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Aesth. Plast. Surg. 31:71 75, 2007 DOI: 10.1007/s00266-005-0063-7

Original Articles

Aesth. Plast. Surg. 31:71 75, 2007 DOI: 10.1007/s00266-005-0063-7 Original Articles A Modified Excision for Combined Reduction

A Modified Excision for Combined Reduction Mammoplasty and Breast Conservation Therapy in the Treatment of Breast Cancer

Donald A. Hudson, F.R.C.S., M. Med.

Department of Plastic and Reconstructive Surgery, University of Cape Town, Cape Town, South Africa

Abstract. Wide local excision combined with postoperative radiotherapy is a useful technique for patients with breast cancer. For patients with macromastia whose tumor is sit- uated in the lower pole of the breast, a breast reduction (keyhole\inverted T pattern ) can be used to achieve wide local excision. However, for patients whose tumor is not in the inferior portion of the breast, and in whom this cancer also is situated close to the skin (requiring excision of skin with a 1-cm margin for oncologic safety), the traditional keyhole pattern cannot be used. A modification of the keyhole pattern\inverted T is described. The pedicle used depends on the site of the tumor. Although the breast scars are in different positions, a similar breast shape as well as symmetry still can be achieved. This is a useful technique for a select subgroup of patients. The outcomes for three patients are presented.

Key words: Breast cancer—Conservation surgery

Breast conservation therapy consisting of wide local excision and postoperative radiotherapy is a well- established form of treatment for breast cancer [2 4]. The technique has the advantage of preserving the original breast skin and retaining the nipple areola complex [2 4]. The disadvantages include the effects of radiotherapy on the breast and the fact that if tissue is excised from only one breast, asymmetry may result. For patients with large breasts whose tumor is situated in the inferior pole of the breast, a bilateral breast reduction can be performed [2 4]. This en- ables a wide local excision of the tumor, and by

Correspondence to D. A. Hudson, F.R.C.S., M. Med.; email:

hudsond@ uctgsh1.uct.ac.za

removal of tissue from both breasts, also creates breast symmetry. In addition, it enables some path- ologic assessment of the opposite breast [2]. This article reports on three patients whose tumor was situated close to the skin in the upper and lateral aspect of the breast. A bilateral breast reduction was performed, but the skin markings were modified to enable an oncologically safe procedure including excision of the overlying skin.

Technique

The technique involves the keyhole\inverted T pat- tern consisting of three triangles (Fig. 1). There is a vertical triangle, a medial triangle, and a lateral triangle. The inferior margins of the medial, lateral, and vertical triangles usually are placed along the inframammary fold. With this technique, the lateral triangle is not positioned at the lateral base of the breast, but is advanced up onto the breast to overlie the tumor (Fig. 2).

Markings

The patient is marked routinely in a standing position before breast reduction. The tumor is identified and the skin overlying the tumor is marked such that a 1-cm tumor clearance of the tumor is achieved (including skin). In the reported cases, the tumor was situated in the upper and lateral aspect of the breast, and would not be included inside the markings of a ‘‘traditional’’ keyhole pattern. The new nipple position is marked at the level of the inframammary fold, according to standard pro- cedure. The markings are completed as if only a vertical and medial reduction is to be performed

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72 Fig. 1. The keyhole\inverted T breast reduction pattern can be considered to consist of three

Fig. 1. The keyhole\inverted T breast reduction pattern can be considered to consist of three triangles: a medial triangle, a lateral triangle, and a vertical or middle triangle. In this article, the lateral triangle is transposed up onto the breast to overlie the tumor (see Fig. 2).

72 Fig. 1. The keyhole\inverted T breast reduction pattern can be considered to consist of three

Fig. 2. The lateral triangle (GFH) is situated over the tumor (X). X=tumor.

Breast Conservation Therapy

72 Fig. 1. The keyhole\inverted T breast reduction pattern can be considered to consist of three

Fig. 3. Preoperative view of patient 1 with a T1NO tumor of the left breast. The tumor was inferior and lateral to the nipple areola complex (NAC). Operative markings are seen. Note that the lateral triangle was placed superior to the inframammary fold.

the borders of the breast tumor. The lateral extent (the apex of the triangle) passes to the lateral border of the breast (Figs. 3, 4, 7, and 8). Any pedicle (viz, superior, superior-medial, infe- rior, or lateral) can be used. The choice is made according to the site of the tumor, the safety of the pedicle, and its ease of rotation. Similarly, if the tumor is situated in the medial quadrant, the medial triangle of the keyhole pattern can be moved supe- riorly to overlie the tumor.

(Fig. 2). The inferior margin of the medial and ver- tical triangles are placed, as usual, in the inframam-

Clinical Cases

mary fold. The two vertical lines are traditionally marked

Case 1

approximately 5 cm in length. However, in these patients, the ‘‘lateral’’ vertical line (line AE in Fig. 2) extends from the (vertical ) apex of the T, not for 5 cm, but to the midline of the breast at the infra- mammary fold (point E in Fig. 2). This means that the lateral vertical line (AE) is longer than the medial vertical line (AB). In Fig. 2, the medial line AB is still marked 5 cm in length, but the lateral vertical line, AE, is obviously longer. The lateral triangle is marked over the site of the tumor such that it also allows a margin of skin excision 1 cm beyond the tumor. This triangle forms the lateral extension of the markings on the breast. To ensure that line AE becomes the same length as

A 44-year-old woman presented with a T2N0 carci- noma of the left breast situated laterally just inferior to the nipple and close to skin. Her right breast was slightly bigger than her left breast (Figs. 3 and 4). The nipple-to-notch distance was 23 cm on the left and 25 cm on the right, and the distance from the infra- mammary fold to the nipple was 8 cm on the right and 9 cm on the left. A bilateral reduction was performed using a superior pedicle, with 150 g excised from each side. At this writing, the patient has completed her course of chemotherapy and radio- therapy, and it has been 10 months since her surgery (Figs. 5 and 6).

AB, the lateral triangle is designed such that the length of the triangle base (GF) equals AB. Described another way, the base of the medial triangle (BD) is

Case 2

the same as that of the lateral triangle (GF). It should be noted that the lateral triangle is marked to enable excision of skin 1 cm beyond

A 44-year-old woman presented with a T2N0 carci- noma of the right breast (Figs. 7 and 8). The carci-

D.A. Hudson

D.A. Hudson Fig. 4. Oblique view showing the site of the tumor and the markings of

Fig. 4. Oblique view showing the site of the tumor and the markings of the lateral triangle.

D.A. Hudson Fig. 4. Oblique view showing the site of the tumor and the markings of

Fig. 5. Postoperative result, anterior view. This patient had 150 g excised from each side. Reasonable symmetry is dis- cernable.

noma was situated in the superior and lateral aspect of the breast (above the position of the nipple) The patient also was markedly obese. The nipple-to-notch distance was 35 cm on the left and 34 cm on the right. The distance from the inframammary fold to the

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D.A. Hudson Fig. 4. Oblique view showing the site of the tumor and the markings of

Fig. 6. Postoperative result. Lateral view showing lateral scar above the inframammary fold.

D.A. Hudson Fig. 4. Oblique view showing the site of the tumor and the markings of

Fig. 7. Preoperative markings in an obese patient (patient 2) with large pendulous breasts and a T2N0 tumor of the right breast. The tumor is situated both above and lateral to the nipple.

nipple was 13 cm on the left and 15 cm on the right. The patient had grade III ptosis (Figs. 7 and 8). A bilateral breast reduction was performed, with 1,100 g excised from the left side and 1,050 g excised from the right side. A superior-medial pedicle was used (Figs. 9 and 10). The patient has subsequently

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74 Fig. 8. Preoperative oblique view showing the lateral tri- angle in a more superior position.

Fig. 8. Preoperative oblique view showing the lateral tri- angle in a more superior position. The superior line of the lateral triangle is at the height of the superior aspect of the areola.

74 Fig. 8. Preoperative oblique view showing the lateral tri- angle in a more superior position.

Fig. 9. Postoperative result after excision of 1,100 g from right side and 1,050 g from the left side. Reasonable sym- metry and shape were obtained.

also had a course of chemotherapy and radiotherapy. At this writing, it has been 9 months since the reduction using the modified pattern.

Case 3

A 44-year-old woman presented with a T2N0 carci- noma of the left breast (tumor in the upper lateral quadrant similar in position to that in case 2). The nipple-to-notch distance was 29 cm on the left and 30 cm on the right. The distance from the inframam- mary fold to the nipple was 11 cm bilaterally. She had a grade III ptosis. A modified pattern breast reduc- tion (similar to that in case 2) was marked, and the superiomedial pedicle was used, with 520 g resected from the left breast and 500 g resected from the right breast. Her postoperative course was complicated by an axillary seroma, which responded to drainage. At this writing, she is 2 months postoperative and about to begin a course of radiotherapy. In all three cases, an axillary dissection was per- formed through the same skin incision.

Breast Conservation Therapy

74 Fig. 8. Preoperative oblique view showing the lateral tri- angle in a more superior position.

Fig. 10. Postoperative result. Oblique view (close-up) showing the site of the lateral scar.

Discussion

Wide local excision using a breast reduction pattern to effect excision of the tumor is an appealing option for patients with macromastia (in whom the cancer is situated in the inferior pole of the breast). It allows the patients both to undergo adequate oncologic treatment of the tumor and to relieve the symptoms of macromastia. The nipple areola complex is retained, and the patients achieve symmetrical breasts with symmetrical scars. When the neoplasm is situated in the upper half of the breast, wide local excision using a breast reduction pattern is more difficult, particularly when the tumor is situated close to skin. This problem is not commonly addressed in the literature. However, because the most common site of breast tumors is the upper outer quadrant of the breast, this site deserves more attention. Clough et al. [1] presented a patient whose tumor was situated in the lateral aspect of the lower quadrant of the breast and rec- ommended canting the whole keyhole pattern lat- erally. These authors, however, did not discuss the results of this technique or its limitations. This is another method that can be used, but it seems really applicable only to tumors still situated in the infe- rior pole of the breast. An alternative method is to modify the key- hole\inverted T pattern as described earlier. The advantage of the technique is that it still allows wide local excision to be performed (including excision of the overlying skin with a 1-cm tumor clearance) even though the tumor is not situated in the inferior pole of the breast. As in any breast reduction, the pedicle can be designated as inferior, lateral, superior-medial, or the like. In the three reported patients, a superior pedicle (one patient) and a superior-medial pedicle (patients 2 and 3 ) were used. Certainly, in cases 2 and 3, for example, an inferior pedicle could also have been used. The pedicle is chosen such that the onco- logic requirements are still met. For example, if the tumor is lateral to the nipple, a medial pedicle may be used to ensure that an adequate tumor margin is achieved.

D.A. Hudson

The disadvantages of the technique include asym- metrical breast scars (Figs. 4 and 9), and the fact that the technique is slightly more demanding for achievement of a symmetrical shape. The surgeon must also be conversant with the use of different pedicles for breast reduction. Additionally, the upper medial quadrant and the superior aspect of the breast (infraclavicular) are areas in which the technique cannot be applied. The modified breast reduction pattern allows excision of a tumor in a widespread area of the breast (including the overlying skin). It can be considered an alternate technique for patients with larger breasts who have ‘‘peripheral’’ tumors close to skin to un- dergo an oncologically safe wide local excision and to relieve the symptoms of macromastia.

References

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