Breast reconstruction after conservative surgery Jean-Yves Petit, © Youssef, C Garusi Introduction Reduction of the psychological distress accompany- ing breast cancer treatment is @ primary aim in development of methods of breast conservation surgery and breast reconstruction post-mastectomy. Results of conservation surgery may deteriorate with time and a joint approach by plastic and oncologi- cal surgeons improves the longer-term cosmetic results of conservation treatment for breast cancer. The criteria for breast preserving surgery are relative, and although initially confined to patients with smaller tumours (<3 cm), conservation surgery may be suitable for women with larger breasts in whom (i) tumours are up to 4 or 5 em in diameter, (i) multifocal tumours are confined to the same quadrant and (iii) large operable tumours have been downstaged by neoadjuvant chemotherapy. The size of the tumour relative to the breast volume is @ Figure 10.1. Deformity of the breast after wide excision ‘without reconstruction of the glandular defect. 101102 Oncoplastic and Reconstuctive Surgery of the Breast critical factor in determining feasibility of conserva- tion surgery and ensuring an optimal cosmetic result, Close collaboration between oncological and plastic surgical teams may in some circumstances broaden the opportunities for successful conserva- tion surgery. Large deficits of glandular tissue can be compensated for by using techniques such as local transposition of glandular tissue or myocuta- neous flaps and symmetry can often be improved by 4 contralateral reduction mammoplasty. Moreover, the use of plastic surgical techniques not only improves the final cosmetic result, but also permits the cancer surgeon to remove the tumour with a greater volume of surrounding normal breast tissue, thus increasing the chance of microscopic clearance with tumourfree margins and improved local control rates. Techniques of partial breast reconstruction Experience has shown that the majority of deformi- ties following breast conservation result from scar Figure 10.2 (a-c) Skin incisions contracture and the local glandular defect which together lead to progressive asymmetry and distor- tion of the breast (Figure 10.1). Immediate partial reconstruction aims to restore the original volume and shape of the breast and to achieve a better match between the operated and contralateral breast? The choice of incision is important from both oncological and cosmetic aspects; redial incisions in the lower part of the breast and circumlinear ones in the upper quadrants of the breast result in the Teast visible scars when closed with subcuticular (intradermal) absorbable sutures. Interrupted (or curved) incisions in the upper outer quadrant can help reduce excessively long scars which may subsequently contract (Figure 10.2). Optimal results are obtained when the deeper glandular tissue has been carefully approximated to obliterate any major glandular defect. This is particularly important following larger resections such as quadrantectomy (Figures 10.3 and 10.4) and should be performed with local glandular flaps or even with distant fasciocutaneous or myocutaneous flaps. Figure 10.3. After wide excision of the cancer the glandular breast tissue is mobilized to reconstruct the breast mound,Breast reconstruction after conservative surgery 103 ws ¥ Figure 10.4 After wide excision of the cancer the glandular breast tisue is mobilized to reconstruct the breast mound. es Figure 10.5 After excision of the cancer the glandular tissue is mobilized atthe level of the pectoralis fascia and the skin to allow approximation of the edges of the breast, Undermining the glandular tissue at the level of the pectoralis fascia facilitates mobilization of adjacent breast tissue to fill the defect (Figure 10.5). This ‘undermining also permits more thorough assessment of the whole glandular tissue by peroperative bidig- ital palpation of the breast parenchyma. However, such extensive undermining can threaten the blood supply to glandular elements and thus increase the risk of postoperative necrosis and secondary sepsis. For those patients with a tumour in relatively large breasts, reduction mammoplasty procedures can be fashioned using a nipple-areolar pedicle based either superiorly or inferiorly?" depending on the site of the tumour {ie. supra or infra-areolar) (Figures 10.6 and 10.7). For details of surgical technique see Chapter 12. Tumours located in the lower quadrants can be treated with the same technique (Figure 10.8). Centrally located tumours mandate excision of the nipple-areolar complex in order to ensure tumour- free margins and minimize the tisk of local recur- rence." Closure of the central defect can be achieved relatively easily by inserting purse-string style Figure 10.6 (a:b) Inferior pedicle breast reduction technique for carcinomas above the nipple or in the lower medial or lateral quadrants of the breast.