Reply: The Use of Reduction Mammaplasty with Breast Conservation Therapy: An Analysis of Timing and Outcomes.

Abstract

Sir: We are most grateful for the comments proposed by Bonomi et al. and their views on the role of pedicled perforator-based breast reconstruction to correct breast conservation therapy deformities. As pointed out by the authors, radiation therapy is a major culprit for the exacerbation of lumpectomy deformities. This causes an increase in breast parenchymal density, skin thickness and tightening, pigmentation changes, breast distortion, and breast shrinkage and fibrosis, with an average of 10 to 20 percent reduction in breast volume.1–4 Moody et al.2 and Gray et al.5 showed that these defects are further enhanced in large breasts as patients develop more asymmetry, retraction, and late irradiation changes. The approach of using oncoplastic reduction mammaplasty at the time of lumpectomy is ideal for patients with macromastia, because it not only reduces the aesthetic burden caused by breast conservation therapy, but also frees the patient from symptoms related to large breasts. However, our article6 did not imply that oncoplastic reduction mammaplasty should be used in all patients undergoing breast conservation therapy; rather, our article aimed to discuss the timing of oncoplastic reduction mammaplasty in women with macromastia: immediate, delayed immediate, and delayed. We agree that, ideally, partial breast reconstruction should be undertaken as an immediate procedure; however, many patients in the United States do not have the option of undergoing reduction mammaplasty at the time of lumpectomy because of lack of resources or adequately trained surgeons. Thus, patients still often present in a delayed fashion. Although complication rates are higher than with an immediate approach, appropriate patient and technique selection can achieve improved outcomes in the delayed group of patients. Reduction mammaplasty is only one of the many techniques at the disposal of the plastic surgeon and does not replace other oncoplastic techniques: volume replacement (e.g., fat grafting, implant placement, local or distant flaps) and volume displacement techniques (e.g., mastopexy). The selection of the appropriate reconstructive technique is based on breast size, tumor site, breast and skin quality, and degree of breast conservation therapy–related deformities. As shown by our previous series and other studies,7–9 less severe deformities and asymmetries tend to be more amenable to local procedures and fat grafting, whereas the more pronounced deformities often required reconstruction with pedicled myocutaneous flaps, with latissimus dorsi myocutaneous flap being the most versatile. The use of perforator flaps (i.e., thoracodorsal artery, lateral intercostal artery, and superior epigastric artery perforator flaps) in oncoplastic surgery has been advocated to reconstruct breasts that are small, with defects that are larger than 30 percent of the breast, or in women who, despite having adequate tissue for volume displacement surgery, prefer to maintain their original breast volume without reducing the contralateral breast.10–13 The main advantages of these techniques, compared with myocutaneous flaps, include a reduction in donor-site morbidity and sparing of muscle function. As our experience with perforator flaps increases, they will likely replace many of the myocutaneous flaps used today. Partial breast reconstruction has greatly evolved over the past two decades with the addition of reduction mammaplasty and pedicled perforator-based flaps to the methods available to the plastic surgeon. We feel that the use of one technique should not exclude the other, and only careful patient selection and the plastic surgeon’s level of experience will dictate surgical morbidity, aesthetic result, and patient satisfaction. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Francesco M. Egro, M.B.Ch.B., M.Sc. Department of Plastic Surgery University of Pittsburgh Medical Center Pittsburgh, Pa. Albert Losken, M.D. Division of Plastic and Reconstructive Surgery Emory University Atlanta, Ga.