Reduction mammaplasty in conjunction with breast conservation

Analysis of Incidentally Found Proliferative Lesions in Oncoplastic and Macromastia Breast Reductions

BACKGROUND

Reduction mammaplasty pathologic specimens can reveal incidentally found proliferative lesions. However, there is a lack of data investigating the comparative incidences and risk factors for such lesions.

METHODS

A retrospective review was conducted of all consecutively performed reduction mammaplasty cases at a single large academic medical institution in a metropolitan city by two plastic surgeons over a 2-year period. All reduction mammaplasties, symmetrizing reductions, and oncoplastic reductions performed were included. There were no exclusion criteria.

RESULTS

A total of 632 breasts were analyzed-502 reduction mammaplasties, 85 symmetrizing reductions, and 45 oncoplastic reductions-in 342 patients. Mean age was 43.9 ± 15.9 years, mean body mass index was 29.2 ± 5.7 kg/m 2 , and mean reduction weight was 610.0 ± 313.1 g. Patients who underwent reduction mammaplasty for benign macromastia had a significantly lower incidence (3.6%) of incidentally found breast cancers and proliferative lesions compared with patients with oncoplastic reductions (13.3%) and symmetrizing reductions (17.6%) ( P < 0.001). On univariate analysis, personal history of breast cancer ( P < 0.001), first-degree family history of breast cancer ( P = 0.008), age ( P < 0.001), and tobacco use ( P = 0.033) were all statistically significant risk factors. Using a backward elimination stepwise reduced multivariable logistic regression model for risk factors associated with breast cancer or proliferative lesions, age ( P < 0.001) was the only retained significant risk factor.

CONCLUSIONS

Proliferative lesions and carcinomas of the breast found in reduction mammaplasty pathologic specimens may be more common than previously reported. The incidence of newly found proliferative lesions was significantly lower in cases of benign macromastia compared with oncoplastic and symmetrizing reductions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Revisiting Reduction Mammaplasty: Complications of Oncoplastic and Symptomatic Macromastia Reductions

BACKGROUND

Oncoplastic breast reduction has been shown to be an effective and safe approach to breast conservation surgery in women with macromastia. However, there remains a paucity of data investigating the comparative outcomes. This study seeks to delineate the complication profiles for oncoplastic and symmetrizing breast reductions versus mammaplasty for benign macromastia.

METHODS

A retrospective review was conducted of all consecutively performed reduction mammaplasty cases at a single institution by two plastic surgeons over a 2-year period.

RESULTS

A total of 632 breasts were analyzed: 502 reduction mammaplasties, 85 symmetrizing reductions, and 45 oncoplastic reductions in 342 patients. Mean age was 43.9 ± 15.93 years, mean body mass index was 29.15 ± 5.66 kg/m2, and mean reduction weight was 610.03 ± 313.13 g. Regarding surgical technique, a medial pedicle was used in 86% of cases. There were similar postoperative complication outcomes for nipple necrosis, wound healing, scar revision, fat necrosis, seroma, hematoma, and overall complication rates for all procedures. However, the rate of postoperative revision among reduction mammaplasty (2%), oncoplastic reduction (6.7%), and symmetrizing reduction (5.9%) was significantly different (P = 0.027). In univariate analysis, diabetes (P = 0.011), smoking (P = 0.007), higher body mass index (P = 0.003), larger reduction weight (P = 0.011), longer nipple-to-inframammary fold measurement (P = 0.014), and longer sternal notch-to-nipple measurement (P = 0.039) were all significant risk factors for a surgical complication in reductions performed for any indication. Using a multivariate logistic regression model, diabetes (P = 0.047), smoking (P = 0.025), and higher body mass index (P = 0.002) were all retained as statistically significant risk factors.

CONCLUSION

The complication profiles for both oncoplastic breast reductions and breast reductions for symptomatic macromastia are similar and acceptably low.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

The no-vertical scar technique for oncoplastic breast reconstruction

INTRODUCTION

Oncoplastic reconstruction can optimize breast conserving therapy. Nipple loss is a concern in patients with significant ptosis and breast hypertrophy particularly with pedicle undermining during tumor resection. The modified Robertson technique (No-Vertical Scar reduction) has been previously described for breast reduction in large, ptotic patients using a wide, bell-shaped inferior pedicle with only inframammary fold and peri‑areolar incisions. The purpose of this study was to evaluate the No-Vertical Scar (NVS) technique applied to oncoplastic reconstruction.

METHODS

Women undergoing oncoplastic breast reduction using a NVS, Wise, or Vertical method were assessed. Predictive variables included patient demographics, comorbidities, and sternal notch to nipple (SNN) distance. Outcome variables were delayed wound healing, surgical site infection, seroma, fat necrosis, nipple necrosis, use of a free nipple graft, and time between surgery and adjuvant radiation.

RESULTS

Fifty patients met inclusion criteria using NVS (N = 15), Wise (N = 16), and Vertical (N = 19) methods. The NVS group had a significantly higher BMI (p=.009), greater sternal notch to nipple distance (p=<0.001) and increased resection volume (p=<0.001) as compared to Wise and Vertical groups. There was no significant difference in complications (p=.25). No nipple necrosis occurred, and no free nipple grafts were required.

CONCLUSION

The NVS approach is a useful technique for oncoplastic reconstruction in select patients with macromastia and severe Grade II or Grade III ptosis. The wide, bell-shaped pedicle is versatile for obliterating a lumpectomy cavity and optimizing nipple perfusion if pedicle undermining occurs during resection.

Combined TRAM flap with latissimus dorsi myocutaneous flap for reconstruction of a large breast post-radiation induced necrosis

Radiation therapy is a critical component of breast cancer management following breast-conserving surgery. Post-radiation sequelae are greater in women with larger breasts, given the need for higher doses and dosing heterogeneity. The goal of breast reconstruction post-mastectomy is to improve the quality of life and add no more health risk. The optimal reconstruction should make the patient feel as natural as possible. Reconstruction of a large-sized breast with aesthetically satisfactory outcome poses a challenge to the breast surgeon. The breast of most Egyptian women is of a large volume with variable degrees of ptosis, thus it is difficult to reconstruct such a large-ptotic breast using an implant. We describe the successful reconstruction of a large-sized breast after radiation-induced necrosis using a combined transverse myocutaneous rectus abdominis flap and latissimus dorsi myocutaneous flap reconstruction. The combined use of both flaps offered a more natural breast reconstruction and avoided the use of any implants.