Lateral Tissue Flap Research Articles

Cosmetic evaluation following volume replacement using lateral tissue flap in breast-conserving surgery

We examined the effectiveness of volume replacement using a lateral tissue flap (LTF) in breast-conserving surgery for a good cosmetic outcome. We analyzed the results of 130 patients with breast cancer who underwent breast-conserving surgery with replacement using an LTF from 2006 to 2010 with cosmetic evaluations performed according to the criteria of the Japanese Breast Cancer Society. We examined scores with regard to the following possible contributing factors: partial resection (Bp) or quadrantectomy (Bq), diameter of the specimen, body mass index (BMI), axillary lymphadenectomy, postoperative irradiation, and position of the tumor. The scores for cases with Bp and non-postoperative irradiation were higher than those for Bq and postoperative irradiation cases, though they were not significant factors in multivariate analysis. A negative correlation was seen between score and diameter of the specimen, whereas there was no significant correlation with BMI. There was no significant difference between scores of cases with or without an axillary lymphadenectomy. However, the score for the extended upper-outer area including the upper and outer borders was significantly higher than scores for other portions. In multiple regression analysis, cases with a tumor diameter less than 4 cm in the extended upper-outer area or less than 2 cm in other areas showed good adaptation. Tumor location and diameter are important factors for cosmetic evaluation of volume replacement using an LTF.

Video-Assisted Breast Surgery and 3-Dimensional Computed Tomographic Mammary Lymphography <1> Aesthetic Results and Curability of Video-assisted Breast Surgery

Background: I have studied endoscopic surgery for breast diseases and have studied 3-dimensional computed tomographic lymphography for sentinel node biopsy. In this chapter, I introduced my works of the endoscopic breast surgery. I devised a new endoscopic operation for breast diseases: video-assisted breast surgery. The goal of endoscopic breast surgery is to obtain better cosmetic outcomes. Methods: A 2.5-cm axillary or periareolar skin incision was made. Under video assistance, the mammary gland was partially or totally resected with a gasless method. A transaxillary retromammary route approach was used even for tumors of the medial aspect of the breast. For malignant tumors, sentinel node biopsy was performed, and axillary nodes were dissected. Breast reconstruction was performed simultaneously. Cosmetic results: Cosmetic results were assessed with a standard 4-step method and the method described in the Japanese guidelines for breast-conserving therapy. More-objective quantitative methods are breast retraction assessment, the method reported by the research group of Sawai, and ABNSW, a 5-item, 4-step method that evaluates asymmetry (A) , breast shape (B) , nipple deformation (N) , skin condition (S) , and wound scar (W) . The cosmetic results in endoscopic breast surgery showed that almost 90% of patients received a total score greater than 11 points, which indicates that this video-assisted breast surgery achieves better cosmetic results. The reconstruction methods in breast-conserving therapy are mammary gland translocation, the lateral tissue flap filling method, and absorbable thread mesh filling. The filling methods are superior to the translocation at the point of less deformation of the breast shape. Reconstruction with filling methods will allow wider excision of the mammary gland while achieving better cosmetic results. Results: Video-assisted breast surgery is less invasive, produces no scars on the breast skin, and achieves better aesthetic outcomes for patients with breast cancer. It also improves quality of life. The long-term results of this surgery in regards to morbidity have proven good after a maximum follow-up period of 8 years. Conclusions: Video-assisted breast surgery achieves good locoregional control and provides aesthetic advantages. It can be used to treat multiple breast diseases and advanced disease after preoperative systemic treatment.

Endoscopic skin-sparing breast-conserving surgery for breast cancer and immediate reconstruction with autologous tissue

566 Background: Endoscopic breast-conserving surgery (E-BCS) for breast cancer has been developed in Japan and is indicated for breast cancer without skin involvement. The surgical incision is made at an inconspicuous site, and skin-sparing partial mastectomy and immediate reconstruction of the breast are performed. This technique affords good cosmetic results. The long-term results are reported herein. Methods: E-BCS was performed on 551 patients. The skin incision was put on a peri-areolar margin or on the mid-axillary line. Skin-sparing partial mastectomy was performed using an endoscope and the lifting and tunneling method. Deformity due to the loss of breast tissue is addressed immediately by reconstructing the breast using autologous tissues via mobilization of the remnant breast gland and fat tissue and use of a lateral tissue flap or latissimus dorsi adipose tissue flap. Morbidity, curability and degree of satisfaction of patients with regard to cosmesis were analyzed. Results: Skin necrosis in 22 patients (4.0%) and necrosis of fatty tissue-muscle flap in 17 patients (3.1%) were recorded as postoperative complications. There were none of other serious complications. Local recurrence occurred in 23 patients (4.2%) after a mean follow-up of 38.4 months. Distant metastasis-free survival rate at 66 months was 100% for Tis, 95.5% for T1 and 90.7% for T2. Overall survival rate was 100% for Tis, 97.3% for T1 and 95.7% for T2. Degree of satisfaction with surgery as investigated by questionnaire was “excellent” for 76.1% of patients. Conclusions: E-BCS for early stage breast cancer have shown none of association with increases in local or distant organ recurrence. The technique yielded improved cosmesis and a high degree of patient satisfaction. Although the observation of patients for a longer period is necessary, the E-BCS give big advantages on the breast cancer patients in terms of aesthetics and curability. No significant financial relationships to disclose.

276 POSTER Breast conserving surgery and immediate reconstruction with lateral tissue flap and latissimus dorsi flap through a single lateral incision

95 NSMs were performed from June 2003 to June 2006. Average age of the selected sample was 44.5 years (range 26-65). – 53 NSMs performed in T1/T2 breast cancer patients. – 12 NSMs performed by patients presenting in situ carcinoma (DCIS/ LCIS). – 15 NSMs performed according to prophylactic purpose. – 13 NSMs performed to repair the breast deformity after poor cosmetic result of previous conservative treatment. The concept of NSM is that the breast gland has to be removed completely. The area behind the areola, where the superficial fascia is interrupted, has been totally cleared out. In order to be sure that cancer cells have not spread to the NAC area, one or two round retroareolar excisions has been performed for intraoperative histological evaluation. By the first consecutive 33/95 NSMs, the skin incision was always periareolar (omega). 18/33 NSMs presented a partial (14 NSMs) or total (4 NSMs) NAC failure. In order to reduce the NAC failure and to get a better cosmetic result, we moved from a periareolar to a lateral incision. 62/95 NSMs were performed using the lateral incision. Since we introduced the lateral approach no necrotic complication were registered. The amount of total or partial NAC necrotic complication was 18/95, all with the periareolar approach. A second surgery was necessary to remove the NAC in 4/95 NSMs. Discordance between intraoperative and final histological result, occurred in 3/95 cases. These patients underwent a second surgery and the nipple was removed. Immediate breast implant reconstruction was performed. In 79/95 NSMs an immediate breast reconstruction with prostheses was performed. The average weight of the prostheses was 250 gr. Remodelling of the contra lateral breast was always performed. Nipple Sparing Mastectomy is a safe and valuable surgical option for patient with small-medium size breast, patients’ satisfaction is very high but further investigation is necessary to confirm these preliminary results.

Video-Assisted Breast Surgery: Reconstruction after Resection of More than 33% of the Breast

Improvements in reconstructive mammoplasty methods have made it possible to resect more of the mammary gland while achieving good esthetic results in breast-conserving surgery. We report the esthetic results of extended wide resection of the breast with reconstruction procedures. Breast-conserving surgery was performed using a video-assisted breast surgery (VABS) technique. Breast reconstruction was simultaneously performed using the following three methods: mobilization of the remnant mammary gland, transplantation of the lateral tissue flap, and filling with an absorbent synthetic fiber mesh or cotton. The cosmetic results were evaluated with an original five-item-by-four-step scoring system: ABNSW-assessing asymmetry, breast shape, nipple shape, skin condition, and wound scar. From December 2001 through March 2006, we performed endoscopic VABS in 130 patients with breast diseases. The candidates were 29 patients with breast cancer who required resection of more than 33% of the mammary gland because of ductal carcinoma in situ (1 patient), multiple cancers (6 patients), widely extended lesions (20 patients), and lesions after preoperative systemic therapy (2 patients). Twenty-one patients underwent resection of 33% to 50% of the breast, and 8 underwent resection of more than 50% of the breast. All surgical margins were negative on examination of permanent histological preparations. The original shape of the breast was preserved. There was no local recurrence after follow-up times of 33 months (maximum) and 19 months (average). The newly devised reconstruction methods with VABS can markedly increase the mammary gland resection volume while achieving a good esthetic outcome, ensuring a precise disease-free surgical margin, and expanding the indications for breast-conserving therapy.

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.

Breast-conserving surgery for invasive cancer: a principle based on segmental anatomy.

As the incidence of breast cancer increases in Japan, breast-conserving surgery becomes an important issue in the light of quality of life. We have demonstrated by 3-D reconstruction studies that ductal carcinoma in situ (DCIS) originates from the terminal duct-lobular unit (TDLU). Normal mammary epithelium anatomically located in the TDLU was shown to be biologically associated with cancerous change, particularly in specimens from patients who subsequently developed invasive carcinoma. Atypical ductal hyperplasia as well as DCIS expressed breast cancer associated antigen, providing further biological evidence that the atypical lesion at the TDLU are premalignant. Intraductal spread of carcinoma was defined as "DCIS was present clearly extending beyond the TDLU, or present prominently within the large ducts," and was classified into 3 grades according to the distribution of carcinoma in the duct-lobular system. We have developed a breast-conserving surgery consisting of quadrantectomy and regional lymph node dissection and immediate volume replacement using lateral tissue-flap (LTF). The quadrantectomy was employed on the basis of segmental anatomy of the duct-lobular system in which breast carcinoma originates. Fairly good cosmetic outcome as well as local control were obtained in the patients who underwent the immediate volume replacement using LTF. It must be emphasized that the quadrantectomy is a radical procedure in the sense that it aims at removal of all the carcinoma cells of the primary tumor.

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

We have developed a breast-conserving surgery consisting of quadrantectomy and regional lymph node dissection and immediate volume replacement using lateral tissue flap (LTF). The quadrantectomy was employed on the basis of segmental anatomy of the duct-lobular system in which breast carcinoma originates. Lateral skin incision was performed from the apex of mid-axillary line to the inframammary fold, without removing the skin overlying the tumor, In the early period of breast reconstruction embraced latissmus dorsi flap (LDF) for 10 patients(reconstruction was not performed on 35 patients), but in the late period we employed LTF for 56 patients. Four of the 101 patients developed ipsilateral breast cancer during a mean follow-up period of 48 months, but none died of breast cancer, Among the 56 patients with LTF replacement no patient developed ipsilateral breast cancer. Fairly good cosmetic outcome was obtained in the patients who underwent the immediate volume replacement. Breast-conserving surgeries are reviewed, and the surgical procedure using LTF for immediate volume replacement is described.