Breast-Coserving Surgery for Primary Breast Cancer: Immediate Volume Replacement Using Lateral Tissue Flap

Lateral thoracic adipofascial flaps in the reconstruction of defects after breast-conserving surgery in breasts with ptosis mild ptosis or without ptosis

OBJECTIVE

To study the feasibility, safety, and effectiveness of lateral thoracic adipofascial flaps in reconstructing the defects following breast-conserving surgery (BCS) in breasts with either no ptosis or mild ptosis.

METHODS

37 female patients who underwent BCS and lateral thoracic adipofascial flap breast reconstruction between June 2020 and July 2022 were analysed. Surgery-related complications, intraoperative positive margin, local recurrence, and cosmetic outcome were assessed.

RESULTS

Three local complications occurred in patients, all of which were cured by conservative treatment. Additionally, four patients had intraoperative positive margins. After a median follow-up period of 17.5 months, none of the patients showed local recurrence. All patients achieved a satisfactory breast shape. Further, patients without ptosis achieved good volume and symmetry. However, the breast symmetry was not satisfactory for patients with ptosis.

CONCLUSION

It is reliable and effective to use the lateral thoracic adipofascial flaps to reconstruct the defects after BCS when the breast is not ptotic and the lesions are located in the lateral and central quadrants.

Oncoplastic breast conserving surgery: Volume replacement vs. volume displacement

Oncoplastic breast conserving surgery (BCS) has emerged as a third option between conventional BCS and mastectomy. Oncoplastic BCS includes two fundamentally different approaches: volume replacement and volume displacement. The former involves partial mastectomy and immediate reconstruction of the breast with the transposition of autologous tissue from elsewhere, while the latter involves partial mastectomy and using the remaining breast tissue to fill the defect resulting from extirpation of the tumor. There are several benefits associated with oncoplastic BCS. First, it allows partial mastectomy without cosmetic penalties, and can achieve better cosmetic outcomes than total mastectomy with immediate breast reconstruction. Second, it avoids the need for total mastectomy in an increasing number of patients without compromising local control. Third, partial breast reconstruction is less extensive and has fewer complications than conventional procedures. Partial mastectomy and partial breast reconstruction can be carried out either simultaneously as a one-stage procedure, or using a two-stage approach. Although patients prefer a one-stage procedure, it requires intraoperative confirmation of complete tumor excision using frozen-section analysis. Moreover, oncoplastic BCS requires combined skills, knowledge, and understanding of both oncological and plastic surgeries, which may be optimally achieved by an oncoplastic surgeon.

Partial mastectomy using manual blunt dissection (MBD) in early breast cancer

BACKGROUND

Breast-preserving surgery (Bp) and sentinel lymph node biopsy (SNB) are established as standard treatment for axillary lymph node-negative early breast cancer.

METHODS

A surgical technique using manual blunt dissection (MBD), in which use of electrocautery, an ultrasonically activated scalpel, and ligation is minimized, is described. This involves an approach from small incisions in the axilla or areola to avoid injury to skin flaps, and with adequate mobilization of the breast, so that regardless of the tumor site, surgical wounds are not noticeable. The usefulness and tolerability of this surgical technique were examined.

RESULTS

This surgical technique was evaluated in 233 patients. Surgery could be performed rapidly, with a mean operative time of 67 ± 21 min and a low mean blood loss of only 35 ± 28 ml. There was little need for postoperative analgesia, and surgery was well tolerated without postoperative bleeding or wound infection.

CONCLUSION

Our proposed technique for partial mastectomy using MBD provides good curative and cosmetic results.

Immediate breast volume replacement using a free dermal fat graft after breast cancer surgery: multi-institutional joint research of short-term outcomes in 262 Japanese patients

BACKGROUND

Immediate volume replacement using a free dermal fat graft (FDFG) has been proven safe with early postoperative benefits. The aims of the present study were to clarify adequate indications and risk factors associated with operative morbidity.

PATIENTS AND METHODS

A multi-institutional analysis of partial mastectomy with immediate volume replacement with FDFG was undertaken in 14 hospitals specializing in breast cancer treatment. Clinical and oncological variables were analyzed to identify factors associated with postoperative complications.

RESULTS

A total of 262 cases were analyzed. Considering the observation period and overlap of patients, 13 (5.4%) out of 242 patients had complications within 1 month of surgery while 7 (4.6%) out of 151 patients developed complications 1-12 months after surgery. Two hundred and eleven out of 242 patients were statistically examined using a multivariate analysis, which revealed that the weight of resected breast tissue, size of implanted FDFG (cranio-caudal length), and weight of implanted FDFG were associated with a higher likelihood of postoperative complications.

CONCLUSIONS

Immediate breast volume replacement using a FDFG after breast cancer surgery should be done for selected patients with breast cancer to avoid postoperative complications. The prospective and larger investigations are warranted for the establishment of appropriate guidelines.

Reconstruction of the breast conservation deformity

The era of breast conserving treatment of early-stage breast carcinoma has created reconstructive challenges for the plastic surgeon. Although good to excellent cosmetic outcomes occur in the majority of patients, a significant number could benefit from additional reconstructive measures. Because of the need for continuing surveillance following breast-conserving therapy, estimated at 5-10% after fifteen years, plastic surgeons should choose techniques that do not interfere with the detection of recurrent breast carcinoma. Myocutaneous flaps-in particular, the latissimus dorsi and transverse rectus abdominis-have fulfilled the reconstructive needs of these patients by providing well-vascularized soft tissue. Postoperative radiological evaluation has demonstrated that these flaps are radiolucent, unlike breast implants that can obscure accurate mammographic interpretation.Myocutaneous flaps have been used for both immediate and delayed reconstruction of post-breast conservation deformities. The delayed approach offers the benefit of an established contour deformity that usually involves cutaneous, parenchymal, and nipple-areolar components. Moderate overcorrection of the defect has been advocated in anticipation of ongoing postradiation wound contraction and fibrosis. Immediate reconstruction of lumpectomy and partial mastectomy defects permits wider initial excision of the breast lesion, but can be compromised by positive histological margins. Long-term results suggest stability of the aesthetic outcome following reconstruction of delayed deformities.

Video-assisted skin-sparing breast-conserving surgery for breast cancer and immediate reconstruction with autologous tissue: clinical outcomes

BACKGROUND

This study analyzed clinical results of video-assisted breast-conserving surgery for breast cancer.

METHODS

Video-assisted breast-conserving surgery is indicated for breast cancer that has not invaded the skin. A skin incision is made at an inconspicuous site. Skin-sparing partial mastectomy was performed endoscopically on 244 patients (stage I, n = 94; stage II, n = 150). Morbidity, curability, and patient satisfaction were analyzed.

RESULTS

Skin necrosis was seen in nine patients. Local recurrence was seen in 13 patients (mean postoperative interval 65.3 months). Distant metastasis-free survival at 60 months was 93.6% for stage I and 90.5% for stage II. Overall survival was 95.7% for stage I and 96.9% for stage II. Satisfaction with surgery as investigated by questionnaire was "good" for 72.3% of patients.

CONCLUSIONS

Video-assisted breast-conserving surgery showed no increases in local or distant recurrence and patient satisfaction was high. Video-assisted breast-conserving surgery appears useful for local treatment of breast cancer.

Transaxillary retromammary route approach of video-assisted breast surgery enables the inner-side breast cancer to be resected for breast conserving surgery

BACKGROUND

Endoscopic surgery for inner-side breast cancer usually is performed by periareolar approach, but leaves deformation or malposition, and sensory disturbance. We devised an approach of retromammary route without subcutaneous removal, from an axillary skin incision, to treat distant cancers and also to preserve sensation to skin touch.

METHODS

We have performed video-assisted breast surgery on 230 patients. The transaxillary retromammary-route approach was performed on 20 patients with early breast cancer. From a 2.5-cm axillary incision, we dissected the major pectoral muscle fascia to detach retromammary tissue. We cut the proximal side of the gland vertically, and dissected the skin flap over the tumor by the tunnel method. Then we cut each side of the gland vertically and removed it through the axillary port.

RESULTS

All surgical margins were negative. The surgical time was 45 minutes longer than the conventional video-assisted breast surgery. The postoperative esthetic results were good.

CONCLUSIONS

The transaxillary retromammary-route approach leaves no injury on whole breast, and can become a single standard method for breast-conserving surgery wherever a cancer is situated.

Significance of irradiation in breast-conserving treatment: comparison of local recurrence rates in irradiated and nonirradiated groups

Breast-conserving treatment (BCT) is a standard therapy for early breast cancer. Many reports have described the effectiveness of post-BCT radiation therapy. However, the post-BCT local recurrence rate of only 5% to 10% indicates that radiation therapy may be unnecessary in many cases. To accurately select those patients who do not require post-BCT radiation therapy, we investigated the significance of irradiation in BCT by comparing local recurrence rates in irradiated and nonirradiated patients, grouped according to clinicopathological criteria that we evaluated. The patients were divided into two groups: a previous-criteria group and a present-criteria group. The former group included 85 patients in whom only two factors were considered as the criteria for radiation therapy: margin-positivity and lymphatic metastasis-positivity. The latter group included 318 patients in whom three additional factors were also considered: lymphatic invasion, intraductal extension, and metachronous/synchronous bilateral breast cancer. The use of five clinicopathological factors rather than two as the criteria for irradiation led to an increase in the irradiation ratio from 47.1% to 63.2% and a decrease in local recurrence from 12.9% to 2.2%. Because of the short average follow-up period of this study, further careful, regular follow-up and randomized comparative studies are required. It may also be necessary to include the patient age and margin condition as mandatory criteria for irradiation.

UK survey of partial mastectomy and reconstruction

BACKGROUND

Partial mastectomy and reconstruction can extend the role of breast-conserving surgery, but the frequency of this type of surgery is unknown.

MATERIALS AND METHODS

A UK survey was performed to determine the frequency, indications, techniques and outcomes of partial mastectomy and reconstruction.

RESULTS

Seventy-one of 180 (39%) respondents offered partial mastectomy and reconstruction. Reasons for not offering partial mastectomy and reconstruction included lack of experience (61%), uncertain indications (33%), uncertain benefits (45%) and concerns about oncological safety (22%). Immediate reconstruction was performed by 50% of respondents and perioperative margin analysis was uncommon. Respondents performed volume displacement or volume replacement or both approaches (23%, 18% and 59%). Complications included fat necrosis (68%), haematoma formation (55%), positive margins (46%), infection (41%) and flap loss or poor cosmetic outcome (10%).

CONCLUSIONS

Partial mastectomy and reconstruction is becoming popular in the UK as an alternative to full mastectomy. Safe introduction of this approach in clinical practice will require a clearer understanding of technique selection, safety and clinical outcomes.

Breast conserving surgery with primary volume replacement using a lateral tissue flap

Breast conserving surgery (BCS) is now a standard surgical treatment for early breast cancer. The number of patients with tumors under 3 cm who underwent breast conserving surgery overtook the number of patients who underwent total mastectomy for the first time in Japan in 2003. We have been employing breast conserving surgery with primary reconstruction using a lateral tissue flap (LTF), and have performed breast conserving surgery for 266 patients from 1990 to 2002. The incidence of local relapse was 5.6%. Although we did not irradiate a low risk group of 101 patients, our method is not inferior to other reports in which all cases underwent irradiation. Primary reconstruction with LTF has three advantages. The first is that we can avoid poly-surgery for breast reconstruction. The second is that the volume of the graft is maintained longer than reconstruction with a musculo-cutaneous flap. The third is that patients can avoid allergic reactions or granulomas as seen with artificial prosthesies. In conclusion, breast conserving surgery with immediate volume replacement with a LTF is a reasonable surgical procedure and has the advantage of avoiding unnecessary surgical procedures for reconstruction and surgical invasion without delaying the diagnosis of local relapse. Moreover, an adequate assessment of risk can spare low risk groups irradiation.

Transaxillary endoscopic partial mastectomy for comparatively early-stage breast cancer. An early experience

For optimal cosmetic results in breast cancer surgery, we developed an alternative operation using endoscopy to remove tumors through a small single incision remote from the breast itself. The tumor is endoscopically resected with electrocautery and low constant suction through a short incision in the axilla, 5 cm long, after which axillary dissection is performed through the same wound in the usual manner, under visualization by the naked eye. Primary reconstruction of the breast is performed with the remaining mammary gland and a subcutaneous fat flap on the serratus muscle. Seven patients underwent this surgery. The postoperative shape of the breasts was judged to be cosmetically satisfactory, and the surgical wounds were not visible from the front in all cases. This operation has the same therapeutic oncological effect as a standard lumpectomy and, in addition, offers a greater cosmetic advantage in cases of early breast cancer.

Expanding the Role of Breast-Cancerving Therapy Using Immediate Volume Replacement

Preventing local recurrence and preserving cosmetic appearance are often in conflict in breast-conserving therapy. Immediate volume replacement with autogenous tissue has been developed to allow a wider excision without compromising the aesthetic results. A review of the literature regarding immediate volume replacement in breast-conserving therapy has led to the following conclusions. When excision of the skin overlying the tumor is unnecessary, a transverse or lateral incision should be used which allows wide excision and immediate volume replacement with autogenous tissue while minimizing scar morbidity. The options for immediate volume replacement include the latissimus dorsi flap with adipose tissue, the latissimus dorsi myocutaneous flap, and the lateral thoracic adipose tissue flap. The choice of technique depends on the amount and position of the skin, subcutaneous tissue, and breast tissue which must be excised. These procedures can be used to extend the indications for breast-conserving therapy, eliminating the need for mastectomy in selected patients. Future developments in the endoscopic harvesting of flaps may further expand the role of volume replacement.