglandular pedicle on which the nipple will rest.
8.8 Incision
There are a myriad of options for the incision; however, the 2 most com-
monly used are the Wise pattern or inverted “T”, and the vertical. The
inverted “T” pattern incision travels along the IMF and traverses centrally
up to the nipple — hence the name. It allows wide access to the breast
parenchyma and can be used with any pedicle, for a tumor in any location;
also, it permits skin excision in both the vertical and horizontal dimen-
sions for optimal breast shaping. Depending on the pedicle and the desire
to avoid wide undermining, a separate small incision may be needed in the
axilla for lymph node sampling or clearance. The Wise pattern, or inverted
“T”, is the most commonly used incision for oncoplastic breast reductions.
For a woman to be a candidate for an oncoplastic breast reduction, she
will most likely have both excess tissue and excess skin. The Wise pattern
is ideal for women who need skin and tissue excision in both the vertical
and the horizontal dimensions, leaving the surgeon the most opportunities
for breast reshaping (see Chapter 2).
The vertical scar mammaplasty was introduced by Lassus28 and modi-
fied by Lejour.29 This incision travels around the NAC and extends down
to the IMF (see Chapter 2). Although the access to the breast parenchyma
is good, the axilla is not easily reached. The vertical scar technique only
allows for breast skin reduction in the horizontal axis. The vertical size
reduction is achieved through a cinching closure of the skin. In the classic
Lejour breast reduction, the volume is also decreased with liposuction, but
it would be advisable to avoid this step in a cancer operation. This incision
is employed when the surgeon or the patient wishes to minimize the scar
as much as possible, while resecting a large volume of breast parenchyma.
Some surgeons believe that the long-term downside of this approach is the
tendency of the inferior pole of the newly reconstructed breast to bottom
out over time as the skin envelope stretches.
The periareolar approach, based on Benelli’s “round block” technique,
leaves an incision that is solely around the nipple and does not extend out
onto the breast (See Chapter 9, Figure 9.9).30 This provides good access to
the upper pole; however, it does not permit a great deal of skin excision.
It is useful for women with mild ptosis in whom a mastopexy might be
considered, but is not a good option when volume reduction is required.
In the majority of women who are candidates for an oncoplastic reduction

Oncoplastic Breast Reduction
137
mammaplasty, a large volume reduction is required; as a result, this is not
a commonly utilized option.
The lateral mammaplasty is similar to the vertical; however, the scar
runs from the nipple laterally out toward the anterior axillary line (see
Chapter 9, Figures 9.7–9.11). This incision is suitable for lateral tumors.
Bearing in mind that the majority of breast tumors are located laterally,
this is an important approach. A benefit to this technique is the avoidance
of thin, large surface-area dermal flaps. It creates thick flaps that are more
tolerant to radiation. This incision may be extended superiorly to gain
access to the axilla. The medial mammaplasty is the reverse of the lateral
mammaplasty, with the incision heading toward the sternum, and is most
useful for medial tumors (see Chapter 9: Case 2 and Figure 9.12).31
The omegaplasty, also referred to as the bat-wing excision, is a trans-
verse scar above and alongside the nipple which is not aesthetically ideal;
however, it provides good access to superomedially located tumors.32 This
is a challenging area because there is little breast volume to begin with in
repose, and even less after ablative resection. No undermining is required
with this incision, which is a plus for radiation, but it does little to decrease
breast volume or address ptosis. If too much skin and parenchyma are
resected with this incision superior to the nipple, it may result in pseudop-
tosis (see Chapter 9: Case 1 and Figure 9.4).
The IMF plasty, similar to the very first breast reductions performed in
the 19th Century, places an incision along the IMF. There is no vertical ex-
tension. This is good for a narrow breast that only requires reduction in the
vertical dimension. Oftentimes, the periareolar scar and nipple dissection
can be avoided with this technique. This method will decrease the nipple-
to-inframammary–fold distance. If it is already short, then superior trans-
position of the nipple and creation of a periareolar scar may be necessary.
8.9 Pedicle
The other decision that needs to be made is pedicle position. The pedicle
is the dermoglandular tissue on which the vascular and nervous supply
to the nipple is carried. The most commonly used pedicles are inferior,
superior, and medial. The superolateral pedicle is less commonly used, but
is an excellent choice for lower, inner tumors.33 The other option, rarely
used in cosmetic surgery but needed for reconstruction after extirpation of
medial tumors, is the lateral pedicle. All have their cosmetic and sensory
advantages and disadvantages. The decision of which one to use for non-
oncologic breast surgery is often based on surgeon preference. However,
in oncoplastic breast-reduction surgery, the pedicle is, by necessity, chosen
based on what remains following the ablation of the tumor. For example,
a lower-pole tumor will clear out the glandular tissue in the lower half of

138
Principles and Techniques in Oncoplastic Breast Cancer Surgery
the breast so the reconstructive surgeon will be left to choose between the
various superior pedicles.
The superior pedicle is solid, reliable, and may better preserve nipple
sensation. Innervation to the nipple is superficial and descends from the
clavicular area, thus preserving sensation. This pedicle, however, is limited
by difficulty in moving the nipple long distances, especially in patients with
significant breast hypertrophy. This is a challenging pedicle to undertake
with a large reduction, as molding the breast into an aesthetically pleas-
ing shape may be difficult with only superior fullness. However, this is a
good pedicle to use for lower quadrant tumors, especially in moderate-sized
breasts.
The medial or superomedial pedicle is increasingly popular in aesthetic
breast surgery. It is shorter than the other pedicles and requires rotation,
not folding, for its inset. Sensory innervation comes from the anterior rami
of the intercostal nerves. Due to its orientation and rotation, the medial
pedicle is excellent for retaining breast shape. This pedicle can be used for a
tumor in the lower quadrants, or laterally on the breast. This is an increas-
ingly popular choice in non-oncologic breast reductions in that regard, as
well as in regards to its excellent maintenance of a natural breast shape
(see Case No. 1).
Case No. 1
A 58-year-old patient underwent a left-breast wide lumpectomy and sen-
tinel node biopsy with positive inferior margins. The patient had always
wanted a breast reduction. We recommended re-excision as part of breast
reduction.
Image 1.1. Preoperative view.

Oncoplastic Breast Reduction
139
Image 1.2. Preoperative view.
Image 1.3. A superio-medial pedicle was planned as the resection would include the
majority of the lower outer quadrant. The skin of the pedicle was de-epithelialized.
The rest of the skin seen within the Wise pattern will be excised.

140
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Image 1.4. The resected tissue included the skin and breast tissue within the Wise
pattern.
Image 1.5. The specimen of breast skin and resected tissue.

Oncoplastic Breast Reduction
141
Image 1.6. Metallic clips are applied to mark the margins of resection. They allow the
radiation oncologist to boost the lumpectomy bed.
Image 1.7. The final defect, with the nipple based on a superio-medial pedicle for blood
supply.

142
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Image 1.8. The NAC pedicle prior to rotation into its new position.
Image 1.9. The NAC rotated into its new position. Notice the 2 vertical limbs of the
Wise pattern being approximated.

Oncoplastic Breast Reduction
143
Image 1.10. The patient as seen 2 weeks after surgery. The pathology showed negative
margins of resection.
Image 1.11. Postoperative view.

144
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Image 1.12. The patient seen 1 year postoperatively. She had completed all her treat-
ment, including RT.
Image 1.13. One year after surgery.

Oncoplastic Breast Reduction
145
The inferior pedicle technique is very common and reliable. A concern
with the inferior pedicle technique, however, is that it lacks parenchymal
support and that eventually the breast may sag or “bottom out”, which
means that there will be excess skin and tissue between the nipple and
IMF. While shortening the nipple-IMF distance can help counteract this
tendency, it must be balanced against excessively tight closure and the
risk of wound-healing complications. This is the pedicle of choice for larger
breasts with longer sternal notch-to-nipple distances. The inferior pedicle
is a good choice for tumors located in the upper quadrants of the breast
(see Case No. 2 for inferior pedicle).
Case No. 2
A 42-year-old patient presented to the plastic surgeons for breast reduc-
tion. The surgeon palpated 2 masses in the right breast and 1 in the left.
We performed a needle biopsy of all the palpable lesions and identified a
5 cm malignant Cystosarcoma Phyllodes in the upper outer quadrant of
the right breast. The 2 other lesions were benign fibroadenomas measur-
ing 3.5 cm each, the first located in the upper inner quadrant of the right
breast, and the second in the upper outer quadrant of the left breast.
Image 2.1. The patient as seen preoperatively with marking delineating the location
of the masses. The dark green mass is the malignant Phyllodes tumor. The light blue
masses are the fibroadenomas.

146
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Image 2.2. The lateral view of the right breast in the preoperative period. The dark
green mass is the malignant Phyllodes tumor.
Image 2.3. The lateral view of the left breast in the preoperative period. The light blue
mass is one of the fibroadenomas.

Oncoplastic Breast Reduction
147
Image 2.4. The patient seen 8 weeks postoperatively. Notice the partial epidermolysis
of the lateral aspect of the right nipple and NAC necrosis. To avoid such complications,
some surgeons prefer to use a free nipple-areola graft in patients with similarly large
and pendulous breasts. We elected to keep the NAC attached to the inferior pedicle.
Image 2.5. Lateral view of the right breast in the eighth postoperative week. Again,
note the parital epidermolysis of the right areola.

148
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Image 2.6. Lateral view of the left breast in the eighth postoperative week.
Image 2.7. The patient 2 years after surgery. Notice the complete healing of the right
areola. The patient has been doing well 6 years after surgery without any recurrence.

Oncoplastic Breast Reduction
149
Image 2.8. Lateral view of the right breast showing very good oncologic and cosmetic
results 2 years after her procedure.
Image 2.9. Lateral view of the left breast 2 years after surgery.
The lateral pedicle may be necessary for medially located tumors which
extend into the upper or lower quadrants. The main problem with this pedi-
cle and the reason it is not often used in cosmetic surgery is the resultant
lateral fullness of the breast if the pedicle is too thick. This is normally only

150
Principles and Techniques in Oncoplastic Breast Cancer Surgery
a technique for women with small-to-moderate–sized breasts who require
a mastopexy or a minor reduction.
In women with gigantomastia, attempts to preserve the blood supply
and nerves to the nipple during reduction mammaplasty are limited by the
length of the pedicle needed to carry the NAC into its new position and
by the ability to adequately reduce the breast with a large pedicle. These
patients are candidates for free-nipple grafting.
Losken et al. demonstrated the ability to use either superomedial or
inferior pedicles for tumors in almost any position. Because the most
common location for breast cancers is the upper outer quadrant, the
most commonly used pedicle was the superomedial.16 Munhoz et al.
recommended superior pedicles in almost all tumors except for superior
pole tumors. In those patients, he recommended an inferior pedicle.34 Most
recently, Kronowitz et al. from the University of Texas MD Anderson
Cancer Center divided the breast into 7 zones composed of the 4 quad-
rants, the retroareolar tissue, and the intersection of the upper and lower
quadrants on each side. They proposed a guide of pedicles and modifica-
tions to achieve local tissue rearrangement by transposing the NAC, as well
as filling the tissue defect.35
8.10 Radiation Therapy
The second phase of BCT consists of breast irradiation. RT is generally
initiated 4 to 6 weeks after the reduction procedure. It consists of whole-
breast irradiation, as well as a boost to the tumor bed. The purpose is to
clear any remaining microscopic deposit of cells that surgery may have left
behind. Aesthetically speaking, an added benefit is that radiation tends to
improve the appearance of scars on the breast.36 In anticipation of radi-
ation, at the time of surgery, attention is directed to avoiding extensive
skin-gland dissection and excessively long parenchymal pedicles that may
be compromised at this time and predisposed to steatonecrosis.
A concern with oncoplastic breast reduction is the altered topography
of the breast parenchyma and not knowing where the true margins of the
resection cavity lie. As previously stated, we recommend that the breast
surgeons place titanium clips at the edges of the resection to help iden-
tify the area for planning of RT and future screening purposes. However,
inherent in the breast reduction procedure is complete rearrangement of the
local tissues within the breast. With the changed landscape of the breast,
the margins of the ablation cavity are shifted and patterns of recurrence
altered. For this reason, a mastectomy is most likely indicated if positive
margins are identified on final pathology following an oncoplastic breast

Oncoplastic Breast Reduction
151
reduction. In addition, the added boost to the tumor bed, which is the
standard treatment, may be compromised as the “cavity”, even if marked
with clips, no longer exists in the 3-dimensional space it once did.
To correct size asymmetries following RT, it is easier to reduce the
contralateral non-irradiated breast than it is to manipulate the radiated
breast. It is for the reason of radiation-induced fibrosis and involution that
the breast about to undergo radiation is sometimes left slightly larger at
the initial surgery. However, with the combination of involution and edema,
it is very difficult to estimate the final size of the reconstructed breast. As
mentioned earlier, it is for this reason that some surgeons prefer to perform
the contralateral symmetrizing reduction in a delayed fashion.
The use of partial-breast irradiation in these cases is limited to intra-
operative radiation, brachytherapy, or external beam. The use of balloon
radiation is not feasible, as the procedure necessitates closure of the defect
and avoidance of seroma. Furthermore, due to the extent of resection with
such procedures, the current available balloon size may not allow adequate
conformity to the area of resection.
8.11 Complications
The complication rate in the literature for oncoplastic bilateral breast
reduction ranges from 17% to 24%.16,34,35 This is significant and a reason
why detailed preoperative counseling is so important. The most commonly
seen complications are skin necrosis, infection, partial or complete NAC
necrosis (Case No. 2, Image 2.4), and suture-line dehiscence. Similar to
patients without cancer, those who are obese and regular smokers at the
time of surgery suffer from higher complication rates.
It is important to note that most morbidities do not cause a delay
in adjuvant treatment. Chemotherapy may not be deterred with a minor
complication. However, any complication which does interfere with wound
healing may delay the beginning of radiation.
8.12 Long-Term Oncologic Results
Up to 4.5 years follow-up, local recurrence varies from 0.0–1.8% per year,
while cosmetic dissatisfaction rates vary from 0.0–18.% overall. In the
largest study to date, Fitoussi et al. followed 540 consecutive patients who
underwent primary oncoplastic breast surgery for cancer. All women had
high tumor-to-breast–volume ratios and locations which precluded a good
aesthetic result with only tumor excision. Techniques included all types
of reductions. The median age was 52 years, and median follow-up was

152
Principles and Techniques in Oncoplastic Breast Cancer Surgery
49 months. Average tumor size was 2.9 cm, and most patients started with
a B or C brassiere cup size. The mean resection weight was 187 g. Close or
involved margins occurred in 18.9%, with mastectomy being necessary in
9.4%. A satisfactory aesthetic outcome at 5 years was obtained in 90.3%.
Five-year overall and distant disease-free survival rates were 92.9% and
87.9%, respectively, with local recurrence in 6.8%.19 These results are com-
parable to standard BCT, demonstrating the equivalent oncologic safety
of the oncoplastic approach.
Caruso et al. identified 63 breast cancers in 61 patients, with a median
age of 45 years, which were suitable for conservation. All but 1 patient had
tumors smaller than 5 cm. All patients were treated with bilateral breast
reductions. Tumors in the inferior pole of the breast were treated with the
superior pedicle technique. Lesions in the upper pole, inferolateral, or infer-
omedial were removed with an inferior pedicle reduction. Breasts that were
of small and medium size required a periareolar approach, regardless of
cancer location. Negative margin was defined as 2 mm between tumor and
edge of specimen. All patients underwent whole-breast irradiation with a
boost to the tumor bed postoperatively. At a mean follow-up of 68 months,
56 patients were alive. One patient recurred locally, but remained alive and
free of disease. She was initially diagnosed with an invasive lobular cancer,
which can prove challenging on pathologic analysis. Five developed dis-
tant recurrences, of whom only 1 survived.38 These data demonstrate the
safety of the oncoplastic approach, but highlight the challenge of dealing
with invasive lobular cancer, which has more insidious margins than its
ductal counterpart.
Rietjens et al., in a series of 148 cases with a median follow-up of 74
months, reported a 3% rate of local recurrence.38 The authors did not
observe any local recurrence for lesions below 2 cm. Kayar et al. reported a
series of 116 patients in which the mean specimen weight was 659 g per side.
The 10-year overall survival rate was 100% for stage I, 89.1% for stage II,
and 53.8% for stage III.39
8.13 Breast Cancer Surveillance
Complex glandular reshaping could become a challenge for less-experienced
breast radiotherapists and for breast radiologists dealing with follow-
up mammograms. In 2009, Losken et al. evaluated long-term postoper-
ative breast cancer surveillance in women who had undergone partial
breast reconstruction. Seventeen patients with an average follow-up of
6.3 years were retrospectively reviewed and compared to 17 women who
had undergone BCT alone. Mammographic findings, such as architectural

Oncoplastic Breast Reduction
153
distortion, cysts, and calcifications were similar between the 2 groups. No
significant difference existed in breast density. The women with oncoplastic
reductions had longer times to mammographic stabilization (21.2 months
versus 25.6 months); however, this was not clinically significant. An
expected trend toward a greater number of postoperative mammograms
and ultrasounds was found in the study group. In addition, the rate of
tissue sampling in the study group was significantly higher (53%) versus
that of the control group (18%).40
The ability to screen for cancer recurrence does not seem to be affected
by oncoplastic breast reduction. Scar tissue may appear suspicious on
physical exam, mammogram, ultrasound, or MRI. It can be evaluated with
fine needle aspiration or, preferably, core needle biopsy. When the onco-
logic surgeon is clinically uncomfortable with a specific area in the breast,
even after extensive imaging and tissue sampling, we do recommend an
excisional biopsy for confirmation. Patients may present with fat necrosis
that may be suspicious for tumor recurrence. Fat necrosis usually presents
early postoperatively, and tends to slowly resolve with time. Resorption of
fat necrosis is a slow process and may not be complete. Adequate clini-
cal follow-up by the same oncologic surgeon is important. Mammographic
findings after oncoplastic surgery include scarring and fibrosis in 50% of
patients, fluid accumulations in 40% of patients, and dystrophic calcifi-
cations in 10% of patients.41 After breast reduction, it is common to see
epidermal inclusion cysts or areas of fat necrosis. These can reliably be diag-
nosed with fine needle aspiration biopsy42 or core needle biopsies. Losken
et al. noted that although cancer screening was not compromised, 26% of
the patients in his study required some type of postoperative tissue sam-
pling; this number is higher than what is seen in traditional BCT.
8.14 Cosmetic and Functional Outcomes
An objective and comparable method for the measurement of cosmetic
outcome has been lacking. With the development of the new BREAST-Q,
which quantifies patient satisfaction and health-related quality of life expe-
rienced by women undergoing breast reconstruction, this may change. But
for now, generally speaking, the published literature and our personal expe-
riences demonstrate uniformly satisfied patients. Chang et al. evaluated the
degree of patient satisfaction with cosmetic form and function via a survey
of 37 patients. Twenty of the 37 responded, with 70% rating the cosmetic
outcome as excellent. All responders expressed a high degree of satisfaction
with cosmetic and functional results, and stated that they would choose
this technique if they had to undergo cancer surgery again.43 Goffman et al.

154
Principles and Techniques in Oncoplastic Breast Cancer Surgery
published a study of 55 patients evaluated by a panel, including a surgical
oncologist, an oncology nurse, a radiation oncologist, and a patient, with
72% of the evaluations reporting “excellent” and “very good” results.44
Losken et al. noted that 95% of women defined their aesthetic result as
satisfactory at their 6-month follow-up exams.16
8.15 Future Directions
Breast surgeons are becoming increasingly interested in performing the
reconstructive portion of the operation, as well as the ablative portion.
There are numerous reasons for this shift. In some places in the United
States, there may be a potential lack of willing and available reconstructive
plastic surgeons. Coordination of the combined surgeon approach can also
pose scheduling difficulties. Breast surgeons are then motivated to either
perform both components of the surgery, or to send the patient to a large
referral center for the combined procedure.45
Management of the patient with breast cancer is changing. Even though
breast cancer has not been eradicated through research, those who treat
breast cancer patients are constantly striving for less-invasive and more aes-
thetically pleasing ways to help patients manage this disease and live with
the aftereffects of their treatment. As physicians treating breast cancer, we
have come a long way since the time of the Halsted radical mastectomy,
but there is still much progress to be made. As plastic surgeons in the
multidisciplinary breast cancer team, our expertise places us in a prime
spot to be a part of that progress and to maintain an active involvement
in the future progression of breast cancer treatment.
References
1. Canady JW, D’Amico RA, McGuire MF. (2009) Discussion. Oncoplastic
breast surgery: Past, present, and future directions in the United States.
Plast Reconstr Surg 124(3):973–974.
2. Fisher B, Anderson S, Bryant J, et al. (2002) Twenty-year follow-up of a
randomized trial comparing total mastectomy, lumpectomy, and lumpec-
tomy plus irradiation for the treatment of invasive breast cancer. N Engl
J Med 347(16):1233–1241.
3. Clough KB, Cuminet J, Fitoussi A, et al. (1998) Cosmetic sequelae after
conservative treatment for breast cancer: Classification and results of surgical
correction. Ann Plast Surg 41(5):471–481.
4. D’Aniello C, Grimaldi L, Barbato A, et al. (1999) Cosmetic results in 242
patients treated by conservative surgery for breast cancer. Scand J Plast
Reconstr Surg Hand Surg 33(4):419–422.

Oncoplastic Breast Reduction
155
5. Petit JY, Rietjens M, Garusi C, et al. (1998) Integration of plastic surgery in
the course of breast-conserving surgery for cancer to improve cosmetic results
and radicality of tumor excision. Recent Results Cancer Res 152:202–211.
6. Clough KB, Soussaline M, Campana F, Salmon RJ. (1990) Mammoplasty
combined with irradiation: Conservative treatment of breast cancer localized
in the lower quadrant. Ann Chir Plast Aesthet 35(2):117–122.
7. Audretsch W, Rezai M, Kolotas C. (1998) Tumor-specific immediate recon-
struction in breast cancer patients. Perspect Plast Surg 11:71–100.
8. Munhoz AM, Montag E, Arruda E, et al. (2008) Assessment of immediate
conservative breast surgery reconstruction: A classification system of defects
revisited and an algorithm for selecting the appropriate technique. Plast
Reconstr Surg 121(3):716–727.
9. Kaur N, Petit JY, Rietjens M, et al. (2005) Comparative study of surgical
margins in oncoplastic surgery and quadrantectomy in breast cancer. Ann
Surg Oncol 12(7):539–545.
10. Cochrane RA, Valasiadou P, Wilson AR, et al. (2003) Cosmesis and satisfac-
tion after breast-conserving surgery correlates with the percentage of breast
volume excised. Br J Surg 90(12):1505–1509.
11. Clough KB. (2008) Keynote speech: Oncoplastic surgery. Presented at the
RACS/CSHK Conjoint Annual Scientific Congress, Hong Kong, May.
12. Dundas KL, Atyeo J, Cox J. (2007) What is a large breast? Measuring and
categorizing breast size for tangential breast radiation therapy. Australas
Radiol 51(6):589–593.
13. Taylor ME, Perez CA, Halverson KJ, et al. (1995) Factors influencing cos-
metic results after conservation therapy for breast cancer. Int J Radiat Oncol
Biol Phys 31(4):753–764.
14. Hernanz F, Regano S, Vega A, Gomez Fleitas M. (2009) Reduction mamma-
plasty: An advantageous option for breast conserving surgery in large-
breasted patients. Surg Oncol 19(4):e95–e102.
15. Rietjens M, Petit JY, Contesso G. (1997) The role of reduction mammaplasty
in oncology. Eur J Plast Surg 20(5):246–249.
16. Losken A, Styblo TM, Carlson GW, et al. (2007) Management algorithm and
outcome evaluation of partial mastectomy defects treated using reduction or
mastopexy techniques. Ann Plast Surg 59(3):235–242.
17. Dieffenbach JF. (1848) Die Operative Chirurgie, Vol 2. Brockhaus, Leipzig.
18. Adams WP. (2002) Reduction mammaplasty and mastopexy. Select Read
Plast Surg 9(29):5.
19. Fitoussi AD, Berry MG, Fama F, et al. (2010) Oncoplastic breast surgery for
cancer: Analysis of 540 consecutive cases [outcomes article]. Plast Reconstr
Surg 125(2):454–462.
20. Penn J. (1955) Breast reduction. Br J Plast Surg 7(4):357–371.
21. 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.
22. Singletary SE. (2002) Surgical margins in patients with early-stage breast
cancer treated with breast conservation therapy. Am J Surg 184(5):383–393.

156
Principles and Techniques in Oncoplastic Breast Cancer Surgery
23. Haid A, Knauer M, Dunzinger S, et al. (2007) Intra-operative sonography:
A valuable aid during breast-conserving surgery for occult breast cancer.
Ann Surg Oncol 14(11):3090–3101.
24. Rahusen FD, Bremers AJ, Fabry HF, et al. (2002) Ultrasound-guided
lumpectomy of nonpalpable breast cancer versus wire-guided resection:
A randomized clinical trial. Ann Surg Oncol 9(10):994–998.
25. Pappo I, Spector R, Schindel A, et al. (2010) Diagnostic performance of
a novel device for real-time margin assessment in lumpectomy specimens.
J Surg Res 160(2):277–281.
26. Pleijhuis RG, Graafland M, de Vries J, et al. (2009) Obtaining adequate
surgical margins in breast-conserving therapy for patients with early-stage
breast cancer: Current modalities and future directions. Ann Surg Oncol
16(10):2717–2730.
27. 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.
28. Lassus C. (1987) Breast reduction: Evolution of a technique – A single ver-
tical scar. Aesthet Plast Surg 11(2):107–112.
29. Lejour M. (1994) Vertical mammaplasty and liposuction of the breast. Plast
Reconstr Surg 94(1):100–114.
30. Benelli L. (1990) A new periareolar mammaplasty: The “round block” tech-
nique. Aesthet Plast Surg 14(2):93–100.
31. Berry MG, Ballester M, Fitoussi A, et al. (2008) Lateral mammaplasty for
oncoplastic breast surgery. Eur J Surg Oncol 34:1156.
32. Anderson BO, Masetti R, Silverstein MJ. (2005) Oncoplastic approaches to
partial mastectomy: An overview of volume-displacement techniques. Lancet
Oncol 6(3):145–157.
33. Strauch B, Elkowitz M, Baum T, Herman C. (2005) Superolateral pedicle
for breast surgery: An operation for all reasons. Plast Reconstr Surg
115(5):1269–1277; discussion 78–79.
34. Munhoz AM, Montag E, Arruda EG, et al. (2006) Critical analysis
of reduction mammaplasty techniques in combination with conservative
breast surgery for early breast cancer treatment. Plast Reconstr Surg
117(4):1091–1103; discussion 104–107.
35. Kronowitz SJ, Hunt KK, Kuerer HM, et al. (2007) Practical guidelines
for repair of partial mastectomy defects using the breast reduction tech-
nique in patients undergoing breast conservation therapy. Plast Reconstr
Surg 120(7):1755–1768.
36. Clough KB, Nos C, Salmon RJ, et al. (1995) Conservative treatment of
breast cancers by mammaplasty and irradiation: A new approach to lower
quadrant tumors. Plast Reconstr Surg 96(2):363–370.
37. Caruso F, Catanuto G, De Meo L, et al. (2008) Outcomes of bilateral mam-
moplasty for early stage breast cancer. Eur J Surg Oncol 34(10):1143–1147.
38. Rietjens M, Urban CA, Rey PC, et al. (2007) Long-term oncological
results of breast conservative treatment with oncoplastic surgery. Breast
16(4):387–395.

Oncoplastic Breast Reduction
157
39. Kayar R, Cobanoglu M, Gungor O, et al. (2006) The value of breast reduction
operations in breast conservation surgery; late results of 116 patients with
breast cancer. Meme Sagligi Dergisi 2:131–138.
40. Losken A, Schaefer TG, Newell M, Styblo TM. (2009) The impact of partial
breast reconstruction using reduction techniques on postoperative cancer
surveillance. Plast Reconstr Surg 124(1):9–17.
41. Mendelsohn AM, Bove EL, Lupinetti FM, et al. (1994) Central pulmonary
artery growth patterns after the bidirectional Glenn procedure. J Thorac
Cardiovasc Surg 107(5):1284–1290.
42. Fajardo LL, Bessen SC. (1993) Epidermal inclusion cyst after reduction
mammoplasty. Radiology 186(1):103–106.
43. Chang E, Johnson N, Webber B, et al. (2004) Bilateral reduction mammo-
plasty in combination with lumpectomy for treatment of breast cancer in
patients with macromastia. Am J Surg 187(5):647–650; discussion 50–51.
44. Goffman TE, Schneider H, Hay K, et al. (2005) Cosmesis with bilat-
eral mammoreduction for conservative breast cancer treatment. Breast J
11(3):195–198.
45. Losken A, Nahabedian MY. (2009) Oncoplastic breast surgery: Past,
present, and future directions in the United States. Plast Reconstr Surg
124(3):969–972.

This page intentionally left blank
This page intentionally left blank

Chapter 9
MASTOPEXY
Mahmoud El-Tamer
Breast Service, Department of Surgery,
Memorial Sloan-Kettering Cancer Center,
New York, NY 10065, USA
9.1 Introduction
In patients with a ptotic breast, one can combine a mastopexy (breast
lift) to the resection of the tumor. In such procedures, the breast tissue
resection is limited to the oncologic procedure only, while the skin incision
has a dual purpose:
1. Exposure for resection of the tumor.
2. Resection of the redundant skin in order to tighten the envelope of the
breast.
These procedures require mobilization of the nipple areola complex in an
upward fashion. We recommend reviewing the text of Chapter 2 for nipple
line guidance. These procedures can be extremely gratifying to the patient
provided the nipple areola complex remains along the nipple line. Any
misplacement of the nipple areola complex, however, will result in a poor
cosmetic result that may be quite challenging to repair, particularly after
radiation therapy.
In this chapter, we will describe 2 different mastopexy techniques, and
variations of those techniques, that allow the oncoplastic surgeon to achieve
those goals.
159

160
Principles and Techniques in Oncoplastic Breast Cancer Surgery
9.2 Dome Mastopexy
The dome mastopexy is a very versatile and easy procedure to learn. It
allows easy access to central and upper hemisphere tumors. The basis of
this procedure is to resect a semicircular ellipse of skin above the areola
(Figure 9.1). The lower aspect of the ellipse of the skin incision to be
excised extends from the 3 o′clock position to the 9 o′clock position at the
upper edge of the areola. The width of the ellipse will dictate the extent
of elevation of the nipple areola complex. We have avoided large resection
of the skin above the nipple areola complex and limited the width of the
ellipse to 2.5–3.0cm. Significant elevation of the nipple areola complex
without adjustment of the distance between the lower edge of the areola and
the inframammary line may result in malpositioning of the nipple areola
complex. In patients with significant ptosis of the breast that necessitates
a larger ellipse or dome, we recommend using a different type of mastopexy
technique.
Dome mastopexy procedures are ideal for lesions in the 12 o′clock axis
(Figure 9.2) or for lesions underlying the nipple areola complex (Case 1).
The skin resection may be used for the purpose of exposure and is resected
separately. Alternatively, the skin may be resected en bloc with the tumor
in one specimen. The lumpectomy does not necessarily need to follow the
shape of the overlying skin.
Figure 9.1.
Dome incision.

Mastopexy
161
Figure 9.2.
Tumors and the ideal location for a dome incision.
Case 1
A 48-year-old woman who presented with 2 breast lesions in the
12 o′clock and subarolar area; both lesions were proven malignant by
needle biopsy. The patient was interested in breast conservation. She
had a cup size A/B breast with minimal ptosis. The patient wanted to
preseve her nipple areola complex. The resection entailed removal of the
breast tissue under the nipple arola complex and at the 12 o′clock axis.
Repair of the defect after such a large resection resulted in redundancy
of the skin, hence the need for partial removal of the overlying skin to be
planned in the form of a dome with lateral extension. The width of the
dome was minimized to avoid significant elevation of the nipple arola as
the patient had minimal ptosis. Following the first resection, the patient
had one positive margin that required re-excision.
1. The patient on the operating room table with a wire localizing each
tumor. Note the limited width of the dome.
2. The defect following approximation of the deep breast tissue.
3. Skin closure after completion of the repair. Of note, following the
first resection, the patient had one positive margin that required
re-excision.
4,5. The patient after surgery.

162
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Image 1.1. The patient on the operating room table with a wire localizing each tumor.
Note the limited width of the dome.
Image 1.2. The defect following approximation of the deep breast tissue.

Mastopexy
163
Image 1.3. Skin closure after completion of the repair. Of note, following the first
resection, the patient had one positive margin that required re-excision.
Image 1.4. Patient after surgery.

164
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Image 1.5. Patient after surgery.
One of the limiting factors of such an approach is the diameter of the
areola. Access to the breast tissue may be limited in patients with small
areolas. Due to the nature of blood supply to the nipple areola complex,
the maximum length of the ellipse in the dome procedure is limited to
50% of the circumference of the areola; that is equal to the radius of the
areola times π. With a nipple areola complex equal to 2 cm in diameter,
the length of the ellipse would be 1 × π = 3.14 cm. Lateral and/or medial
extension may be necessary for patients with small areolas (Figure 9.3).
Figure 9.3.
Batwing incisions.

Mastopexy
165
Figure 9.4.
Dome with extensions. (a) Draw a semicircle around the upper edge of the
areola extending from 3 o′clock to 9 o′clock. (b) Draw exactly the same semicircle at
a distance equal to the desired elevation of the nipple. (c) Draw equidistant lines from
the edges of the semi-circles. The lengths of these lateral/medial extensions depend on
the extent of exposure desired. The wider the exposure, the longer the lines.

166
Principles and Techniques in Oncoplastic Breast Cancer Surgery
The lateral/medial extensions are of a limited distance and serve mainly to
enhance exposure. These extensions are in the form of an extra triangle of
skin to be excised medially and laterally. Bilateral triangular extensions to
the dome have been popularized as “batwings” by Dr. Melvin Silverstein1
or as the “Omega technique” by the Institut Curie group.2,3
The design of a dome with medial and lateral extensions is demon-
strated in Figures 9.4a–c. Please refer to Case 1 for a clinical example of a
dome mastopexy with a central tumor. Figures 9.5 and 9.6 demonstrate the
batwing defect and repair for a subareolar tumor. With the dome incision,
it is obvious that the upper edge of the skin incision is longer than the
lower or peri-areolar edge.
Figure 9.5.
“Batwing” or “dome” defect. The width of the dome in this drawing was
set at 1 cm. The width is dependent on the desired nipple areola complex elevation.
Figure 9.6.
Batwing closure.

Mastopexy
167
Figure 9.7.
(a) Combining dome mastopexy and radial resection. The main purpose of
this radial extension is exposure for a laterally located tumor.
Figure 9.7.
(b) Dome mastopexy with extension to excise an ellipse of skin overlying
the tumor. The skin of the dome may be only de-epithelialized as in Case No. 2, Image
2.4. Again, the width of the dome depends on the extent of nipple areola complex
elevation desired.

168
Principles and Techniques in Oncoplastic Breast Cancer Surgery
The “dome” technique may be combined with a radial resection. The
combination of these 2 techniques allows elevation of the nipple areola com-
plex with resection of a peripheral tumor Figure 9.7(a). The radial resection
may be designed to include an en bloc excision of the tumor with the overly-
ing skin when indicated as in Figure 9.7(b) and in Case No. 2, Images 2.2
and 2.3. With this combination, we do not recommend full resection of
the skin and breast tissue of the dome. We feel that simply removing the
epithelial layer of the dome or its skin will be sufficient for achieving the
nipple areola elevation while maintaining its neurovascular supply (Case 2,
Image 2.4). The dome with unilateral radial extension tumor was popular-
ized as “hemi-batwing” By Dr. Silverstein4 and described in detail by the
Institute Curie group.5
Case 2
A 54-year-old woman underwent a large resection of a right breast tumor
located in the 3 o′clock axis with positive superior and medial margins.
The resection resulted in a deformity of the breast. The plan was to re-
excise the positive margins and perform a mastopexy in the same setting.
Image 2.1. The patient preoperatively with significant loss of volume in the medial
aspect of the right breast associated with deviation of the nipple medially.

Mastopexy
169
Image 2.2. The nipple line has been marked in the erect position with a preliminary
plan of resection and mastopexy.
Image 2.3. The patient on the operating table.

170
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Image 2.4. Following margin resection, the patient was positioned at a 75-degree
back-up position; the mastopexy was replanned by stapling the edge of the areola
to its new position. It was evident that the extent of skin resection needed to be
modified. Note the resection of the skin and margins was performed en bloc down to
the fascia, whereas the skin over the dome was only de-epithelialized.
Image 2.5. The skin of the upper edge of the dome was elevated offthe breast to a 1-
cm distance. The edge of the areola was approximated to the upper edge of the skin.
Note that the sutures in the upper skin edge were taken transversely while those on
the edge of the areola were horizontal. This modification of the technique was made
to accommodate for the length difference between the 2 edges. See Figure 9.8.

Mastopexy
171
Image 2.6. The patient 2 weeks postoperatively. Notice that the technique used to
approximate the edge of the dome has resulted in a very satisfactory cosmetic result
in spite of the difference in lengths.
Image 2.7. The patient 2 weeks postoperatively. The contralateral procedure was
delayed awaiting completion of radiation therapy.
The resection of the primary, as well as the closure of the defect, fol-
lows the same principles described in Chapter 6. Skin closure of the dome
does not follow the classical principles as the outer part of the ellipse or
the dome is longer than the inner part. We close these wounds by using
transverse dermal sutures on the upper flaps and a vertical suture on the
lower flap (Figure 9.8) (Case 2, Image 2.5). The final postoperative result

172
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Figure 9.8.
Suturing of the dome skin. Multiple interrupted sutures are applied to
distribute the discrepancy in size. The suture is taken transversely deep in the dermis of
the longer segment of the dome and vertically at the aerolar edge (the shorter segment).
A continuous subcuticular closure is then applied in the superficial dermis. See Case
No. 2, Images 2.5 and 2.6 for a clinical demonstration.
is cosmetically acceptable (Case 2, Images 2.6 and 2.7). With the batwing
technique, the lengths of the upper and lower flaps are equal, and a regular
skin closure would be applied.
9.3 Benelli Mastopexy
This eponymous technique was first described and popularized by Dr. Louis
Benelli.6 The procedure was designed to minimize scarring in breast
surgery. In a Benelli mastopexy, the skin incision starts with a circumareo-
lar design surrounded by a tear drop-shaped incision. The tear drop-shaped
incision is drawn using the following criteria (Figure 9.9):
1. The new position of the apex of the areola should be the apex of the
tear drop (point A).
2. The distance of the lower edge of the areola from the inframammary
line is the bottom of the tear drop (point B).
3. The width of the tear drop depends on the extent of skin excess to be
excised. (Line CD).
More recently, some oncoplastic surgeons have adopted this procedure
with some modifications using a circumferential periareolar incision with
a surrounding ellipse [Figure 9.10(a)] or a second surrounding circle
[Figure 9.10(b)], better known as “donut mastopexy.”

Mastopexy
173
Figure 9.9.
Benelli mastopexy as originally described by Louis Benelli.6
Figure 9.10.
Modified Benelli mastopexy. (a) The outer incision line is elliptical.
The first circle is around the edge of the areola or centered around the
nipple; its diameter depends on the desired final size of the new areola.
The outer ellipse or circle is directly related to the extent of skin resection
needed to tighten the skin envelope of the breast and the desired elevation
of the nipple areola complex using the same principles for the Benelli tear
drop points A,B,C, and D in Figure 9.9.

174
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Figure 9.10.
(b) The outer incision line is a second circle, better known as “donut
mastopexy.”
The skin between the larger circle or ellipse and the outer edge of
the inner circle is de-epithelialized rather than excised, therefore main-
taining the blood and nerve supply of the nipple areola complex (Case 2,
Image 2.4). The skin incision through the dermis and subcutaneous tissue
is made at the edge of the outer circle. The skin is elevated, exposing the
underlying breast tissue. This procedure gives access to any quadrant. The
lumpectomy is then performed. The breast tissue is approximated radially
with 2-0 or 3-0 Vicryl as described in Chapter 7. The skin edge at the
outer circle is pulled toward the edge of the areola and approximated to
each other in 2 layers. As described in the dome mastopexy closure, the
length of the outer edge is longer than the inner edge; therefore we rec-
ommend using the same technique of approximation previously described:
transverse suture on the outer edge and vertical suture on the inner edge
(Figure 9.8). Originally, Benelli described his mastopexy as using a con-
tinuous non-absorbable sub-cuticular suture to approximate the 2 edges
of skin. More recently, many surgeons have abandoned this this type of
approximation and resort to 2 layers of closure, an interrupted deep dermal
layer as described in Figure 9.8, followed by a continuous mono-filament
sub-cuticular layer.
The donut mastopexy can be combined with a full-thickness radial
resection in the lower quadrants as shown in Figure 9.11. Such a com-
bination is usually the basis of the J-mastopexy. Such combinations of
donut mastopexy and radial resection may be applied to any quadrant in

Mastopexy
175
Figure 9.11.
Combining donut mastopexy with resection of lesions in the lower outer
quadrant in the form of a J-mastopexy.
Figure 9.12.
Benelli mastopexy with radial extensions: Any of these extensions (1, 2,
or 3) could be used with a Benelli procedure.
the breast (Figure 9.12). As we have previously stated in Chapter 4, we
avoid radial incisions between 11 o′clock and 2 o′clock axes on the right
side, and the 9 o′clock and 1 o′clock axes on the left (Figure 4.3), as they
may result in unsightly scars.

176
Principles and Techniques in Oncoplastic Breast Cancer Surgery
For further reading on the subject of more-complex reduction and
mastopexy, please refer to Chapter 8: Oncoplastic Breast Reduction.
We strongly recommend that breast/general surgeons who are novices
in these complex procedures collaborate with their plastic surgery
colleagues.
References
1. Silverstein MJ. (2003) An argument against routine use of radiotherapy for
ductal carcinoma in situ. Oncology (Williston Park). 17(11):1511–1533.
2. Berry MG, Fitoussi AD, Cutnier A, Couturaud B, Salmon RJ. (2010)
Oncoplastic breast surgery: A review and systematic approach. J Plast
Reconst Aesthet Surg 63:1233–1243.
3. Fitoussi A, Berry MG, Couturaud B, Salmon RJ. (2009) Oncoplastic breast
surgery. Oncoplastic and Reconstructive Surgery for Breast Cancer. The Insti-
tut Curie Experience. Springer-Verlag, Berlin, Heidelberg.
4. Silverstein MJ. (2009) Oncoplastic breast conservation surgery. In: Nahabe-
dian MY (ed.), Oncoplastic Surgery of the Breast, Elsevier, China, pp. 47–70.
5. Fitoussi A, Berry MG, Couturaud B, Salmon RJ. (2009) Oncoplastic breast
surgery. P. 29 Figure (a-b). In: Oncoplastic and Reconstructive Surgery
for Breast Cancer. The Institut Curie Experience, Springer-Verlag, Berlin,
Heidelberg.
6. Benelli L. (1990) A new periareolar mammaplasty: The “round block” tech-
nique. Aesthet Plast Surg 14:93–100.

Chapter 10
SKIN-SPARING MASTECTOMY
Walter Paul Weber and Mahmoud El-Tamer
Breast Service, Department of Surgery,
Memorial Sloan-Kettering Cancer Center,
New York, NY 10065, USA
10.1 Introduction
The original technique of skin-sparing mastectomy (SSM) for removal of
malignant tumors was first described by Toth and Lappert in 1991.1 While
the exact definition of SSM continues to be the subject of discussion, the
procedure generally involves the removal of the entire gland, together with
the nipple areola complex (NAC) and any biopsy scars, while preserving
most if not all of the overlying skin.2 The preservation of the skin envelope
and the inframammary fold (IMF) allows for maintaining the shape of the
breast for immediate reconstruction and still provides access to the axilla
for possible lymph node dissection. Hence, SSM can be performed as a
total mastectomy or as a modified radical mastectomy.
The success of the SSM procedure depends largely on the meticulous
preservation of the blood supply to the skin flaps. The anatomy of the
arterial system irrigating the skin overlying the breast was described as
early as 1939 in Salmon’s landmark anatomic studies on the main arteries
of the female breast in deceased women between 20 and 45 years of age.3
The internal thoracic artery is the main artery of supply via perforators
through the second, third, and fourth intercostal spaces. A principal vessel
passes through the second or third space, giving offmany branches to
the superficial fascia and skin. An equally significant contribution comes
from branches of the lateral thoracic artery or from the superficial thoracic
artery directly offthe axillary artery. These vessels enter the breast in
the upper outer quadrant and give branches to the skin. Superiorly, there
177

178
Principles and Techniques in Oncoplastic Breast Cancer Surgery
may be an additional contribution from the cutaneous branches of the
thoracoacromial axis (for details, see Chapter 1).
10.2 Incision
The most common approaches are the elliptical incision (Figure 10.1),
and the circumareolar incision (Figure 10.2) with medial and/or lateral
extensions when the areolar diameter is small (Figure 10.3).4−6 Figure
10.4 shows a clinical example of elliptical, circumareolar and circumareolar
incisions with lateral and medial extensions. In large- or ptotic-breasted
women, a Wise-pattern incision may be an option (Figure 10.5). Alterna-
tively, a reduction mammoplasty or mastopexy incision can be used (Fig-
ure 10.6). Excess skin can be excised around the areola, and an extension
may be added in the form of a J-mastopexy. Modifications include lat-
eral extensions — commonly referred to as “tennis racquet” or “fish-tail”
(Figures 10.7–10.8) incisions — to facilitate access to the axilla. Some sur-
geons prefer a separate axillary incision.7,8 We have frequently used a sepa-
rate axillary incision when performing a circumareolar incision without any
extension. The type of incision is ultimately based on the preferences of the
breast and the reconstructive surgeons and, as such, should be planned by
both in agreement. The incision is determined by multiple factors, including
the need for skin resection (skin involvement of retraction), the size and
Figure 10.1.
Elliptical incision: An ellipse is drawn around the areola. This type of
incision is chosen most frequently when using a breast implant for reconstruction.

Skin-Sparing Mastectomy
179
Figure 10.2.
The circumareolar incision is ideal for patients who undergo breast recon-
struction with tissue transfer. The skin of the myocutaneous flap will be limited to
replace the resected areola and will be used to reconstruct the nipple. Such reconstruc-
tion achieves an excellent cosmetic result (see Figure 10.8). It is occasionally used with
implant reconstruction, and the skin is closed with a purse-string suture.
Figure 10.3.
The circumareolar incision with lateral/medial extension is also ideal for
large-breasted patients who are undergoing breast reconstruction with tissue transfer.
It also may facilitate access to axillary node dissection or biopsy (see Figure 10.9).