E Smyth, I Depasquale and A Curnier
Aberdeen Royal Infirmary
Oncoplastic Breast surgery branch of surgery that combines plastic surgery techniques with the oncological priniples Breast Conserving Surgery. Breast Conserving Surgery is a firmly established mainstay of treatment due to the 20 year series of Veronesi (in Europe) & Fisher (In the US) comparing breast conserving surgery with mastectomy. The result of this work is that Breast Conserving Surgery has become the gold standard in producing a sensate, aesthetically normal breast after breast cancer.
Lateral Mammoplasty is one such technique that was used since the late 1990's and was presented as data from the Institut de Curie at BAPRAS in 2009. It is simple reproducible and deals with a significant proportion of tumours of the breast, by virtue of the fact that the Lateral part of the breast is the area most frequently involved by breast tumour.
Tumour in the Lateral portion of the breast which is the majority of breast tumours.
A large tumour to breast volume ratio, ideally tumour volume more than 10% of the breast.
Smaller but anatomically related clusters of tumours
Contraindications for Lateral Mammoplasty are previous Radiotherapy of any form.
Inflammatory Breast cancers where the margins are not easily delineated.
And obviously multcentric tumours which are disseminated throughout the breast.
The pre-operative markings for Lateral Mammoplasty are simple.
The breast meridian is drawn and the surgeon marks the tumour and the circumference of the new areola which should be roughly equivalent to the circumference of the original areolar when it is finally closed. The lateral excision is fusiform and the overall shape is one of a pipestem, with the base of the pipeline around the Nipple Areloar Complex (NAC) pointing slightly upwards and medially from the original NAC.
The patient is positioned supine, with both arms out & both breasts exposed for symmetry. And axillary dissection can be done through the tail of the wound or alternatively a separate incision can be made.
A small disc of skin around the NAC is de-epithelialised and every attempt is made to preserve the subdermal plexus of veins for nipple viability. The tumour is excised with a safe margin of normal tissue (often with bracketing wires), and the excision is down from skin down to the muscle fascia. The tumour bed is marked with clips for identification post operatively for Radiotherapy.
The faxitron is used to demonstrate the tumour well within the body of the specimen with a margin of normal tissue and the specimen is oriented according to the unit's protocol. Suction drains put in the wound.
The breast mound is mobilized and undermined slightly around the NAC to allow more freedom for relocation of the nipple. Then it is reconstituted using Monocryl or PDS suture and the skin is then approximated first with a deep dermal layer and then with a subcuticular layer.
Normally the NAC should sit nicely on top of the breast mound. If this is not the case, the NAC can be in set with staples temporarily and the circle of the new breast mound corrected so the NAC sits nicely in the middle.
Post Op results:
Approximately 70% of patients require symmetrisation, but this not always done at the time of the original surgery as there is a risk (approximately 1 in 10) that the final margins will be incomplete and either further surgery or the default mastectomy will be required. It is therefore not prudent to routinely symmetrise the other breast at the time of oncological surgery.
The most significant postoperative complication is incomplete margins and if at histological examination, the margin is close or focally breached, it may be possible to re-excise the previous scar quite simply without re-marking the breast and therefore gain complete clearance.
It is important that there is no significant haematoma or seroma after the wound, as the patient will be proceeding rapidly for radiotherapy and these tend to cause distortion as they shrink during radiotherapy.
Abscess formation is rare. Hypertrophic scarring is rare because of the radiotherapy. NAC necrosis is rare because the NAC is usually not moved very far.
Hints & tips:
Following the basic model of Lateral Mammoplasty, the scar can be moved superiorly or inferiorly as required. It is worth noting that as the scar moves superiorly, it becomes more noticeable as shown in the final video. If this is the case, it may be more useful to keep the scar laterally and do a stepped wise excision subcutaneously so that the tumour excision is higher and the scar is lower.
The converse, as the scar gets lower the Lateral Mammoplasty simply becomes a J-plasty and this is very straightforward as well.
Normally we do not do symmetrising procedures at the same time as the oncological procedure. Exceptional circumstances might be when the normal breast requires reduction or mastopexy for other reasons, or if a unilateral procedure will result in significant asymmetry
The first thing to do is to remark everything on the table, and then measure the length of lateral and medial lines and make sure that they are the same length or longer than the line inferior line in the IMF to decrease tension on the closure. The pedicle is de-epithelialised using curved scissors of a knife and the the resection and reduction is done as shown in the video trying to mirror the resection in both sides to achieve better symmetry