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Part 1 book “Oncoplastic breast surgery - A guide to clinical practice” has contents: Introduction, round block lumpectomy, round block lumpectomy with resection of the nipple, doughnut lumpectomy, batwing (omega) quadrantectomy, batwing quadrantectomy, inferior rotation flap,… and other contents.
Oncoplastic Breast Surgery A Guide to Clinical Practice Second Edition Florian Fitzal Peter Schrenk Editors 123 Oncoplastic Breast Surgery Florian Fitzal • Peter Schrenk Editors Oncoplastic Breast Surgery A Guide to Clinical Practice Second Edition Editors Florian Fitzal, FEBS, MD Professor of Surgery Hospital of the Sisters of Charity and Cancer Comprehensive Center Medical University Vienna Linz Austria Peter Schrenk, MD Allg Öffentl Krankenhaus Abt Chirurgie II Linz Austria ISBN 978-3-7091-1873-3 ISBN 978-3-7091-1874-0 DOI 10.1007/978-3-7091-1874-0 (eBook) Library of Congress Control Number: 2015942456 Springer Vienna Heidelberg New York Dordrecht London © Springer-Verlag Vienna 2015 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made Printed on acid-free paper Springer-Verlag GmbH Wien is part of Springer Science+Business Media (www.springer.com) Acknowledgement We would like to thank Bernard Ammerer for providing his expertise in drawing several illustrations within this second edition of the Oncoplastic Surgery book v Contents Introduction Florian Fitzal and Peter Schrenk Part I Breast Conserving Oncoplastic Techniques: Round Block or Doughnut Technique Round Block Lumpectomy Hisamitsu Zaha Round Block Lumpectomy with Resection of the Nipple Peter Schrenk Doughnut Lumpectomy: Caveat I Florian Fitzal 13 Doughnut Lumpectomy: Caveat II Hisamitsu Zaha 17 Part II Breast Conserving Oncoplastic Techniques: Batwing Technique Batwing Lumpectomy with Skin Resection Elias E Sanidas 21 Hemibatwing No Man’s Land Elias E Sanidas 25 Batwing (Omega) Quadrantectomy Peter Schrenk 29 Batwing Quadrantectomy Peter Schrenk 33 Part III 10 Breast Conserving Oncoplastic Techniques: Rotation/ Advancement Flap Breast Conservation Surgery and Defect Reconstruction with a Rotation Flap from the Lateral Thoracic Wall Peter Schrenk 39 vii Contents viii 11 Tumor Quadrantectomy and Defect Remodeling with an Epigastric Skin Flap Vesna Bjelic-Radisic 43 12 S-Mammoplasty No Man’s Land Elias E Sanidas 45 13 Rotational Advancement Flap Quadrantectomy Victor J Hassid and Steven J Kronowitz 49 14 Inferior Rotation Flap Päivi Vaara and Marjut Leidenius 53 15 Inferior Rotation Flap: Caveat Päivi Vaara and Marjut Leidenius 57 16 Intramammarian Flap Reconstruction: Partial Flap Necrosis Christoph Rageth 17 Breast Conservation Surgery Using the J Mammoplasty Elias E Sanidas 18 Breast Conservation Surgery Using a Thoracoepigastric Flap Elias E Sanidas Part IV 19 20 63 67 Breast Conserving Oncoplastic Techniques: Superior Pedicle Segment Resection Using a Vertical Reduction Mammaplasty Florian Fitzal Segment Resection of a Breast Cancer in the Submammary Fold Using a Vertical Reduction Technique Florian Fitzal 21 Breast Conservation Surgery: The Vertical Mammoplasty Elias E Sanidas 22 Superior Pedicle Reduction Mammoplasty and Defect Reconstruction Using an Inferior-Based Pedicle with a Skin Island Peter Schrenk 23 61 Oncoplastic Superior-Based Pedicle Reduction Mammoplasty and Defect Reconstruction with an Inferior Pedicle Vesna Bjelic-Radisic 73 75 79 81 85 Contents ix 24 25 26 Superior Pedicle Quadrantectomy and Defect Reconstruction with an Inferior-Based Pedicle: Secondary Mastectomy and Immediate Reconstruction with a Latissimus Dorsi Flap Peter Schrenk Superior-Based Pedicle Quadrantectomy and Reconstruction of the Quadrantectomy Defect with an Inferior Pedicle Flap Peter Schrenk Superior-Based Pedicle Quadrantectomy and Defect Reconstruction with Inferior-Based Pedicle: Secondary Prophylactic Mastectomy and Implant Reconstruction Peter Schrenk Part V 89 93 97 Breast Conserving Oncoplastic Techniques: Inferior Pedicle 27 Defect Reconstruction with Inferomedial Pedicle Technique 103 Victor J Hassid and Steven J Kronowitz 28 Inferior Pedicle Reduction Mammoplasty 107 Peter Schrenk 29 Inverted-T Technique for Multicentric Breast Cancer 111 Florian Fitzal 30 Inferior Pedicle Reduction Mammoplasty: Position of the Nipple Too High 115 Peter Schrenk 31 Inferior Pedicle Reduction Mammoplasty: Poor Result Due to a Large Defect 119 Peter Schrenk Part VI Breast Conserving Oncoplastic Techniques: B Plasty 32 The B-Mammoplasty for Upper Outer Quadrant Tumors 127 Elias E Sanidas 33 Oncoplastic Breast Surgery: The B Plasty 131 Peter Schrenk 34 Breast Conservation Surgery: The B Plasty, Involved Margins, Skin-Sparing Mastectomy, and Immediate Reconstruction 135 Peter Schrenk P Schrenk 122 a b c Fig 31.3 (a–c) A large defect in the upper breast after quadrantectomy may be reconstructed with tissue from the medial quadrant (a) (when the defect is in the central or lateral part of the breast), from the lateral quadrant (b) (when the defect is in the central or medial part of the breast), or both medial and lateral quadrant (c) (when the defect is in the central part of the breast) The tissue is rotated into the defect 31 Inferior Pedicle Reduction Mammoplasty: Poor Result Due to a Large Defect a 123 b c d e Fig 31.4 (a–f) Pre- (a, b) and postoperative views of a 48-year-old patient with a large DCIS in the upper outer quadrant of the right breast Wide tumor quadrantectomy f was performed with an inferior-based pedicle mammoplasty, and tissue from the upper medial quadrant was shifted into the defect P Schrenk 124 Fig 31.5 Superior-based pedicle reduction mammoplasty The defect is reconstructed with an inferior pedicle usually discarded in reduction mammoplasty a Fig 31.6 (a, b) The 70-year-old patient had bilateral breast cancer The cancer in the left breast was in the cranial quadrant with additional large DCIS and was treated with an inferior pedicle quadrantectomy Postoperative result found a tissue deficiency in the upper central quad- b rant The tumor in the right breast was an invasive cancer with extensive DCIS and was treated with a superiorbased reduction mammoplasty, and the defect in the upper outer quadrant was reconstructed with a de-epithelialized inferior pedicle Part VI Breast Conserving Oncoplastic Techniques: B Plasty The B-Mammoplasty for Upper Outer Quadrant Tumors 32 Elias E Sanidas 32.1 The Patient A 47-year-old patient was diagnosed with an invasive carcinoma in the upper outer quadrant of the right breast (Fig 32.1a, b) A B-mammoplasty was planned The breast was of medium size and moderate ptosis 32.2 Surgery After wide resection of the tumor, the flaps were adequately mobilized from the major pectoralis muscle fascia and closed over the tumor bed The periareolar region was de-epithelialized, and the nipple-areola complex was recentralized (Fig 32.2a–c) 32.3 Clinical and Cosmetic Outcome Final histology found a 24 mm invasive cancer (G3, triple negative, Ki 67:60 %) with wide clear margins and five negative sentinel lymph nodes Postoperatively chemotherapy and radiation were suggested The early postoperative result was rated as excellent (Fig 32.3a, b) E.E Sanidas, MD, FACS Department of Surgery, Herakleion Crete Medical School, Herakleion, Crete, Greece e-mail: eliassanidas@gmail.com, esanidasbreastsurgeon@gmail.com © Springer-Verlag Vienna 2015 F Fitzal, P Schrenk (eds.), Oncoplastic Breast Surgery: A Guide to Clinical Practice, DOI 10.1007/978-3-7091-1874-0_32 127 E.E Sanidas 128 a Fig 32.1 (a, b) Preoperative view of a 47-year-old woman with an invasive cancer in the upper outer quad- a b rant of the right breast (a, b) Drawing for the B-mammoplasty (b) b c Fig 32.2 (a–c) Intraoperative view After wide local resection of the tumor (a), the tissue flaps were mobilized from the fascia of the pectoralis major muscle and closed over the defect (b) Immediate postoperative view (c) 32 The B-Mammoplasty for Upper Outer Quadrant Tumors a 129 b Fig 32.3 (a, b) Early postoperative result after B-mammoplasty showed an excellent cosmetic outcome 32.4 Comments of the Author • B-mammoplasty may be used for tumors in the upper outer quadrant A medium- or large-size breast with at least moderate ptosis allows adequate resection of even larger tumors with an excellent cosmetic result • Sentinel node biopsy can be performed through the same incision Oncoplastic Breast Surgery: The B Plasty 33 Peter Schrenk 33.1 The Patient A 54-year-old postmenopausal woman was diagnosed with a 22 mm receptor positive, HER2/neu negative, G2 invasive breast cancer with concomitant intraductal carcinoma in situ in the upper outer quadrant of the left breast Axillary lymph node status was negative The breast was of medium size and ptotic (Fig 33.1a, b) 33.2 Surgery The tumor was palpable in the upper outer quadrant of the left breast Due to concomitant intraductal carcinoma in situ, a wide resection was planned using a B plasty (Fig 33.1a, b) The area around the areola was de-epithelialized Quadrantectomy was done with a wedge of tissue resected underneath the nipple-areola complex The tissue around the areola was incised to facilitate rotation of the flaps for closure The breast flaps were adequately mobilized from the major pectoralis muscle fascia and sutured together Sentinel lymph node biopsy was done through the same incision and found two negative nodes 33.3 Clinical and Cosmetic Outcome The permanent histological examination found a 22 mm invasive cancer and a 30 mm intraductal carcinoma of intermediate grade which were both removed with wide free margins The postoperative course was uneventful Postoperative radiation and endocrine treatment were suggested The postoperative cosmetic result was rated as excellent by both the patient and the surgeon (Fig 33.2a, b) 33.4 Comments of the Author • The B plasty may be indicated in patients with medium- and large-size breasts with moderate ptosis The breast should not be too small (or the tissue to be resected too large) for this accounts for defects and distortion of the nipple toward the axilla (Fig 33.3a, b) • The B plasty allows resection of the entire breast quadrant from lateral to medial and underneath the nipple (and even with resection of the nipple when necessary) Therefore, it may be used for patients with multifocal tumors or larger intraductal carcinoma in situ P Schrenk, MD Second Department of Surgery, Breast Care Center, Akh – LFKK Linz, Linz, Austria e-mail: peter.schrenk@liwest.at © Springer-Verlag Vienna 2015 F Fitzal, P Schrenk (eds.), Oncoplastic Breast Surgery: A Guide to Clinical Practice, DOI 10.1007/978-3-7091-1874-0_33 131 P Schrenk 132 a b Fig 33.1 (a, b) Preoperative view The 54-year-old patient had a 22 mm invasive breast cancer and DCIS in the upper outer quadrant of the left breast Preoperative drawings for B plasty a b Fig 33.2 (a, b) Postoperative result Three years after surgery, the patient showed an excellent cosmetic result • It is important to shift the areola adequately in the opposite direction of the incision as well as cranially (recentralization of the areola) Otherwise, the tension of the scar results in a nipple position which is too far laterally (Fig 33.3c, d) • When the breast is of a larger size and a wide quadrantectomy has to be done due to tumor size, too much tissue may remain in the inner quadrant In this case tissue from the retroareolar and medial area may be mobilized into the defect Alternatively in these patients, a reduction mammoplasty may be performed • The B plasty may be used for treatment of tumors in almost all quadrants of the breast Figure 33.4a–c show a B plasty for resection of a tumor in the inner breast quadrant (Fig 33.4a–c) 33 Oncoplastic Breast Surgery: The B Plasty 133 a b c d Fig 33.3 (a–d) The 62-year-old patient had a triple negative breast cancer in the upper outer quadrant of the left breast (a, b) Neoadjuvant chemotherapy was declined by the patient A B plasty was performed Due to the small breast and the large resection volume, the B plasty resulted in a distinct defect with distortion of the areola toward the axilla (c, d) Correction of the defect (recentralization of the areola, lipofilling) was declined by the patient P Schrenk 134 a b c Fig 33.4 (a–c) A 48-year-old patient had a quadrantectomy for intraductal carcinoma in situ at another hospital Due to involved margins, a B plasty was performed including the previous quadrantectomy scar (a, b) The postoperative result shows a distortion of the breast in the inner lower quadrant, which was due to the large amount of skin resected (c) Breast Conservation Surgery: The B Plasty, Involved Margins, Skin-Sparing Mastectomy, and Immediate Reconstruction 34 Peter Schrenk 34.1 The Patient A 49-year-old premenopausal patient (Fig 34.1) underwent breast conservation surgery (B plasty) for invasive cancer of the left breast Concomitantly a (histologically confirmed) fibroadenoma was removed of the right breast Permanent histology found the invasive cancer completely removed but revealed involved resection margins for a previously not known intraductal carcinoma in situ of the left breast The fibroadenoma of the right breast was completely removed, but found incidentally intraductal carcinoma in situ of high grade around the fibroadenoma Reoperation surgery was done with wide reexcisions on the left breast and a B plasty quadrantectomy on the right breast Histology of both specimens again revealed involved margins Due to a positive family history (no mutation defect found in genetic testing), an otherwise unsuspicious mammogram (no microcalcifications, no masses in the radiological examinations), and a poor cosmetic outcome after bilateral quadrantectomy and re-excision, the patient decided for a bilateral mastectomy and immediate reconstruction with implants Following multiple previous surgeries, the patient revealed two small non-ptotic breasts with scars from the B plasties (Fig 34.2a–c) 34.2 Surgery A bilateral skin-sparing mastectomy was performed The resection of the nipple-areola complex (NAC) was done due to the preference of the patient, the extensive intraductal carcinoma, and the uncertain blood supply of the NAC when a nipple-sparing mastectomy is performed after a B plasty Sentinel node biopsy found two nodes in each breast, which were negative in the frozensection examination Immediate reconstruction was done with 250 cc anatomical implants inserted in the subpectoral pocket (Fig 34.3a, b) The space between the major pectoralis muscle and the serratus anterior muscle was covered with an acellular dermal matrix (Veritas®, Baxter) P Schrenk, MD Second Department of Surgery, Breast Care Center, Akh – LFKK Linz, Linz, Austria e-mail: peter.schrenk@liwest.at © Springer-Verlag Vienna 2015 F Fitzal, P Schrenk (eds.), Oncoplastic Breast Surgery: A Guide to Clinical Practice, DOI 10.1007/978-3-7091-1874-0_34 135 P Schrenk 136 to the tissue deficit in the lateral quadrants and an asymmetry with the left breast being smaller than the right breast (Fig 34.4a–c) 34.4 Fig 34.1 Preoperative view The 49-year-old patient was scheduled for a quadrantectomy (B plasty) for invasive cancer of the left breast and excision of a fibroadenoma of the right breast 34.3 Clinical and Cosmetic Outcome The postoperative course was uneventful Final histology showed invasive multicentric receptorpositive cancer in the left breast (pT2m of 21 and 11mm, G2, HER2/neu negative), extensive intraductal carcinoma in situ, and one micrometastatic lymph node out of two No further axillary surgery was done Histology of the right breast showed multicentric intraductal carcinoma in situ and two negative sentinel nodes Endocrine therapy was suggested to the patient Nipple-areola reconstruction was declined by the patient The cosmetic result was considered by the surgeon (not the patient!) to be a poor result This was due Comment of the Author • The B plasty allows removal of tumors in the lateral and medial breast quadrants, and this can be done with a good cosmetic result in patients with medium- or large-size ptotic breasts The B plasty, however, may constitute a problem in patients with a large cancer or a small breast and when re-excisions are necessary • In patients with the need for a secondary mastectomy after a B plasty, resection of the NAC is suggested This is due to the uncertain blood supply of the NAC when a nipple-sparing mastectomy is done after a B plasty • Autologous tissue reconstruction (latissimus dorsi muscle flap or a DIEP) was offered for reconstruction However, the patient requested implant reconstruction for she declined having additional scars either on her back or the abdomen Autologous reconstruction, however, in my opinion would have resulted in a more favorite cosmetic outcome (Fig 34.5a–f) • No revision surgery was wanted by the patient Possible corrections would have been insertion of a larger implant, lipofilling, and reconstruction of the NAC • It is unclear whether the reconstruction with an expander and the exchange to a permanent implant would have resulted in more volume and better symmetry of both breasts 34 Breast Conservation Surgery: The B Plasty, Involved Margins, Skin-Sparing Mastectomy a 137 b c Fig 34.2 (a–c) Following B plasty and re-excision on the left breast and tumorectomy and B plasty for incidentally found cancer on the right breast, the patients showed small non-ptotic breasts with scars after bilateral B plas- a Fig 34.3 (a, b) Intraoperative view Following mastectomy, an implant was inserted into the submuscular pocket (a), and the defect between the major pectoralis muscle ties A tissue deficit was seen in the lateral quadrants of both breasts with the nipple position too far laterally Drawings were made for bilateral skin-sparing mastectomy and immediate reconstruction with implants b and the serratus anterior muscle was covered with an acellular dermal matrix (Veritas®) (b) P Schrenk 138 a b c Fig 34.4 (a–c) Postoperative view years after surgery The inferior cosmetic result was due to the tissue deficit in the lateral quadrants and an asymmetry with the left breast being smaller compared to the right breast ... Springer-Verlag Vienna 2 015 F Fitzal, P Schrenk (eds.), Oncoplastic Breast Surgery: A Guide to Clinical Practice, DOI 10 .10 07/97 8-3 -7 09 1- 1 87 4-0 _2 H Zaha a Fig 2 .1 (a) A circumferential incision was... obvious, and the breasts on both sides © Springer-Verlag Vienna 2 015 F Fitzal, P Schrenk (eds.), Oncoplastic Breast Surgery: A Guide to Clinical Practice, DOI 10 .10 07/97 8-3 -7 09 1- 1 87 4-0 _5 17 H Zaha 18 ... skin flap The contralateral symmetrization was performed with also doughnut mastopexy 5.3 H Zaha, MD Department of Breast Surgery, Nakagami Hospital, Okinawa, Japan e-mail: hisamitu@nakagami.or.jp