Biplanar Oncoplastic Surgery: A Novel Approach to Breast Conservation for Small and Medium Sized Breasts

Breast Reconstruction: The Oncoplastic Approach

Breast reconstruction surgery is continualladvancing, significantly enhancing patient well-being. Current surgical techniques prioritize minimizing donor site morbidity while achieving a more natural breast appearance. Increasing patient preferences for avoiding prosthetic materials in reconstruction, along with advancements in oncological safety and heightened aesthetic expectations, are driving the exploration and development of innovative approaches. Today's reconstructive options range from straightforward oncoplastic glandular remodeling to intricate microsurgical procedures. This narrative review, titled "Breast reconstruction: the oncoplastic approach," provides a comprehensive overview of contemporary trends in breast-conserving treatment. It evaluates the indications for these techniques and offers guidance to plastic surgeons in crafting personalized treatment plans. This approach presents a valuable single-stage alternative or adjunct to traditional prosthetic or microsurgical reconstruction methods.

Oncoplastic breast reconstruction: Principles, current techniques, and future directions

Oncoplastic breast reconstruction has improved esthetic results after breast-conserving surgery with low complication rates and stable oncologic outcomes. Basic principles can be applied across different volume displacement and replacement techniques including restoration of breast shape and symmetry through esthetic incisions while eliminating dead space. Technique selection is guided by several factors including breast size, resection-to-breast ratio, and patient desires. A surgeon familiar with all techniques will allow individualization of treatment and optimization of outcomes.

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

Background:

Oncoplastic breast-conserving surgery describes a set of techniques that allow for generous oncological resection with immediate tumor-specific reconstruction. These techniques are classically divided into either volume displacement (local breast flaps and or reduction mammaplasty/mastopexy strategies) versus volume replacement strategies (transfer of autologous nonbreast tissue from a local or distant site and, less commonly, implant placement). There have been few descriptions of merging these 2 classical approaches to facilitate breast-conserving surgery. The purpose of this report was to evaluate the efficacy of combining the most common oncoplastic volume displacement strategy (Wise pattern mammaplasty) with simultaneous autologous volume replacement from the lateral intercostal artery perforator (LICAP) flap to reconstruct the extensive partial mastectomy defect in patients with ptosis.

Methods:

A retrospective analysis of 25 consecutive patients with multifocal or multicentric breast cancers who underwent simultaneous volume replacement from the LICAP flap and volume displacement (Wise pattern mammaplasty) to achieve breast conservation was performed between January 2016 and January 2018. Clinical outcomes and postoperative complications were examined.

Results:

Twenty-five consecutive patients with a mean age of 56 years (range, 37–74 years) and mean body mass index of 28 kg/m² (range, 22–37 kg/m²) all successfully underwent breast conservation by simultaneously employing the LICAP flap and Wise pattern mammaplasty to reconstruct the partial mastectomy defect. The average resection specimen weight was 220 g (range, 130–310 g) and average size of the malignancy resected was 6.5 cm (range, 3.7–9.2 cm). Three patients (12%) required re-excision for close or positive margins but were ultimately cleared. There were no complications related to the donor site. There were 4 patients (16%) with delayed wound healing related to the Wise pattern closure but no instances of LICAP necrosis or failure.

Conclusions:

The merger of Wise pattern volume displacement and autologous volume replacement techniques represents a novel strategy that is useful in the most challenging breast conservation patients with some degree of ptosis.

Pedicled Descending Branch Latissimus Dorsi Mini-flap for Repairing Partial Mastectomy Defect: A New Technique

Supplemental Digital Content is available in the text.

Volume loss is 1 of the major factors influencing cosmetic outcomes of breast after partial mastectomy (PM), especially for smaller breasts, and therefore, volume replacement is critical for optimizing the final aesthetic outcome. We present a novel technique of raising a pedicled descending branch latissimus dorsi (LD) mini-flap for reconstruction of PM defects via an axillary incision. After PM, the LD mini-flap is harvested through the existing axillary incision of the axillary dissection or the sentinel lymph node biopsy. The descending branches of thoracodorsal vessels and nerve are carefully identified and isolated. The transverse branches are protected to maintain muscle innervation and function. The LD muscle is then undermined posteriorly and inferiorly to create a submuscular pocket and a subcutaneous pocket between LD muscle and superficial fascia. Once the submuscular plane is created, the muscle is divided along the muscle fibers from the deep surface including a layer of fat above the muscle. Finally, the LD mini-flap is transferred to the breast defect. Given the limited length and mobility of the LD mini-flap, this approach is best utilized for lateral breast defects. However, for medial defects, the lateral breast tissue is rearranged to reconstruct the medial breast defect, and an LD mini-flap is then used to reconstruct the lateral breast donor site. This technique can therefore be employed to reconstruct all quadrants of the breast and can provide aesthetic outcomes without scars on the back, with minimal dysfunction of LD muscle.

Oncologic reconstruction: General principles and techniques

Halsted's principle of radical mastectomy influenced cancer treatment for decades. Randomized controlled trials resulted in a paradigm shift to less radical surgery and the use of adjuvant therapies. Oncologic reconstruction performed by plastic surgeons has evolved, ranging from skin grafts and local flaps for smaller defects to pedicled flaps and free flaps for larger and more complex defects. Immediate reconstruction facilitates resection is oncologically safe and contributes to meaningful improvements in quality of life. J. Surg. Oncol. 2016;113:852-864. © 2016 Wiley Periodicals, Inc.

The biplanar oncoplastic technique case series: a 2-year review

BACKGROUND

Oncoplastic techniques for breast reconstruction following partial mastectomy are now commonly included in the armamentarium of most reconstructive plastic surgeons. These techniques have been frequently used for women with large breast volume and less frequently used form women with small to moderate breast volume. Most women with smaller breast volumes have been typically considered for mastectomy. As an alternative to mastectomy, the biplanar technique was designed and described as an oncoplastic option. The purpose of this manuscript is to review our 2-year experience using this technique in a series of women with small to moderate breast volume.

METHODS

A retrospective review of patients who underwent oncoplastic surgery from 2011-2012 by the senior authors (RM and MYN) was completed. Ten patients were identified that had the biplanar technique involving glandular tissue rearrangement in conjunction with the immediate placement of a submuscular implant or tissue expander. Patient demographics, perioperative details, and post-operative outcomes were evaluated.

RESULTS

The mean age and BMI of the ten patients in the study was 56 years (range, 40-68 years) and 24.1 years (range, 20.3-28.6 years) respectively. The mean resection volume was 76.5 g (range, 25-164 g). Eight patients had placement of a permanent implant and two patients had placement of a tissue expander. The average volume of the implanted devices was 138 cc (range, 90-300 cc). In eight patients, a sheet of acellular dermal matrix was used. Immediate biplanar reconstruction was performed in seven patients and a staged-immediate biplanar reconstruction was performed in three patients. Complications included a positive margin on final pathology requiring mastectomy (n=1), infection (n=1), incisional dehiscence following radiation (n=1), and loss of nipple sensation (n=2). Follow-up ranged from 4.5-27 months (mean of 19.5 months).

CONCLUSIONS

The biplanar oncoplastic technique may represent a valuable option in women with small to moderate breast volumes that choose to have breast conservation therapy (BCT). This technique has demonstrated success with minimizing contour irregularities and maintaining breast volume. Based on our early experience, patient satisfaction is favorable.

Evaluation of eligibility and utilization of breast conservation treatment in an Asian context

BACKGROUND

Breast conservation treatment (BCT) has long been recognised to provide survival outcomes equivalent to mastectomy for the treatment of breast cancer. However, published reports of BCT rates in Asian communities are lower than those from Western countries. This study sought to investigate the eligibility and utilisation of BCT in a predominantly Asian population.

MATERIALS AND METHODS

All patients treated surgically by a single surgeon at a private medical facility between 2009 and 2011 were included in the study. Patients were deemed to have successful BCT if they underwent breast conserving surgery with pathologic clear margins and completed all recommended adjuvant treatment. Those who did not complete adjuvant treatment were excluded from the analysis.

RESULTS

Data from a total of 161 patients who underwent treatment during the study period were analysed. The mean age was 48.8 years. One hundred and six patients (65.8%) were of Chinese ethnicity, 12 were Indian (7.5%), 11 were Malay (6.8%), 18 were Caucasian (11.2%) and 14 (8.7%) were of other Asian ethnicity. One hundred and thirty-eight women (85.7%) underwent BCT. Of the 23 (14.3%) who underwent mastectomy, 8 (5.4%) elected to undergo a mastectomy despite being eligible for BCT. In total, it was assessed that 146 of 161 patients (90.7%) were eligible for BCT and utilisation was 94.5%.

CONCLUSIONS

In this study, eligibility, utilisation of BCT and eventual successful breast conservation rates are similar to published rates in Western communities. Additional research is needed to investigate the reasons for the lower published BCT rates in Asian countries and determine ways to improve them.