Breast Reconstruction: Reduction Mammaplasty

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For further in depth information on breast reconstruction surgery, the following pages can be can also be consulted:

Breast Reconstruction: Local and Remote Flaps

Breast Reconstruction: Breast Reconstruction after Mastectomy

Breast Reconstruction: Immediate versus delayed breast reconstruction

Breast Reconstruction: Latissimus dorsi and thoracodorsal artery perforator flaps

Since 1982 reduction mammaplasty has been frequently utilized for oncoplastic surgery. There have been several studies that have reported on outcomes. Krishna Clough MD has been a significant contributor and proponent of oncoplastic resection. He began performing reduction-based oncoplastic operations in the 1980s and recently reported on his 14-year experience from the Curie Institute in Paris, France. Subjects included 101 women who were selected for oncoplastic resection because a standard lumpectomy would have resulted in a significant contour abnormality.

The primary reduction technique utilized was an inverted ‘T’ with the NAC based on a superior pedicle. The contralateral reduction mammaplasty was performed immediately in 83% of women and secondarily in 17% of women. Mean tumor excision weight was 222 g. The 5-year local recurrence rate was 9.4%, the overall survival rate was 95.7%, and the metastasis-free survival rate was 82.8%. Cosmetic outcome was satisfactory in 82% of women. It was demonstrated that cosmetic outcome tended to deteriorate when radiotherapy was delivered preoperatively compared to postoperatively.

Scott Spear MD, et al have reported on their 6-year experience from 1996 to 2002, combining wide excision of tumor with immediate bilateral reduction mammaplasty. These operations were all performed in a multidisciplinary fashion. All women in this cohort had large breasts and wore ‘D’ cup brassières. The mean excision volume was 1085 g per breast. Follow-up ranged from 1 to 6 years with a mean of 24 months. No woman developed a local recurrence, although one woman died of metastatic disease. Complications included fat necrosis (n = 3), nipple hypopigmentation (n = 2), hematoma, and complex scar. Patient satisfaction was scored on a visual analog scale that ranged from 1 to 4 with a mean score of 3.3. A panel of independent observers also graded the outcomes and scored the pre-radiation outcome as 2.9 and the post-radiation outcome as 3.03. The principal conclusions from this study were that oncoplastic resection of tumor followed by immediate bilateral reduction mammaplasty avoided the significant asymmetry that would occur following BCT alone or following total mastectomy with immediate total breast reconstruction. Another important conclusion was that the combination of wide excision with immediate reconstruction was oncologically safe.

Albert Losken MD and the group at Emory University in Atlanta, Georgia, have reported on their 10-year (1991–2000) experience utilizing reduction mammaplasty in the setting of oncoplastic surgery. A total of 20 women were included in this review. Mean tumor size was 1.5 mm and the mean weight of the tumor specimen was 288 g. The excised surgical margins were negative in 80%. The most common reduction technique was a superomedial or inferior pedicle. Postoperative abnormal mammograms were noted in 8 women (40%), all of whom underwent additional biopsy. No woman was noted to have a recurrence with a mean follow-up of 23 months. Breast aesthetics and patient satisfaction was acceptable in all women.

These studies, as well as others, have demonstrated the utility of reduction mammaplasty in the setting of oncoplastic surgery. Because the techniques are variable and a greater attention to operative detail is necessary with reduction mammaplasty, a two-team approach isadvocated. The contralateral breast is usually reduced simultaneously; however, when obtaining a clear surgical margin is uncertain, a delayed approach can be safely performed.

Adjacent tissue rearrangement

Adjacent tissue rearrangement is perhaps the most common method by which the partial mastectomy defect is reconstructed. This is because these techniques rarely require a two-team approach as the ablative surgeon will apply the principles and techniques to close these defects. The specific techniques fall within the domain of volume displacement procedures. These techniques are primarily indicated when the partial deformity extends to the chest wall and there is sufficient adjacent tissue to close the defect and maintain a natural contour. Volume replacement techniques are usually not necessary because there is sufficient local tissue. Although several surgeons have described various volume displacement techniques, it is generally accepted that Melvin Silverstein MD was one of the pioneers who introduced and popularized the concepts.

The need to develop these volume displacement techniques stems from the fact that traditional methods of lumpectomy and closure frequently resulted in a contour abnormality of the breast. The reason was that the excision was confined to the lesion and not the surrounding parenchyma. Adjacent tissues were not adequately mobilized and the excision defect was closed primarily. With these volume displacement techniques, the excision is usually extended to the chest wall and the adjacent parenchyma is undermined and mobilized in order to permit the closure of small or large deformities without creating a contour abnormality. There are several pioneers who deserve credit and mention in the evolution of these techniques. Veronesi and colleagues introduced the concept of segmental parenchymal wide excision including the overlying skin. This allowed for the quadrantectomy approach, which was instrumental in establishing the feasibility of breast conservation therapy. These operations were generally performed using a radial approach for tumors that were laterally based. An alternative to the radial approach was the periareolar approach initially described by Amanti, et al. This permitted excisions that resulted in less conspicuous scars.

With the introduction of periareolar subcutaneous quadrantectomy, also known as periareolar donut mastopexy, incisions could be created circumferentially around the NAC and remain relatively inconspicuous. Silverstein has introduced various concepts that include skin incisions using a parallelogram pattern and batwing mastopexy. These parallelogram incisions allowed for wider excision margins while maintaining the natural contour of the breast. Batwing mastopexy is an extension of this concept and is used primarily for centrally situated tumors near the NAC. Clough, et al have introduced the technique of reduction mastopexy lumpectomy. This technique has been especially useful for tumors situated near the lower pole of the breast. Standard lumpectomy of these tumors would often result in an inferiorly displaced NAC. All of these techniques have specific indications based on tumor location.

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