An Oncoplastic Approach to Reconstruct Upper Pole Partial Mastectomy Defects in Minimally Ptotic and Average Size Breasts.

Abstract

Sir: Breast conservation of upper pole breast cancers without oncoplastic reconstruction can lead to contour deformities and translocation of the nipple-areola complex after radiation therapy.1–3 Traditional methods to reconstruct upper pole partial mastectomy defects involve a Wise pattern skin incision with rotation of adjacent tissue.4 This technique is best suited for ptotic and large breasts, but is difficult to use in minimally ptotic or average sized breasts. The circumvertical pattern may be more suitable for these patients. Benefits include fewer incisions and no concern for T-junction skin necrosis.5 The authors translate these benefits to oncoplastic surgery through a novel rotation of breast tissue from the 6-o’clock position into the superior pole partial mastectomy defect, based on either a medial or lateral pedicle, all through a circumvertical skin incision. The patient’s breasts are marked preoperatively. The vertical limb is not drawn, as this is created with a tailor-tacking method after the partial mastectomy is completed. The location of the tumor guides the marking of either a lateral or medial pedicle. The breast surgeon performs intraoperative ultrasound to mark the skin margin directly anterior to the biopsy marker. If a close or positive anterior margin exists on the final pathologic examination, the marked skin can be excised 2 to 3 weeks after surgery. The plastic surgeon then makes the outer periareolar and areolar incision, and deepithelializes the intervening skin. The oncologic breast surgeon then performs the needle-localized partial mastectomy through the outer border of the deepithelialized area, leaving the pedicle to the nipple-areola complex based either laterally or medially. The base of the partial mastectomy defect is marked with clips to guide radiation therapy. The areolar and periareolar incisions are then made on the contralateral breast, and the intervening skin is deepithelialized. The areolas are stapled into the 12-o’clock position and the patient is sat up to tailor-tack the vertical limb. The vertical limbs are marked and incised, and the skin on the cancer side is deepithelialized. The 6-o’clock tissue that is normally discarded during a vertical breast reduction is incised in a V shape and elevated as an extension of the pedicle (Fig. 1). The flap is elevated, with care taken to avoid dividing any deep perforators into the pedicle. Before rotation, the distal flap dermis is checked for punctate bleeding. The rotated flap stays in place with closure of the vertical pillars (Fig. 2). The contralateral reduction is then performed with excision of the 6-o’clock breast tissue. The contralateral breast is made 5 to 10 percent smaller, to account for volume loss caused by radiation therapy on the cancer side.Fig. 1: Lateral pedicle with extension. Lateral pedicle with inferior extension that would be thrown away in a traditional circumvertical breast reduction.Fig. 2: Rotation of tissue. Rotation of inferior extension into the superior mastectomy defect.The proposed technique uses a circumvertical skin incision and rotation of the tissue from the 6-o’clock position into the defect, based on either a medial or lateral pedicle. The authors believe that this technique is suited for minimally ptotic or average sized breasts, and allows for improved cosmesis of the reconstructed breast compared with traditional techniques. DISCLOSURE All authors have no commercial associations or information that might pose or create a conflict of interest with the information presented within this article. Ajul Shah, M.D. Anup Patel, M.D. Section of Plastic Surgery Andrew Kenler, M.D. Department of Surgery Yale University School of Medicine New Haven, Conn. Shareef Jandali, M.D. Plastic and Reconstructive Surgery Bridgeport Hospital Bridgeport, Conn.