Free PDF Download - European Review

Oliver Johansen | Download | HTML Embed
  • Jan 25, 2010
  • Views: 35
  • Page(s): 10
  • Size: 224.41 kB
  • Report



1 European Review for Medical and Pharmacological Sciences 2008; 12: 387-396 Conservative and radical oncoplastic approches in the surgical treatment of breast cancer G. FRANCESCHINI, S. MAGNO, C. FABBRI, F. CHIESA, A. DI LEONE, F. MOSCHELLA, I. SCAFETTA, A. SCALDAFERRI, S. FRAGOMENI, L. ADESI BARONE, D. TERRIBILE, M. SALGARELLO, R. MASETTI Breast Unit, Department of Surgery, Catholic University of the Sacred Heart Rome (Italy) Abstract. In the attempt to optimise the Accurate preoperative evaluation of the clini- balance between the risk of local recurrence cal and biological features of the tumor as well and the cosmetic outcomes in breast surgery, as of the morphological aspects of the breast al- new surgical procedures, so-called oncoplastic techniques, have been introduced in recent low the surgeon to make a decision if a radical or years. The term oncoplastic surgery refers to conservative approach is preferable and select surgery on the basis of oncological principles the most effective surgical technique. Available during which the techniques of plastic surgery options are discussed with the patient, highlight- are used, mostly for reconstructive and cosmet- ing the advantages and disadvantages of each ic reasons. The advantage of the oncoplastic procedure and the technical challenges. surgery for breast cancer is the possibility of performing a wider excision of the tumour with When no major obstacle exists in achieving a good cosmetic result. Oncoplastic surgery is optimal local control and good cosmetic results a broad concept that can be used for several with preservation of the breast, the treatment of different combinations of oncological surgery choice is breast-conserving surgery1-3. Total mas- and plastic surgery: excision of the tumour by tectomy is considered mandatory only for multi- reduction mammoplasty, tumour excision fol- centric disease, T4 and inflammatory tumors, ex- lowed by remodelling mammoplasty, mastecto- tensive malignant mammographic microcalcifi- my with immediate reconstruction of the breast and partial mastectomy with reconstruction. cations or when clear surgical margins cannot be Careful patient selection and preoperative plan- achieved without generating a significant and not ning are key components for the success of any adjustable local deformity5-6. oncoplastic operation for breast cancer. Accu- Oncoplastic skills are incorporated in the sur- rate preoperative evaluation of the clinical and gical planning, both when using breast-conserv- biological features of the tumour as well as of ing surgery or total mastectomy2-4. the morphological aspects of the breast allow the surgeon to make a decision if a conserva- tive or radical approach is preferable and select the most effective oncoplastic surgical tech- nique. In this review we summarise the indica- Planning of Breast Conserving tions, advantages and limitations of several on- Oncoplastic Procedures coplastic procedures. When a breast conserving approach is feasible, selection of the most appropriate technique is guided mainly by the location of the tumor, also Key Words: taking into account the volume and shape of the breast, the size of the lesion and the morphologic Breast cancer, Oncoplastic surgery. changes that the surgical act is likely to deter- mine. For cancers that are small relative to breast size and do not require extensive parenchymal excisions, traditional techniques of breast-con- Introduction Careful patient selection and preoperative serving surgery can be applied with excellent planning are key components for the success of cosmetic results. But when resection of more any oncoplastic operation for breast cancer. than 20% of parenchymal volume is required for Corresponding Author: Gianluca Franceschini, MD; e-mail: [email protected] 387

2 G. Franceschini, S. Magno, C. Fabbri, F. Chiesa, A. Di Leone, et al. adequate local control, particularly for cancers located in the central, medial or lower pole of the breast, oncoplastic techniques acquire major im- portance to avoid the risk of an unpleasant cos- metic outcome7-11. In our Center, planning for oncoplastic breast- conserving surgery includes: accurate preoperative skin marking according to the technique selected for parenchymal ex- cision; evaluation of the most appropriate volume dis- placement or volume replacement technique to be used for reshaping of the post-resection de- fect; evaluation of the risk that the parenchymal ex- cision may cause displacement of the nipple areolar complex and adaptation of the skin drawings to assure that it may be repositioned to the center of the breast mound, if signifi- cantly displaced; Figure 1. In the donut mastopexy, two concentric circles evaluation of the need for symmetrization of of different diameter are designed around the nipple. the contralateral breast, and selection of the most appropriate technique. The first step is to select the oncoplastic tech- signed so as not to exceed that of the original nique that can provide the most effective onco- areola diameter by more than 20-25 mm, in order logic resection with the least cosmetic impair- to prevent widening of the circumareolar scar or ment and the dominant criteria that we use for excessive flattening of the breast. selection is the location of the tumor within the The initial step is the incision of the inner cir- breast. Breast size, age, general status and per- cle, which will represent the new border of the sonal desires of the patient are also taken into ac- areola. The outer circle is then incised and the count. donut of skin between the two circles is excised. Quadrant resection of the breast parenchyma can Planning for Periareolar Lesions then be performed through a wider incision, al- Oncoplastic volume displacement techniques lowing for better control of the tumor removal provide excellent outcomes in the treatment of than when the resection is performed through periareolar lesions. For breasts with moderate conventional conservative skin incisions. Re- ptosis, we prefer a donut mastopexy or a batwing shaping of the breast can be performed appropri- mastopexy, while for breasts with severe ptosis ately by displacement of the residual gland. At or redundant skin we favor a reduction mammo- this regard, we normally proceed to separate the plasty pattern. residual gland off the pectoralis fascia using the With a donut mastopexy approach, comfort- electrocautery, paying attention to limit the num- able access can be gained to any lesion in the pe- ber of major perforating vessels that are sec- riareolar region as compared to traditional breast- tioned, in order not to threaten the blood supply conserving techniques. In this operation, two to the residual glandular tissue. After careful concentric circles of different diameter are de- haemostasis has been obtained, the residual signed around the nipple (Figure 1). The areolar breast parenchyma is reapproximated to facilitate skin is stretched only mildly when the inner cir- a natural appearing breast. Sutures are placed in cle is designed, to avoid that the final areolar di- the deep portion of the residual gland, right ameter may result smaller than desired. The di- above the fascia, to secure the posterior edges in ameter of the inner circle is usually set between their new position. We normally use 2-0 vicryl 4.0 and 4.5 cm, depending on the size of the sutures for this purpose, while for reapproxima- breast. The diameter of the outer circle is de- tion of the superficial portion of the breast we 388

3 Conservative and radical oncoplastic approches in the surgical treatment of breast cancer use 4-0 absorbable sutures in the dermis. If need- ed, a purse-string suture is used to reduce the di- ameter of the larger circle and is then sutured to the new border of the areola, leaving only a peri- areolar scar at the end of the procedure (Figure 2). Axillary dissection is usually performed through a separate incision, but occasionally can be conducted through the same periareolar inci- sion. If the two circles are concentric, the NAC is not elevated, while if the outer circle is centered around a point located higher than the existing nipple, the NAC can be slightly elevated as a consequence of the procedure. After completion of skin closure, the thorax of the patient is wrapped in an elastic bandage to reduce the risk of hematoma formation. A batwing mastopexy pattern is ideal for can- Figure 3. The batwing mastopexy: final result four months cers located in the upper periareolar region, par- after surgery. ticularly when the lesions are in proximity of the skin. Two half-circles are designed, one on the border of the areola and one 20-25 mm above it, Some uplifting of the NAC may result at the and connected with angled wings on each side of end of the procedure, but normally it does not de- the areola. Designing of the skin incisions should termine significant asymmetry (Figure 3). be made with the patient sitting erect. The areo- For breasts with severe ptosis, reduction mam- lar half-circle is incised first, followed by the up- moplasty patterns may offer better results. The re- per half circle and the wings. Full-thickness section of the tumor with wide macroscopically lumpectomy is performed and the residual gland clear margins can be easily achieved in combina- is lifted off over the pectoralis fascia to allow ad- tion either with an inferior or superior pedicled equate advancement of tissue in order to remodel flap to recreate a normally shaped breast and shift the defect. Remodeling of the breast defect is the NAC to an appropriate position. achieved with similar skills as indicated for the donut mastopexy. The procedure allows for am- Planning for Central, Retroareolar Lesion ple removal of the skin overlying the lesion, and For centrally located tumors, involving the therefore can increase the safety of oncologic retroareolar region or for Paget disease, several control of cancers located superficially. breast conserving oncoplastic procedures have been used in recent years as an alternative to to- tal mastectomy. All these techniques include a complete excision of the tumor with the entire NAC and the correspondent underlying cylinder of parenchyma down to the pectoralis fascia. The central defect is then restored either with simple purse-string suture, linear sutures or skin- parenchymal flaps. We usually utilize the Grisotti technique, as it is simple and offers excellent cosmetic results. With the patient in the sitting position, a circle is drawn along the borders of the areola. Another circle is drawn below the areola and lines from the medial and lateral sides of the upper circle are connected laterally on the inframammary fold (Figure 4). Incisions are made along the drawings and the Figure 2. Donut mastopexy: final result six months after skin below the areola is excised, with exception surgery; only a periareolar scar remains visible. of the skin included in the lower circle. The NAC 389

4 G. Franceschini, S. Magno, C. Fabbri, F. Chiesa, A. Di Leone, et al. about 5 cm from the edge of the wound. The cir- cular skin defect, caused by the excision of the NAC, is closed using a purse-string suture with a 3-0 monofilament absorbable suture, without po- sitioning a drain and avoiding deep parenchymal sutures. Immediately after the operation, the skin looked wrinkled in the center of the breast but it flattened in few weeks. Planning for Lesions Located in the Lower Quadrants Cancers located in the lower region of the breast expose to a higher risk of cosmetic failure if treated with standard lumpectomy techniques. Downturn- ing of the NAC and/or introflection of the lower pole are often seen with these procedures. Figure 4. In the Grisotti procedure, two circles are drawn, For these lesions, we tend to prefer a reduction one along the borders of the areola, the other below the areola mammoplasty pattern, that may allow resection and lines from the medial and lateral sides of the areolar circle are connected down and laterally on the inframammary fold. of large amounts of breast tissue with excellent cosmetic outcomes and wide surgical margins, even in small breasts. A vertical pattern, a L-shaped pattern or a with the underlying tumor is completely excised key-hole pattern incision may be used, and we down to the pectoralis fascia. The skin-glandular normally prefer the latter. The patient is marked flap mobilized from the inferior lateral pole of with the shoulders held back and level. A mark the residual gland is used to create the new areo- is made in the center of the sternal notch; each la. The flap is incised medially down to the pec- clavicle is marked 6 cm laterally from this ster- toralis fascia and separated from the latter to al- nal mark (Figure 6). A straight line is drawn low for adequate rotation and advancement. It is from each clavicular mark to the nipple of the then sutured to the gland stump superiorly, in or- breast below. The center of the proposed nipple der to give adequate projection to the tip of the location is sited on this line, at a distance placed breast mound and the circular area of preserved between 19 and 23 cm from the sternal notch skin is sutured to replace the excised areola. Care mark, depending on the size of the patient. A should be taken to avoid excessive devascular- circle of 5 cm diameter is drawn centered on the ization of the skin-glandular flap, to minimize new nipple location and radial lines of 6 cm are the risk of ischemic injury to the neo-areola. At designed from the lower half of the circle, and the end of the procedure, the breast may result slightly smaller than the controlateral, but with a pleasant shape (Figure 5). If desired by the pa- tient, reconstruction of the nipple can be per- formed immediately or at a later stage, with tat- toing of the areola. An alternative oncoplastic technique is a cen- tral quadrantectomy with complete excision of the NAC and subsequent remodelling of the breast12. In particular, a circular periareolar cuta- neous incision is made and extended down to the fascia of the large pectoral muscle, so as to per- mit the excision of a cone of glandular tissue, containing the tumour and wide margins of healthy tissue. Then, a remodelling of the breast is performed by the separation of the glan- dular tissue from the fascia of the large pectoral Figure 5. Grisotti procedure: appearance of the breast two muscle and from the skin, extended around to weeks after surgery. 390

5 Conservative and radical oncoplastic approches in the surgical treatment of breast cancer Figure 7. A reduction mammaplasty pattern: final result six months after surgery. Figure 6. Skin marking is particularly important when a reduction mammaplasty pattern is used. A mark is made in the center of the sternal notch and each clavicle is marked 6 proves the cosmetic appearance of the breast cm laterally from this point. A straight line is drawn from but also can facilitate the delivery of postopera- each clavicular mark to the nipple of the breast below. The center of the new nipple location is sited at a distance be- tive radiotherapy. Due to the size of the breast, tween 19 and 23 cm from the sternal notch mark. consistent positioning for radiotherapic treat- ment may be quite difficult in these patients, resulting in dosing inhomogeneity, a higher percentage of unacceptable late radiation reac- connected in straight lines to markings previ- tions, and overall inadequate local treatment. ously made on the existing inframammary By reducing the size of the breast with a masto- creases. Medially these lines should connect at plasty approach, these risks may be avoided, about 1cm from the midline, and should never without any significant interference with clini- reach the medial drawings of the contralateral cal or radiologic follow-up. breast. Marking of the lateral end of the infra- mammary crease is not on its natural ending (as Planning for Lesions Located in it extends too laterally and too low), but rather the Upper Quadrants is crossed superiorly on the mid-axillary line to Excision of small tumors located in the upper terminate 2-3 cm superior to the crease. This outer quadrant often does not require any partic- end is connected with a straight line to the infe- ular reconstruction and adequate cosmetic results rior end of the lateral wing. can be achieved simply by approximation in lay- The skin markings are progressively incised, ers of the residual parenchyma. When the exci- and the lesion is completely excised with the sion of the tumor generates a larger defect, either overlying skin. The parenchymal excision is con- in the upper outer or upper inner quadrants, some ducted down to the fascia of the pectoralis major form of reconstruction is mandatory. Volume re- muscle and a superior pedicle flap is created to placement techniques may be considered in these mobilize the NAC. For cancers located in the in- cases, transferring autologous tissue from a re- fero-lateral or infero-medial quadrants, the mote site to fill the resection defect. This com- parenchymal excision can be oriented as to in- monly involves the use of the latissimus dorsi, clude more lateral or medial portions of the either as a muscle-subcutaneous flap, a musculo- breast. This requires more extended undermining cutaneous flap (including the overlying skin), or of either the medial or lateral flap. After com- a muscle-sparing pedicled skin and fat-only flap. pleting the parenchymal excision, the medial and (TDAP = Thoraco Dorsal artery Perforator flap). lateral flaps are sutured together in order to re- As the volume is restored, symmetry is usually store the normal shape of the breast mound, leav- mantained and contralateral surgery is rarely re- ing a vertical or L-shaped or a typical inverted T- quired. Complications of latissimus dorsi flap scar (Figure 7). may include donor site morbidity, shoulder dys- A reduction mammoplasty approach results function and partial or total flap loss. Complica- particularly convenient in women with very tion of TDAP flap (partial or total flap loss) are large and pendolous breasts, as it not only im- minimal. The cosmetic outcome is generally bet- 391

6 G. Franceschini, S. Magno, C. Fabbri, F. Chiesa, A. Di Leone, et al. ter when replacement techniques are used to re- store a defect in the upper outer quadrant. If volume displacement techniques are used in these cases, repositioning of the NAC is usu- ally required to guarantee good cosmetic re- sults. The incision is therefore extended to in- clude the entire border of the areola and a semicircular area of skin adjacent to the areola is removed on the side opposite to the excision; finally, the NAC moved to the tip of the new breast mound, with subcuticular 4-0 Biosyn su- tures to close the skin. Figure 8. Concentric mastopexy for symmetrizazion of the Procedures on the Contralateral Breast Independently from the location of the tu- right breast performed simultaneously with an oncoplastic mor or the choice of the oncoplastic procedure, upper external quadrantectomy of the left breast. Final result reshaping of the contralateral breast may be in- six months after surgery. cluded in the treatment planning6. The option of mastopexy or volume reduction of the con- tralateral breast to improve simmetry and cos- metic outcome should be discussed with the Planning of Total Mastectomy and patient, particularly in women of younger age Breast Reconstruction or with large and pendolous breast. In case the oncoplastic procedure use the mammoplasty When a breast conserving approach cannot pattern, the same pattern should be used for guarantee adequate local control and good cos- the controlateral surgery. With a well-trained metic result, total mastectomy is selected13-14. team, the operation can be conducted on both In this case, the option of immediate breast re- sides at the same time, thus reducing the surgi- construction is offered almost to all patients as cal time. it can improve the quality of life and does not If the difference between the two breasts is not interfere with further treatments. Patients excessive, we often utilize a concentric ma- scheduled for immediate breast reconstruction stopexy, as it is relatively simple and fast, and al- are evaluated jointly in the preoperative period lows to elevate the contralateral breast for a max- by the breast surgeon and the plastic surgeon imum of 2 cm. The decision to adopt this proce- and at that time the options of autologous and dure can be taken at the end of the oncologic pro- prosthetic reconstruction are rediscussed in de- cedure, even directly at the operating table, if the tail. In the Authors practice, prosthetic imme- need to better balance the cosmetic result be- diate reconstruction has its most favorable re- comes apparent (Figure 8), as the design for the sults in patients with small- or moderate-vol- concentric mastopexy can be made with the pa- ume breasts with or without ptosis, who have tient in the supine position. Reduction mammo- not received and are not expected to receive ra- plasty is more time consuming, but allows for diotherapy, and particularly for bilateral recon- more effective symmetrization, particularly structions. It may also offer good results in se- when dealing with large, ptotic breasts that lected patients with large breast. Autologous need major lifts. This procedure needs to be reconstruction is offered to all patients that planned before surgery, as the markings have to have undergone preoperative radiotherapy (pre- be made with the patient in a standing or sitting vious breast conserving surgery with radiother- position. When performing symmetrization apy) or will need to receive postoperative ra- procedures, the surgeon should take the oppor- diotherapy because of local extension of the tunity to remove any suspicious tissue in the disease. It is also offered to patients who will contralateral breast that may have been shown require a skin-reducing mastectomy for ad- on the preoperative mammogram. In many se- vanced breast cancer or cutaneous recurrences, ries, this has resulted in a 5% detection rate of in patients with large breast and surplus of ab- contralateral subclinical cancers5. dominal tissues, and in patients unwilling to 392

7 Conservative and radical oncoplastic approches in the surgical treatment of breast cancer A B Figure 9. A, Preoperative view: skin incision includ- ing the areola and the scar of previous biopsy. B, C, Postoperative view at 8 months. C endure an implant. Authors main choice for through a periareolar incision (more than 70% of immediate autologous reconstruction is the cases). All patients with small/medium breast DIEAP flap. and medium/large areolae are suitable candidates for periareolar SSM. For patients with small are- Planning for Total Mastectomy olae (inferior to 3 cm) and large breast, a periare- When a final decision is made with the patient olar approach with a lateral extension (if pros- about the surgical strategy, cutaneous incisions thetic reconstruction is planned) or with vertical and/or skin excision pattern for the total mastec- extension (if autogenous reconstruction is tomy are agreed upon between the breast surgeon planned) is adopted to facilitate dissection and to and the plastic surgeon according to the princi- avoid skin flap complications by excessive trac- ples of oncoplastic surgery in order to optimize tion. In case of previous surgery to the index the aesthetic results of the breast reconstruction. breast, or when the tumor is very close to a limit- The effort is to preserve the mammary skin ed portion of skin, the SSM incision can be envelope as much as possible, using skin-sparing traced so as to include the areola and the scar or techniques, and the same applies to the fascia of the skin overlying the tumor (if there is a small the pectoralis major muscle and the deep tho- distance between them) (Figure 9 A-C). As an al- racic fascia, particularly when a prosthetic recon- ternative, two separate skin incisions can be struction is planned. The inframammary fold is traced in order to avoid skin flap necrosis. also usually preserved to enhance the cosmetic Skin Reducing Mastectomy (SRM) techniques results of the immediate reconstruction. may be selected either for oncological reasons A skin-sparing mastectomy (SSM) is therefore (large superficial tumors, that are close to ex- the preferred choice, and we usually perform it tended portions of skin) or for aesthetic reasons 393

8 G. Franceschini, S. Magno, C. Fabbri, F. Chiesa, A. Di Leone, et al. (patients with large and/or ptosic breasts). In planned, the Authors prefer a one-stage surgical these latter cases, SRM is performed utilizing the approach, with the placement of a definitive skin incision of the reduction mammoplasty (ver- anatomical silicone-filled textured prosthesis and tical, L, or inverted T patterns) in order to re- contralateral symmetrization18,19. The implant is duce the skin envelope (Figure 10 A-B). The ver- placed in a subpectoral-subfascial pocket, under- tical pattern is the most suitable, as it better pre- mining the pectoralis major muscle and the in- serves the vascularity of the mastectomy flaps. vesting deep thoracic fascia which is elevated in For symmetry reasons, the same pattern used for continuity with the inferior edge of the pec- the SRM should be selected for the contralateral toralis muscle. Thus, the implant is completely aesthetic procedure (Figure 11). separated from the mastectomy skin flaps. Use of Nipple-Sparing Mastectomy (NSM) is consid- a tissue expander is limited to cases in which ad- ered only in strictly selected cases15-17. The Au- ditional periareolar skin has been removed, thus thors favor the inferior periareolar incision be- rendering primary skin closure over the defini- cause of its central position on the breast mound, tive implant difficult (5% of cases). but inframammary incision or even every inci- The patient is placed in hemi-seated position. sion from previous biopsy can suit to the NSM. A median line is drawn from the jugulus to the Further surgical steps are the same than for SSM. xifoid. The inframammary line is also traced Particular attention is payed to the thickness of bilaterally and tattooed. The subpectoral-sub- the mastectomy flaps, especially under the NAC fascial pocket is thus created. Starting from where a 3-4 mm cylinder of subareolar breast tis- the supero-lateral edge of the pectoralis major sue is left, in order to reduce its post-operatory muscle, blunt undermining of the muscle is morbidity, and to spare the deep thoracic fascia, performed, then the fiber optic light retractor is if a prosthetic reconstruction is planned. inserted below the muscle, to elevate the inferi- Axillary dissection is performed either through or part of the muscle and in continuity the in- a separate axillary incision or through the mas- vesting deep thoracic fascia up to inframamma- tectomy incision, depending on the size of the in- ry fold. The base of the dissection is the costal cision and the laxity of the skin. cage superiorly, the anterior fascia of the rectus muscle inferiorly. At the level of the inframam- Prosthetic Breast Reconstruction mary fold the subcutaneous tissue is entered up Prosthetic breast reconstruction offers the ad- to its subdermal level. This manoeuvre helps to vantages of minimal scarring, avoidance of define the fold. The appropriate shape and size donor-site morbidity, reduced operative times of the implant is selected according to the con- and faster postoperative recovery. It is well ac- tralateral breast. The subpectoral-subfascial cepted by many patients who are unwilling to pocket is closed over the implant, in order to bear prolonged recovery and donor-site morbidi- keep the subcutaneous tissue of the mastectomy ty. If a prosthetic immediate reconstruction is flaps separated from the prosthesis. Whenever A B Figure 10. A, Preoperative view: possible skin incisions (circumareolar, small ellipse). B, Postoperative view at 6 months. 394

9 Conservative and radical oncoplastic approches in the surgical treatment of breast cancer abdominal perforators completely sparing the rectus muscle and its innervation thus reducing abdominal morbidity and is anastomosed to the internal mammary vessels. Anastomosing and molding the flap is performed through the cir- cumareolar incision, eventually adding a short vertical incision if the periareolar one is very small, or through the mammoplastic pattern. Re- cent technical improvements come from the pre- operative planning with the multidetector23 that allows to choose the dominant perforator in the preoperative set. It enables to harvest the abdom- inal flap with the best angiosome thus enhancing the reliability of each flap. Figure 11. Left mastectomy with vertical pattern and right In conclusion, the Authors recommend one- vertical mastopexy: postoperative view at 12 months. stage breast reconstruction for all mastectomy patients, either with definitive implant after SSM or with DIEAP flap. These techniques al- low to achieve very good cosmetic results in a is possible, the skin incision is closed by a unique surgical stage with a low rate of compli- purse-string in order to keep the final scar cations. short. When a purse-string suture is performed, Close cooperation between the breast surgeon the skin envelope looks wrinkled after surgery, and the plastic surgeon is essential to allow opti- but will flatten in few weeks. mal care for these patients. Contralateral surgery for symmetrization is performed as needed (70% of the cases in our practice). Reconstruction of the nipple-areola Bullet Points complex is usually delayed to a second stage, 1-2 months after the end of chemotherapy, in order to Careful patient selection and preoperative place the NAC in the correct position and to opti- planning are key components for the success mize the symmetry. of any oncoplastic operation for breast cancer. Prosthetic reconstruction leads to good aes- The location of the tumor within the breast is thetic results, and the level of patient satisfaction the dominant criteria to select the most appro- is usually high. Immediate complications are priate oncoplastic technique. Breast size, age, limited, and mainly represented by infections general status and personal desires of the pa- (5%) and partial necrosis of the mastectomy tient are also taken into account. flaps (7%). Periprosthetic infection is usually The donut or the batwing mastopexy are the solved with e.v. antibiotics, and very rarely re- techniques of choice for periareolar lesions, quires removal of the implant. Skin slough while for subareolar lesions a central quadrante- and/or small flap necrosis happen around the comy with the Grisotti technique is preferable purse-string suture when the mastectomy flaps Reduction mammoplasty techniques offer ex- are very thin, and are usually managed with con- cellent results, both in terms of local control servative measures. Extensive flap necrosis re- and cosmetic outcome, particularly for lesions quiring explantation of the prosthesis occur very that occur in pendulous breasts. rarely. Seroma and hematoma are also rare. The option of symmetrization of the contralat- Long term complications are mainly represented eral breast should be proposed to the patient, by capsular contracture (3%) (II and IV grade ac- particularly for women with higher cosmetic cording to Bakers classification) that shifts toward expectations. autogenous reconstruction with the DIEAP flap. Dieap Flap Reconstruction DIEAP flap reconstruction follows the general References guidelines as they are described in the litera- 1) BRDART A, PETIT JY. Partial mastectomy: a balance ture20-22: the DIEAP flap is raised on one or more between oncology and aesthetics? Lancet Oncol- 395

10 G. Franceschini, S. Magno, C. Fabbri, F. Chiesa, A. Di Leone, et al. ogy 2005; 6: 130. Oncol 2005; 12: 539-545. 2) ANDERSON B, MASETTI R, SILVERSTEIN M. Oncoplastic 12) FRANCESCHINI G, MASETTI R, D'ALBA P, CONSORTI G, approaches to partial mastectomy: an overview of PICCIOCHI A. Conservative treatment with nipple- volume-displacement techniques. Lancet Oncolo- areolar resection for subareolar breast cancer. gy 2005; 6: 145-157. Breast J 2006; 12: 91-92. 3) MASETTI R, PIRULLI PG, MAGNO S, FRANCESCHINI G. On- 13) TOTH BA, LAPPERT P. Modified skin incision for mas- coplastic techniques in the conservative surgical tectomy: the need for plastic surgical input in pre- treatment of breast cancer. Breast Cancer 2000; operative planning. Plast Reconstr Surg 1991; 7: 276-280. 87: 1048-1053. 4) MASETTI R, DI LEONE A, FRANCESCHINI G, MAGNO S. 14) PROTOCOLLO DI DIAGNOSI E TRATTAMENTO DEL CARCINOMA Oncoplastic techniques in the conservative surgi- MAMMARIO FONCAM. Edizione OIC, Firenze, 2001. cal treatment of breast cancer: an overview. 15) S IMMONS R, H OLLENBECK ST, L AT RENTA G. Areola Breast J 2006; 12: S174-180. sparing mastectomy with immediate breast re- 5) SMITH ML, EVANS GR, GRLEK A, BOUVET M, SINGLE- construction. Ann Plast Surg 2003; 51: 547-551. TARY SE, AMES FC, JANJAN N, MCNEESE MD. Reduc- 16) SIMMONS R, HOLLENBECK ST, LATRENTA G. Two year fol- tion mammoplasty: its role in breast conservation low-up of areola-sparing mastectomy with immedi- surgery for early-stage breast cancer. Ann Plast ate reconstruction. Am J Surg 2004; 188: 403-406. Surg 1998; 41: 234-239. 17) VLAJCIC Z, ZIC R, STANEC S. Nipple-areola complex 6) C ODY III HS. Current surgical management of preservation: predictive factors of neoplastic nip- breast cancer. Gynecol Oncol Pathol 2002; 14: ple areola complex invasion. Ann Plast Surg 45-52. 2005; 55: 240-244. 7) LANFREY E, RIETJENS M, GARUSI C, PETIT JY. Mammo- 18) SALGARELLO M, FARALLO E. Immediate breast recon- plasty for symmetry of the contralateral breast struction with definitive anatomical implants after and its oncologic value. Ann Chir Plast Esthet skin sparing mastectomy. Br J Plast Surg 2005; 1997; 2: 160-167. 58: 216-222. 8) CLOUGH KB, CUMINET J, FITOUSSI A, NOS C, MOSSERI 19) SPEAR SL, PELLETTIERE CV. Immediate breast recon- V. Cosmetic sequelae after conservative treat- struction in two stages using textured, integrated- ment for breast cancer: classification and results valve tissue expanders and breast implants. Plast of surgical correction. Ann Plast Surg 1998; 41: Reconstr Surg 2004; 113: 2098-2103. 471-481 20) ALLEN RJ, TREECE P. Deep inferior epigastric perfo- 9) CLARK J, ROSENMAN J, CANCE W, HALLE J, GRAHAM M. rator flap for breast reconstruction. Ann Plast Extending the indications for breast-conserving Surg 1994; 32: 32. treatment to patients with locally advanced breast cancer. Int J Radiat Oncol Biol Phys 1998; 42: 21) BLONDEEL PN. One hundred free DIEP flap breast 345-350. reconstruction: a personal experience. Br J Plast Surg 1999; 52: 104-111. 10) C LOUGH KB, L EWIS JS, C OUTURAUD B, F ITOUSSI A, NOS C, FALCOU MC. Oncoplastic techniques al- 22) HAMDI M, WEILER-MITHOFF EM, WEBSTER MH. Deep low extensive resection for breast-conserving inferior epigastric perforator flap in breast recon- therapy of breast carcinomas. Ann Surg 2003; struction: experience with the first 50 flaps. Plast 237: 26-34. Reconstr Surg 1999; 103: 86-95. 11) KAUR N, PETIT JY, RIETJENS M, MAFFINI F, LUINI A, GATTI 23) GRANZOW JW, LEVINE JL, CHIU ES, ALLEN RJ. Breast G, REY PC, URBAN C, DE LORENZI F. Comparative reconstruction with the deep inferior epigastric study of surgical margins in oncoplastic surgery perforator flap: history and an update on current and quadrantectomy in breast cancer. Ann Surg technique. J Plast Reconstr Aesthet Surg 2006; 59: 571-579. 396

Load More