New Approach to Oncoplastic Breast Conservation: Combining Autologous Volume Replacement and the Wise-pattern Mammaplasty

Combining Wise-pattern Volume Displacement and Autologous Volume Replacement to Facilitate Oncoplastic Breast Conservation

Background

Oncoplastic breast conservation has been classically divided into volume displacement (VD) or volume replacement (VR) techniques. There have been few descriptions of merging these two approaches. This report describes our experience combining Wise-pattern VD and autologous VR to repair extensive partial mastectomy defects in patients with ptosis.

Methods

A retrospective chart review was performed for patients who underwent combined Wise-pattern VD surgery and autologous VR by the author from June 2017 to June 2023, with at least 6 months follow-up. Patient demographics, oncological and intraoperative details, and complications were recorded.

Results

Forty patients underwent Wise-pattern VD surgery combined with a medial intercostal artery perforator flap (five patients), lateral thoracic artery perforator/lateral intercostal artery perforator flap (18 patients), anterior intercostal artery perforator flap (five patients), or muscle-sparing latissimus dorsi flap (12 patients). The average tumor size was 4.0 cm (range, 1.5-9.1 cm), and specimen weight was 152 g (range, 33-415 g). Six patients (15%) required re-operation for positive margins. There was delayed healing of three (7.5%) donor sites. There were no flap failures. Two (5%) patients had clinically apparent fat necrosis without requirement for surgical revision.

Conclusions

This report demonstrates the feasibility of combining Wise-pattern VD and autologous VR. We propose that oncoplastic breast-conserving surgery be no longer divided into two mutually exclusive approaches and that surgeons make liberal use of combining these approaches to address challenging cases of breast-conserving surgery.

No Doppler Single Position-Lateral Intercostal Artery Perforator Flap (NDSP-LICAP): a Safe and Versatile Flap for Breast Oncoplasty in Resource-Limited Setting

INTRODUCTION

The lateral intercostal artery perforator flap (LICAP) has emerged as one of the safest and less morbid flaps for lateral and central breast defects. We hereby describe a reproducible no Doppler single position (NDSP) technique to harvest it in single position without handheld Doppler, making it a versatile flap for lateral breast defects in resource-limited setting also.

MATERIALS AND METHODS

With this technique, we performed a total of 22 LICAP turnover flaps over a period of 18 months from January 2020 to June 2021. In all 22 cases, the indication of flap was to fill the post-breast conservation surgery (BCS) defects in outer quadrant of breast. All LICAP flaps were harvested by surface marking of anatomical landmarks and without handheld Doppler.

RESULTS

Out of 22 LICAP turnover flaps, thirteen were harvested for left breast and nine for right breast. The median width and length of the flap were 12.2 cm and 19.6 cm, respectively. The additional mean operative time was 41 min. All LICAP flaps survived well, and grade 1 Clavien-Dindo morbidity was documented in four cases. Mean hospital stay was 2.6 days. All patients received radiotherapy on their stipulated schedule. Early cosmetic outcome was good, and long-term outcomes are awaited.

CONCLUSION

NDSP-LICAP flap is a workhorse for lateral breast defects. Precise knowledge of perforators and anatomical landmarks can be used for harvesting these flaps, thus avoiding ultrasound Doppler and dedicated training for perforator localization. This technique has short learning curve without the need for any plastic surgery training. The early cosmetic outcomes are good.

Combining Multiple Oncoplastic Techniques to Facilitate Extreme Oncoplastic Breast Conservation

Centers of excellence strive for high rates of breast conservation surgery. Given the increased patient satisfaction, evidence for improved survival, decreased rates of complications, reduced costs, and fewer surgical procedures compared to mastectomy and reconstruction, this makes sense. As such, surgeons have devised approaches to offer breast conservation to patients with more extensive disease that would have been classically recommended to undergo mastectomy. These ambitious attempts at breast conservation are supported by recent studies that have established their oncological safety. "Extreme oncoplasty" refers to Wise-pattern volume displacement surgery where the breast is immediately reconstructed after a multifocal or multicentric breast cancer is excised. The authors that described this concept also described a Wise-pattern "split reduction" to allow for excision of the skin directly over the cancer, insuring a clear anterior margin. Although extreme oncoplasty has been broadly discussed and published on by many groups, there are few reports that provide insight into the surgical details necessary to successfully perform this surgery. Here, we combine three different oncoplastic techniques: the Wise-pattern split reduction, immediate nipple reconstruction, and autologous volume replacement to demonstrate our approach to extreme oncoplastic breast conservation in a challenging patient.

Modified chest wall lateral intercostal artery perforator (MCW-LICAP) flap: a versatile flap in the era of oncoplastic breast surgery

BACKGROUND

Breast reconstruction following oncological resection is becoming more common in recent years. In some ladies, implant reconstruction is not ideal due to significant implant visibility or palpability. Autologous reconstruction addresses the limitations of implant reconstruction but results in potential donor site morbidities. To date, there is no clear advantage ascribed to any technique. With appropriate selection, patients with adequate lateral mammary fold have the option of reconstruction with MCW-LICAP flap. We present our techniques and outcomes from a series of 29 patients who underwent MCW-LICAP flap.

METHODS

A retrospective review of consecutive patients who underwent curative resection for breast cancer with immediate MCW-LICAP flap reconstruction, between July 2018 to April 2022 was conducted. The techniques used with its variations along with video demonstrations are presented.

RESULTS

A total of 29 patients underwent 34 procedures. Nineteen breast conserving surgeries and 15 mastectomies were completed, and immediate reconstruction performed in all cases. Twenty-three patients had MCW-LICAP, 1 with a Stacked intercostal artery perforator (STICAP) flap, and 5 had MCW-LICAP combined with a Goldilocks mastectomy. There were no cases of complications requiring re-operation. All patients had acceptable time to adjuvant therapy with a median of 36 days. Learning curve analysis showed a significant reduction in operative time after the 6th case.

CONCLUSION

In our preliminary experience, MCW-LICAP flap is a safe, reliable, and versatile oncoplastic reconstruction option.

Immediate fine-tuning of DIEP flaps using the Wise pattern mastectomy: Description of the technique and a retrospective analysis of complication rates

INTRODUCTION

Elliptical skin-sparing mastectomy in patients with large or ptotic breasts usually leaves loose mastectomy skin flaps, which need to be either resected or gathered over the DIEP flap. This results in poor control of the breast footprint and under-projected DIEP flaps in a loose mastectomy skin pocket, that tend to slip laterally towards the axilla. We believe that the use of a Wise pattern mastectomy will allow for immediate treatment of these concerns.

MATERIALS AND METHODS

A retrospective, uncontrolled analysis of a prospectively-maintained database of patients operated by the five surgeons performing breast reconstructions at the University of Montreal Hospital Centre. Study population was patients with a BMI of over 25 and grade II/III breast ptosis who underwent a Wise pattern mastectomy with immediate DIEP flap reconstruction. Analysis was performed of the complication rates of the technique in the first six months after the surgery.

RESULTS

Out of a total of 53 breasts in 44 patients reconstructed with a DIEP flap immediately post Wise pattern mastectomy, we report nine cases of partial mastectomy-flap necrosis not needing revision, five cases of significant mastectomy flap necrosis needing debridement and skin grafting, and two cases of inability to adequately close the Wise pattern intraoperatively after DIEP placement, necessitating retention of DIEP skin in the inferior pole. None of the mastectomy flap complications occurred in irradiated breasts.

CONCLUSION

In patients with large or ptotic breasts, the Wise pattern mastectomy before an immediate DIEP reconstruction allows for immediate shaping of the breast by controlling the breast pocket, footprint, and excess skin.

Lateral chest wall perforator flaps in partial breast reconstruction

BACKGROUND

Breast conserving surgery (BCS) has been a standard procedure for the treatment of breast cancer instead of mastectomy whenever possible. Lateral chest wall perforator flaps are one of the volume replacement techniques that participate in increasing the rate of BCS especially in small- to moderate-sized breasts with good cosmetic outcome. In this study, we tried to evaluate the outcome of those flaps as an oncoplastic procedure instead of the conventional flaps.

METHODS

This study included 26 patients who underwent partial mastectomy with immediate reconstruction using lateral chest wall perforator flaps in the period from October 2019 to November 2020. The operative time, techniques, and complications were recorded. The cosmetic outcome was assessed 3 months post-radiation therapy through a questionnaire and photographic assessment.

RESULTS

Lateral intercostal artery perforator (LICAP), lateral thoracic artery perforator (LTAP) and combined flaps were performed in 24, 1, and 1 patients, respectively. The mean operative time was 129.6 ± 13.2 min. The flap length ranged from 10 to 20 cm and its width from 5 to 9 cm. Overall patients' satisfaction was observed to be 88.5% as either excellent or good and the photographic assessment was 96.2% as either excellent or good.

CONCLUSIONS

Lateral chest wall perforator flaps are reliable and safe option for partial breast reconstruction with an acceptable aesthetic outcome. In the era of oncoplastic breast surgery, they deserve to gain attention especially with the advantages of some modifications added to the classic technique.

Aesthetic breast surgery: putting in context-a narrative review

Objective

This review article summarises the latest evidence for commonly undertaken procedures in aesthetic breast surgery with a focus on key principles of breast augmentation, reduction, and mastopexy. The paper also outlines various approaches and controversies as well as complications such as breast implant associated anaplastic large cell lymphoma (BIA-ALCL) and breast implant illness (BII) which are increasingly being recognised and becoming a challenge to manage.

Background

Changing trends of aesthetic breast surgery over the decades has warranted a continuous evolution of this field. The ability to deliver safe and appropriate care is dependent upon sound reconstructive principles and proper training. The lack of uniformity in either is a cause of concern. The impact of social media and changing perception of body image can also no longer be overlooked in the field of aesthetics and reconstruction.

Methods

Review of literature including recent journals, textbook chapters, online databases like PubMed, and current government and surgical society guidelines.

Conclusions

Breast reconstruction is based on sound surgical principles and it is imperative to follow these for the practice of this speciality. There are two important issues that revolve around this aspect of surgery. First relates to the urgent need to invest time and effort in improving regulations and outcomes in the cosmetic surgery industry. Second, it is crucial to promote and prioritize the development and training in this field as the principles of aesthetic breast surgery underpins oncoplastic breast surgery for management of cancer.

Reduction Mammoplasty Approach to Oncoplasty-Zone-Wise Planning in Indian Patients

Introduction This article is an attempt to formulate certain guidelines for planning of zone-wise reconstruction after breast conservation surgery. The planning involves applying reduction mammoplasty principles with certain modifications to address the defect.

Patients and Methods This is a retrospective study of 61 patients with breast cancer who underwent breast conservation surgery and reconstruction of partial breast defects with oncoplastic techniques between January 2014 to March 2019. Patients having low tumor to breast ratio and thus good candidates for volume displacement techniques were included in the study.

Results A total of 61 breast cancer cases were included; 22 cases were located in zone 1, nine in zone 2, seven in zone 3, three in zone 4, four in zone 5, one in zone 6, 12 in zone 7, two in zone 8, and three in zone 9. The most common pedicle design used was superomedial in 38 cases, followed by inferior in 19 and medial in 6 cases. Vertical short scar technique was used in 33 cases and Wise pattern skin incision in 30 cases. Follow-up period ranged from 4 months to 65 months, with a mean of 31 months. Four patients had partial skin necrosis, three had suture line dehiscence, two had wound infection, one had seroma, and eight patients had fat necrosis. All patients were satisfied with the cosmetic outcome.

Conclusion Breast oncoplastic techniques are effective, reliable, oncologically safe, and conducted with minimal complications in patients with moderately large ptotic breasts, thereby making planning easier and more reproducible by following the reconstruction procedures described in the article. We believe that these techniques should be incorporated in the armamentarium of every plastic surgeon to manage the defects created after breast conservation surgery, in order to achieve the best cosmetic outcomes.

"Bifidus pedicle", The Use of Bilobed Superomedial Pedicle for Breast Reshaping Following Upper Outer Quadrantectomy: A New Oncoplastic Breast Surgery Technique

INTRODUCTION

The aim of this work was to describe our technique, the "Bifidus pedicle", which is a modification of the superomedial pedicle, for managing large breast cancers (BCs) in the upper outer quadrant (UOQ) in patients with medium/large breasts and associated ptosis. Observed complications, cosmetic outcome and oncologic safety were also reported.

MATERIALS AND METHODS

Thirty patients underwent our modification of the superomedial pedicle combined with a Wise skin resection pattern for large BCs in the UOQ. All patients underwent contralateral Wise pattern breast reduction/mastopexy for symmetry.

RESULTS

The average weight of the quadrantectomy specimen was 235 grams (range: 36-400 grams). Mean free tumour margin was 19.4 mm (range: 16-30). Mean operative time was 165 minutes (range: 150-220). Eight (13.2%) breasts had minor complications: two partial NAC necrosis, and six minimal wound dehiscences. Mean follow-up was 22 months (range: 12-30). Overall satisfaction rate was 91%; patients reported to be satisfied the most with the shape (92%) of the breasts, the achieved symmetry (94%), and the volume (85%), focusing on the fullness in the UOQ.

CONCLUSIONS

Our Bifidus pedicle allowed to fill even wide defects in the UOQ, because we selectively employed it in patients with medium to large ptotic breasts where the lower pole had enough tissue to be displaced. Satisfactory cosmetic and oncologic outcomes were achieved with low complication rate.

LEVEL OF EVIDENCE IV

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Lateral intercostal artery perforator (LICAP) flap for breast volume augmentation: Applications for oncoplastic and massive weight loss surgery

Background

Lateral intercostal artery perforator (LICAP) flap for breast volume augmentation provides the benefits of addressing axillary tissue excess and avoiding intramuscular dissection. Previous experience with the LICAP flap in patients with prior breast conservation therapy (BCT) has led to the development of an extended version for massive weight loss (MWL) patients as well.

Methods

A retrospective review of all cases of LICAP flaps was performed by a single surgeon. Data were subsequently extracted and analyzed including patient demographics, indication and timing of volume augmentation, complications, and follow-up length.

Results

From 2016 to 2020, 12 patients underwent 16 LICAP flaps for volume augmentation. Indications for volume augmentation included deficits from prior oncologic surgery (ten patients) and loss of volume due to MWL (two patients). The average BMI was 29.9 kg/m². Among the oncologic group, eight patients had delayed reconstruction, while two were immediate. Nine patients underwent radiation prior to volume augmentation. Eight of the 14 patients simultaneously received fat grafting. There were 4 cases of delayed wound healing that improved with local wound care. There were no statistically significant differences in complication rates between the oncologic and MWL groups. The average length of follow-up was 11.4 months.

Conclusions

This study supports that the application of the LICAP flap can be effectively broadened from the oncologic population to the MWL population. If needed, extending the flap provides an option to simultaneously address excess axillary and back tissue.