Ebook Oncoplastic breast surgery - A guide to clinical practice (2/E): Part 1

Part 1 book “Oncoplastic breast surgery - A guide to clinical practice” has contents: Introduction, round block lumpectomy, round block lumpectomy with resection of the nipple, doughnut lumpectomy, batwing (omega) quadrantectomy, batwing quadrantectomy, inferior rotation flap,… and other contents.

Breast Surgery

A Guide to Clinical Practice

Second Edition

Florian Fitzal Peter Schrenk

Editors

123

Oncoplastic Breast Surgery

Florian Fitzal • Peter Schrenk Editors

Oncoplastic Breast Surgery

A Guide to Clinical Practice Second Edition

ISBN 978-3-7091-1873-3 ISBN 978-3-7091-1874-0 (eBook)

DOI 10.1007/978-3-7091-1874-0

Library of Congress Control Number: 2015942456

Springer Vienna Heidelberg New York Dordrecht London

© Springer-Verlag Vienna 2015

This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software,

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Editors

Florian Fitzal, FEBS, MD

Professor of Surgery

Hospital of the Sisters of Charity and

Cancer Comprehensive Center Medical

University Vienna

Linz

Austria

Peter Schrenk, MD Allg Öffentl Krankenhaus Abt Chirurgie II

Linz Austria

We would like to thank Bernard Ammerer for providing his expertise in drawing several illustrations within this second edition of the Oncoplastic Surgery book

Acknowledgement

1 Introduction 1Florian Fitzal and Peter Schrenk

Part I Breast Conserving Oncoplastic Techniques:

Round Block or Doughnut Technique

2 Round Block Lumpectomy 5Hisamitsu Zaha

3 Round Block Lumpectomy with Resection of the Nipple 9Peter Schrenk

4 Doughnut Lumpectomy: Caveat I 13Florian Fitzal

5 Doughnut Lumpectomy: Caveat II 17Hisamitsu Zaha

Part II Breast Conserving Oncoplastic

Techniques: Batwing Technique

6 Batwing Lumpectomy with Skin Resection 21Elias E Sanidas

7 Hemibatwing No Man’s Land 25Elias E Sanidas

8 Batwing (Omega) Quadrantectomy 29Peter Schrenk

9 Batwing Quadrantectomy 33Peter Schrenk

Part III Breast Conserving Oncoplastic Techniques: Rotation/

Advancement Flap

10 Breast Conservation Surgery and Defect Reconstruction

with a Rotation Flap from the Lateral Thoracic Wall 39Peter Schrenk

Contents

11 Tumor Quadrantectomy and Defect Remodeling

with an Epigastric Skin Flap 43

Vesna Bjelic-Radisic

12 S-Mammoplasty No Man’s Land 45

Elias E Sanidas

13 Rotational Advancement Flap Quadrantectomy 49

Victor J Hassid and Steven J Kronowitz

14 Inferior Rotation Flap 53

Päivi Vaara and Marjut Leidenius

15 Inferior Rotation Flap: Caveat 57

Päivi Vaara and Marjut Leidenius

16 Intramammarian Flap Reconstruction:

Partial Flap Necrosis 61

20 Segment Resection of a Breast Cancer

in the Submammary Fold Using a Vertical

Reduction Technique 75

Florian Fitzal

21 Breast Conservation Surgery: The Vertical Mammoplasty 79

Elias E Sanidas

22 Superior Pedicle Reduction Mammoplasty and Defect

Reconstruction Using an Inferior- Based Pedicle

with a Skin Island 81

Peter Schrenk

23 Oncoplastic Superior-Based Pedicle Reduction

Mammoplasty and Defect Reconstruction

with an Inferior Pedicle 85

Vesna Bjelic-Radisic

Contents

25 Superior-Based Pedicle Quadrantectomy and Reconstruction of the Quadrantectomy Defect with an Inferior Pedicle Flap 93Peter Schrenk

26 Superior-Based Pedicle Quadrantectomy and Defect Reconstruction with Inferior- Based Pedicle: Secondary Prophylactic Mastectomy and Implant Reconstruction 97Peter Schrenk

Part V Breast Conserving Oncoplastic Techniques:

Inferior Pedicle

27 Defect Reconstruction with Inferomedial Pedicle Technique 103

Victor J Hassid and Steven J Kronowitz

28 Inferior Pedicle Reduction Mammoplasty 107

Peter Schrenk

29 Inverted-T Technique for Multicentric Breast Cancer 111

Florian Fitzal

30 Inferior Pedicle Reduction Mammoplasty:

Position of the Nipple Too High 115

Peter Schrenk

31 Inferior Pedicle Reduction Mammoplasty:

Poor Result Due to a Large Defect 119

Peter Schrenk

Part VI Breast Conserving Oncoplastic Techniques: B Plasty

32 The B-Mammoplasty for Upper Outer Quadrant Tumors 127

Peter Schrenk

Contents

Part VII Breast Conserving Oncoplastic Techniques:

Central Resection

35 Central Quadrantectomy and Reconstruction

of the Nipple- Areola Complex with a De-epithelialized

Inferior- Based Pedicle with a Skin Island 143

37 Modifi ed Reduction Mammoplasty for Cancer

in the Upper Inner Quadrant 155

Peter Schrenk

38 Hall Findlay: Bad Case 159

Florian Fitzal

Part IX Mastectomy and Immediate Reconstruction:

Acellular Dermal Matrix/Mesh Cases

39 Nipple Sparing Mastectomy and Immediate

Implant Reconstruction with an Acellular

Dermal Matrix (ADM) 165

Peter Schrenk

40 Skin-Sparing Mastectomy and Immediate Implant

Breast Reconstruction with an Acellular Dermal

Matrix (ADM) Following Nipple-Areola

Complex Reconstruction 175

Vesna Bjelic-Radisic

41 Nipple-Sparing Mastectomy and Immediate

Implant Reconstruction with a Mesh 179

Peter Schrenk

42 Nipple-Sparing Mastectomy and Immediate

Implant-Based Reconstruction with an Acellular

Dermal Matrix (ADM) 185

Peter Schrenk

43 Immediate Implant-Based Breast Reconstruction

with an Acellular Dermal Matrix (ADM): Reconstruction

Failure Due to Postoperative Hematoma Causing

Skin Necrosis and Implant Extrusion 191

Vesna Bjelic-Radisic

Contents

44 Nipple-Sparing Mastectomy and Immediate Reconstruction with an Acellular Dermal Matrix (ADM): Revision Due to Nipple Necrosis

and Secondary Reconstruction with a DIEP Flap 195

Peter Schrenk

Part X Mastectomy and Immediate Reconstruction: Latissimus

Dorsi Flap/Dermoglandular Flap

48 Latissimus Dorsi Flap Reconstruction with Inverted T Mastectomy: Good Result 217

Hisamitsu Zaha

49 Latissimus Dorsi Flap Reconstruction with Inverted

T Mastectomy: Bad Result 221

Hisamitsu Zaha

50 Skin-Sparing Mastectomy and Immediate Implant-Based Reconstruction Using a Dermoglandular Flap 225

Peter Schrenk

Part XI Lipofi lling

51 Breast Reconstruction After Mastectomy with Lipofi lling 231

and Correction with Lipofi lling 241

Peter Schrenk

Contents

54 Correction of a Postlumpectomy Deformity

Scar by Lipofi lling 245

Rupert Koller and Christoph Grill

Part XII Problems Associated with Radiation

55 Round Block Quadrantectomy for Invasive

Breast Cancer Following Cosmetic Breast

Augmentation 251

Peter Schrenk

56 Nipple-Sparing Mastectomy and Immediate Implant

Reconstruction with an Acellular Dermal Matrix

(ADM) Followed by Postmastectomy

Radiation Treatment (PMRT) 255

Peter Schrenk

57 Local Recurrence After Quadrantectomy

and Radiation Treated by Oncoplastic

Reduction Mammoplasty 259

Peter Schrenk

58 Local Recurrence After Breast Conservation

and Radiation: Mastectomy and Immediate

Reconstruction with a Latissimus Dorsi (LD) Flap 263

Peter Schrenk

59 Mastectomy and Immediate Expander/Implant

Reconstruction with Lipofi lling: Postmastectomy

Radiation Treatment 269

Peter Schrenk

60 Mastectomy and Immediate Implant-Based Breast

Reconstruction Followed by Postmastectomy

Radiation Treatment: Implant Exposure

and Revision with a Latissimus Dorsi Flap 273

Peter Schrenk

61 Mastectomy and Immediate Expander Reconstruction

for Local Breast Recurrence After Previous

Quadrantectomy and Radiation 277

Peter Schrenk

62 Correction of Postquadrantectomy Deformity

with a DIEP Flap 281

Rupert Koller and Christoph Grill

Contents

Part XIII Revisional Surgery (Surgery After Surgery)

63 The Inverted T Mammoplasty for Defect Correction After Previous Breast Conservation Surgery 287

Elias E Sanidas

64 Breast Conservation Surgery Following Cosmetic Reduction Mammoplasty 291

Peter Schrenk

Part XIV Nipple Areola Complex

65 Nipple-Areolar Complex (NAC) Reconstruction:

Good Case 297

Florian Fitzal

Contents

Florian Fitzal , FEBS, MD Breast Health Center ,

and Cancer Comprehensive Center Medical University Vienna,

Hospital of the Sisters of Charity , Linz , Austria

Christoph Grill , MD Department of Plastic, Aesthetic and Reconstructive

Surgery , Breast Health Center Wilhelminenspital , Vienna , Austria

Victor J Hassid , MD Department of Plastic Surgery , The University

of Texas MD Anderson Cancer Center , Houston , TX , USA

Rupert Koller Department of Plastic, Aesthetic and Reconstructive

Surgery , Breast Health Center Wilhelminenspital , Vienna , Austria

Steven J Kronowitz , MD, FACS Department of Plastic Surgery , The

University of Texas MD Anderson Cancer Center , Houston , TX , USA

Marjut Leidenius , MD, PhD Comprehensive Cancer Center, Breast

Surgery Unit , Helsinki University Central Hospital , Helsinki , Finland

Vesna Bjelic-Radisic , PD, PhD Division of Gynecology, Department

of Obstetrics and Gynecology , Medical University of Graz , Graz , Austria

Christopher J Rageth Brust-Zentrum , Zürich , Switzerland

Elias E Sanidas , MD, FACS Department of Surgery , Herakleion Crete

Medical School , Herakleion , Crete , Greece

Peter Schrenk , MD Second Department of Surgery , Breast Care Center,

Akh – LFKK Linz , Linz , Austria

Päivi Vaara , MD, PhD Comprehensive Cancer Center, Breast Surgery

Unit , Helsinki University Central Hospital , Helsinki , Finland

Hisamitsu Zaha , MD Department of Breast Surgery , Nakagami Hospital ,

Okinawa , Japan

Contributors

Florian Fitzal and Peter Schrenk

In the book Oncoplastic Breast Surgery: A guide

to clinical practice (edited in 2010), oncoplastic

breast conservation surgical techniques as well as

immediate reconstruction after mastectomy were

described in detail Based on these techniques,

the current book describes 64 cases of

oncoplas-tic surgery presented by different authors

Contrary to other books, the authors present

not only cases with a good outcome, but an

emphasis is put on complications and poor

cos-metic results

Each case presentation is followed by a

com-ment of the author discussing why the surgical

technique used provided a good outcome as well

as what went wrong in case of an inferior result

The poor cases are critically analyzed with

respect to patient and case selection, the surgical

technique used, and the experience of the geon Possible solutions are provided on how to improve or correct a poor result or, more impor-tant, how a poor outcome may have been avoided

sur-Case selection in this book primarily prises oncoplastic breast conservation surgery but also refers to new techniques like matrix- assisted breast reconstruction, lipofi lling, or problems associated with postsurgical radiation treatment

com-The book should help the reader to obtain good clinical and cosmetic results and to avoid making the same mistakes as other surgeons have done before and should help in decision-making and problem-solving in case of postoperative complications

F Fitzal , FEBS, MD (*)

Breast Health Center, and Cancer Comprehensive

Center Medical University Vienna, Hospital of the

Sisters of Charity , Linz , Austria

e-mail: fl orian.fi tzal@meduniwien.ac.at ,

P Schrenk , MD

Second Department of Surgery , Breast Care Center,

Akh – LFKK Linz , Linz , Austria

e-mail: peter.schrenk@akh.linz.at

1

Part I Breast Conserving Oncoplastic Techniques:

Round Block or Doughnut Technique

A 41-year-old woman had a palpable mass in the

upper inner quadrant of her left breast

Radiological workup and biopsy showed an

inva-sive ductal carcinoma with triple-negative

fea-tures which was 3.7 cm in size After 6 months of

neo-adjuvant chemotherapy, the tumor achieved

clinical complete response; then, breast-

conserving surgery became possible She had

small-sized breasts without ptosis, and the

origi-nal tumor location was 5 cm away from the

nip-ple Thus, we decided to perform a modifi ed

round block technique (MRBT) (Zaha et al

exci-sion without exciexci-sion of the periareolar skin and

also gives the surgeon the opportunity to use

ade-quate adjacent breast tissue to fi ll the breast

defect even in a small-sized breast

2.2 Surgery

After a sentinel lymph node biopsy, a ential periareolar incision was made along the outer wedge of the areola, and deep subcutaneous dissection was carried out via the incision

excised nor deepithelialized Subcutaneous section was extended not only to the tumor- bearing upper quadrants but also to the entire breast including the inferior quadrants, which made it easy to access the distally located tumor without periareolar skin excision The nipple- areola complex (NAC) was then completely detached from the surrounding skin fl ap, and a wound retractor was placed to widen the periare-

breast parenchyma were pushed downward

Partial mastectomy defect was repaired by

H Zaha , MD

Department of Breast Surgery ,

Nakagami Hospital , Okinawa , Japan

e-mail: hisamitu@nakagami.or.jp

2

Fig 2.1 ( a ) A circumferential incision was made without

excision or deepithelialization of the periareolar skin

Although the areola was 3.5 cm in diameter, the wound

automatically became wider after a full-thickness

peri-areolar incision ( b ) Subcutaneous dissection was extended to the entire breast including the lower quad- rants A wound retractor could widen the wound and facilitated entire subcutaneous dissection

Fig 2.2 ( a ) The nipple-areola complex (NAC) was pushed downward, and the wound was moved above the tumor ( b )

Partial mastectomy was completed with a good fi eld of view

mobilizing and suturing the surrounding breast

mobi-lize the residual breast parenchyma because it

had been already widely dissected from the skin

fl ap After remodeling of the breast was

com-pleted, the wound was easily closed with the

NAC with continuous subcuticular absorbable

2.3 (Clinical and Cosmetic)

Outcome

The postoperative follow-up was uneventful Pathological analysis revealed pathological com-plete response The cosmetic result was rated excellent by the surgeon as well as by the patient

1 year after surgery (Fig 2.4 )

H Zaha

contralat-2.4 Comment of the Author

MRBT is best suited for patients with small- to

medium-sized breasts with areolae that are

smaller than 3 cm in diameter or when the tumor

is located peripherally Characteristic steps that

are distinct from RBT are omission of the

excision or deepithelialization of the periareolar

skin and extensive subcutaneous dissection of the

late-onset scar widening and changes in both shape

and position of the NAC can be minimized in MRBT even in small-sized breast

Extensive subcutaneous dissection including the inferior quadrants allows easy access to the tumor by detaching the NAC from the surround-ing skin fl ap and by moving the wound above the tumor A round periareolar wound can be widened

up to at least 5 cm in diameter through tion of a wound protector, even without excision

applica-or deepithelialization of the periareolar skin Extensive subcutaneous dissection also enables

2 Round Block Lumpectomy

easy remodeling of the breast; however,

dissec-tion between the residual breast parenchyma and

the pectoralis muscle should be limited only to

the upper half of the breast parenchyma to

main-tain the vertical blood supply to the NAC, when

remodeling is performed

References

Benelli L (1990) A new periareolar mammaplasty: the

“round block” technique Aesthetic Plast Surg

14:93–100

Fitzal F (2010) Round block technique (Doughnut pexy) In: Fitzal F, Schrenk P (eds) Oncoplastic breast surgery A guide to clinical practice Springer, Wien/ New York, pp 71–75

Zaha H, Onomura M, Unesoko M (2013) A new scarless oncoplastic breast-conserving surgery: modifi ed round block technique Breast 22:1184–1188

H Zaha

A 53-year-old postmenopausal woman was

diagnosed with a 10 mm tumor in the left breast

3 cm from the nipple in the upper outer quadrant

Clinically the patient presented with bloody

nipple discharge; mammography found small

clusters of suspicious microcalcifi cations

peritu-morally The breast was of small size and

non-ptotic (Fig 3.1a, b )

3.2 Surgery

A round block quadrantectomy was done, and

this included resection of the nipple and the

breast duct with the nipple discharge This duct

was identifi ed through ductoscopy and marked

with a thin wire inserted through the ductoscope

The medial and lateral pillars of breast tissue

were mobilized off the skin and the pectoralis

muscle fascia and closed to avoid any dead space

The skin of the areola complex was dissected off

the breast tissue and the wound closed as a round

P Schrenk , MD

Second Department of Surgery ,

Breast Care Center, Akh – LFKK Linz , Linz , Austria

e-mail: peter.schrenk@akh.linz.at

3

a

b

Fig 3.1 ( a , b ) Preoperative view A 53-year-old patient

had a small invasive cancer and intraductal carcinoma in situ in the upper outer periareolar region of the left breast

e

Fig 3.2 ( a – e ) Intraoperative view ( a ) The new areola is

outlined ( inner circle ), another circular incision is in a

15 mm distance The tissue and the nipple to be resected

are outlined on the skin ( b ) The subcutaneous tissue is

dissected off the skin The tissue to be resected is marked

on the breast ( c ) The tumor is resected together with the

nipple, and the skin of the areola is mobilized from the

subcutaneous tissue ( d ) The skin of the areola and the

breast tissue are closed ( e ) Immediate postoperative result

P Schrenk

3.3 Clinical and Cosmetic

Outcome

The postoperative course was uneventful Final

histology found a 10 mm invasive cancer (G2,

receptor positive, Her-2-neu negative, Ki67:

5 %) and a 20 mm ductal carcinoma in situ of

intermediate grade both completely removed

Postoperatively the patient underwent radiation

and endocrine treatment The cosmetic result 5

years after surgery was judged as excellent by

3.4 Comments of the Author

• In this patient the nipple was excised due to

nipple discharge and intraductal carcinoma

in situ close to the nipple-areola complex

The discharging breast duct was identifi ed intraoperatively with ductoscopy and through wire guidance, which allowed selective excision of the discharging duct

In case of malignant microcalcifi cations not closer than 20 mm to the nipple, we would try to preserve the nipple and make further resections dependent of the fi nal his-tologic result

block quadrantectomy are those with medium- sized breasts and a moderate degree of ptosis The tumor should be defi ned to one quadrant

or otherwise the resection results in large defects, and the pedicles to be mobilized for adequate closure have to be undermined too much with the risk of fatty tissue necrosis or increased tension on the tissue resulting in tis-sue defects and a poor cosmetic result

Fig 3.3 ( a , b ) The postoperative result after 5 years shows good volume and breast symmetry

3 Round Block Lumpectomy with Resection of the Nipple

A 57-year-old woman had a palpable mass in the

upper outer quadrant of her right breast

Radiological workup showed a 1 cm unilateral

lesion Breast conservation was possible, and

biopsy showed an invasive lobular endocrine

responsible breast cancer She had a medium-

nipple-areola complex (NAC) is situated at the

right place, and the patient did not want any

con-tralateral symmetrization Any type of

oncoplas-tic surgery using breast reduction would have

yielded in major asymmetry Thus, we decided to

perform a classical doughnut mastopexy This

technique leaves the NAC in place and gives the

surgeon the opportunity to use adjacent breast

tis-sue to fi ll the breast defect after oncologic

F Fitzal , FEBS, MD

Breast Health Center, and Cancer Comprehensive

Center Medical University Vienna, Hospital of the

Sisters of Charity , Linz , Austria

e-mail: fl orian.fi tzal@meduniwien.ac.at ,

fl orian.fi tzal@bhs.at

4

Fig 4.1 Preoperative picture of a 58-year-old patient with a 1 cm invasive lobular breast cancer in the upper outer quadrant of her right breast

4.3 (Clinical and Cosmetic)

Outcome

After surgery, the cosmetic result seemed to be

small defect was visible in the upper outer

quad-rant of the right breast This defect increased

after radiotherapy and was quiet visible 1 year

after surgery (Figs 4.4 and 4.5 )

4.4 What Went Wrong or What

Was the Problem?

In this case the patient was suitable for a

dough-nut mastopexy The medium breast size and the

location of the tumor were good indications A

reduction mammoplasty with a vertical technique

might have also been appropriate However, the

patient initially refused any type of contralateral

symmetrization surgery, which would have been

necessary to fi nally achieve a good result

the breast tissue medial and lateral from the defect has not been adequately dissected from

Fig 4.2 This fi gure shows the defect after doughnut

mastopexy and resection of the upper outer breast lump

On both sides of the defect, the breast parenchyma is not

adequately freed from the skin and the pectoralis fascia

No sutures have been placed to approximate the breast

lumps adjacent to the defect This resulted in inadequate

defect reconstruction

Fig 4.3 Directly after closing the skin, there seemed to

be no defect within the breast

Fig 4.4 One year after surgery, the defect is visible

F Fitzal

the skin and the pectoralis fascia The defect has not been closed using parenchymal sutures However, both steps are necessary to achieve a good result

4.5 Comment/Possible Solution

In order to improve the result, adipose tissue infi ltration may be an option A second option would be to perform bilateral reduction mammo-plasty In this case the patient refused both options

Fig 4.5 One year after surgery, the defect is visible

4 Doughnut Lumpectomy: Caveat I

A 61-year-old woman had a palpable mass in

the upper outer quadrant of her left breast

Radiological workup and biopsy showed an

invasive ductal endocrine responsible breast cancer

which was 2.5 cm in diameter She had medium-

sized ptotic breasts; then, we recommended

breast-conserving surgery with vertical scar reduction

denied major elevation of the breast; thus, we

decided to perform a classical doughnut mastopexy

5.2 Surgery

After sentinel node biopsy, the skin around the

NAC was deepithelialized in a typical fashion

After incision of the dermis, the breast

parenchyma around the tumor was dissected

from the skin Partial mastectomy was performed

under palpable control of the tumor maintaining

2 cm macroscopic margins The defect within the

surrounding breast parenchyma without further dissection of the skin fl ap The contralateral symmetrization was performed with also

H Zaha , MD

Department of Breast Surgery ,

Nakagami Hospital , Okinawa , Japan

e-mail: hisamitu@nakagami.or.jp

5

Fig 5.1 Preoperative picture of a 61-year-old patient with a 2.5 cm invasive ductal breast cancer in the upper outer quadrant of her left breast Because of ptosis of the breasts, breast-conserving surgery with bilateral reduction mammoplasty was fi rst planned

became asymmetrical one year after surgery

(Fig 5.3 )

5.4 What Went Wrong or What

Was the Problem?

During doughnut surgery, the breast tissue medial

and lateral from the defect has not been

ade-quately dissected from the skin and the pectoralis

fascia The infl uence of the radiation therapy

should have been taken into the consideration,

and the contralateral breast should have been

more elevated even though the patient did not

want major elevation of the breasts

5.5 Comment/Possible Solution

Possible solution might be lipofi lling of the defect in the left breast and contralateral symme-trization once again Doughnut mastopexy can probably be adapted repeatedly for contralateral symmetrization

Fig 5.2 The patient denied major elevation of the

breasts, and operative plan was changed into doughnut

mastopexy The defect was repaired by suturing the

sur-rounding breast parenchyma; however, dissection from

both skin fl ap and the pectoralis fascia was not enough for

remodeling

b a

Fig 5.3 ( a ) The left breast shrank, and the breasts on

both sides became asymmetrical one year after surgery

( b ) The defect appeared in the upper outer quadrant close

to the axilla which caused slight upper outer deviation of the left nipple-areola complex

H Zaha

Part II Breast Conserving Oncoplastic Techniques: Batwing Technique

This case shows a 64-year-old woman with two

non-palpable lesions at 9 o’clock and 12 o’clock

deep near the major thoracic muscle and about

6 cm distance between their projections on the

skin surface A J wire was inserted

mammograph-ically at the 9 o’clock lesion, and another J wire

was US guided inserted intraoperatively at the 12

o’clock lesion Preoperative staging was negative

6.2 Surgery

• The patient underwent lumpectomy including

the above lying skin, sentinel node biopsy

with blue dye-only technique, and immediate

axillary dissection due to palpation of

multi-ple enlarged nodes

• The technique gives the possibility to excise 2

(or more) multifocal or multicentric lesions

including the overlying skin Furthermore it is

possible to lift the breast in case of a ptosis

patient sitting upright The lateral drawing

lines have to outweigh the round central diameter in length (Fig 6.1 )

incised; the cranial resection margin was fi rst developed by vertical dissection down to the

E E Sanidas , MD, FACS

Department of Surgery , Herakleion Crete

Medical School , Herakleion , Crete , Greece

pectoralis fascia Thereafter, the dissection is

carried out between the nipple-areola complex

and the segment, and under palpable control,

the segment including the skin is excised

(Fig 6.2 )

• Without further dissection between the skin

and the breast, the defect is simply closed

(Fig 6.3 )

• After the insertion of a drain, suturing is done

after approximation with interrupted PDS 3.0

sutures in two layers (deep and superfi cial)

followed by continuous subcutaneous PDS

6.3 Outcome (Clinical

and Cosmetic)

The fi nal histology showed a high-grade DCIS

with 5 mm in diameter at 9 o’clock and an sive ductal adenocarcinoma pT1c G2 R0 resec-

inva-tion with negative lymph nodes pN0 (0/25), ER

85 % (2+), PR 30 % (1+), and Her2 negative at

the 12 o’clock position The patient underwent adjuvant breast radiotherapy and endocrine treat-ment with an aromatase inhibitor The cosmetic

the patient and the physician 12 months after surgery

6.4 Author’s Comment

This oncoplastic technique can be applied to all ptotic breasts However, there must be a “logical” relation between the ptosis and the breast area to

be excised If the ptosis is small and the excision area big, we will end up with a high riding nipple- areola complex Thus, the projection of the infra-mammary fold must be marked on the anterior breast surface, and the upper end of the areola in

its new position must NOT be above it

Fig 6.2 Preoperative drawing lines fully incised

Fig 6.3 Defect closed

Fig 6.4 After insertion of drain and suturing

E.E Sanidas

6.5 Editor’s Comment

Moreover it must be necessary to excise the skin; otherwise, there are other methods which do not need such large scars all the way to the breast such as simple inferior pedicled technique (Eren, Frey) or Hall-Findlay reduction mammoplasty

Fig 6.5 Cosmetic result 12 months after surgery

6 Batwing Lumpectomy with Skin Resection

This case shows a 51-year-old woman with two

adjacent non-palpable lesions of the inner half

of the left breast at the 9 o’clock position This

is also called the no man’s land due to bad

cosmetic results after breast conservation

without oncoplastic techniques The two lesions

can be seen marked on the skin after US

localization (Fig 7.1 )

7.2 Surgery

medio-cranial part of the left breast

• Preoperative markings are similar to a hockey

incision or J incision without

deepithelializa-tion around the nipple-areola complex

(Figs 7.2 and 7.3 )

both lesions are resected with macroscopic

clear margins (Figs 7.4 and 7.5 )

skin is simply closed (Fig 7.6 )

E E Sanidas , MD, FACS

Department of Surgery , Herakleion Crete

Medical School , Herakleion , Crete , Greece

Fig 7.3 Preoperative markings

Fig 7.4 Markings are incised and both lesions resected

Fig 7.5 Markings are incised and both lesions resected

Fig 7.6 Specimen

E.E Sanidas

7.3 Outcome (Clinical

and Cosmetic)

Final histology demonstrated a ductal invasive

adenocarcinoma in both lesions with 1.4 and

0.5 cm in diameter, thus pT1c, G3, L1 pN0 (0/5)

R0 resection; ER 95 % (2+) and PR 45 % (1–2 %);

and HER2 neg The patient received adjuvant

chemoendocrine treatment and radiotherapy

7.4 Author’s Comments

This modifi cation of the batwing technique is used if the ptosis grade is not too high and the tumor is not too large It is a combination of a radial excision and a crescent excision/ deepithelialization to compensate for the inward movement of the nipple It is excellent for tumors

of the inner half no man’s land (8–10 o’clock) where breast tissue is usually “missing.”

7.5 Editor’s Comments

This technique is easy to use and results in excellent cosmesis However, in cases of larger lesions, surgeons should think about deepitheli-alization around the nipple-areola complex such as in the J-technique in order to be able to further compensate the unilateral nipple dysrotation

Fig 7.7 Wound is closed in layers

7 Hemibatwing No Man’s Land

A 76-year-old woman was diagnosed with a

24 mm receptor-positive carcinoma in the

superior quadrant of the right breast 6 cm above

the nipple The breast was of medium size and

ptotic, with the right breast slightly smaller than

the left breast (Fig 8.1a, b )

8.2 Surgery

The patient underwent breast conservation

surgery using a batwing (omega)

quadrantec-tomy Sentinel node biopsy was done through the

same incision and found two negative sentinel

nodes Following quadrantectomy, the mammary

gland was dissected off the pectoralis major

muscle fascia, and the caudal breast tissue was

raised superiorly to close the defect No drain

The cosmetic result was rated excellent by both the surgeon and the patient The right breast showed good breast volume (although being smaller than the left breast) and location of the

8.4 Comments of the Author

option for tumors in the upper, upper outer, or upper inner quadrant in medium-sized ptotic breasts The nipple-areola complex (NAC) is shifted up on the breast median The tumor should not be located too far cranially or be too large for in these cases the NAC would be transferred too high on the breast median and the defect would be too pronounced (Fig 8.3a–d )

P Schrenk , MD

Second Department of Surgery ,

Breast Care Center, Akh – LFKK Linz ,

Linz , Austria

e-mail: peter.schrenk@akh.linz.at

8

• The extensions of the batwing incision in the

lat-eral and medial direction allow excision of tumors

located more laterally or medially in the breast

Alternatively, in these patients a hemibatwing

• In patients with a more pronounced ptosis,

an inferior cosmetic result may be seen This

is due to the fact that the batwing

quadran-tectomy resects tissue only in the cranial part

of the breast and leaves the ptosis in the

lower part of the breast nearly untouched

(Fig 8.5a–d )

used for retroareolar tumors In these patients the NAC is removed with the batwing quadrantectomy

instead of the batwing quadrantectomy would have been a round block quadrantectomy or

an inferior based pedicle mammoplasty The round block technique, however, in patients with ptotic breasts may lead to a less pro-nounced breast-like appearance and even to a

fl at (pancake-like) breast

Fig 8.1 ( a , b ) Preoperative view The tumor was in the cranial quadrant of the right breast ( cross )

Fig 8.2 ( a , b ) Postoperative view 7 years after surgery The scars around the nipple are hardly visible; the breast shows

good form and volume Reduction mammoplasty of the left breast was declined by the patient

P Schrenk

Fig 8.3 ( a – d ) This 42-year-old patient had multifocal

invasive receptor-positive breast cancer ( circles ) in the

cranial quadrant Neoadjuvant chemotherapy found a

clinically partial remission, and a batwing

quadrantec-tomy was planned ( a , b ) Due to the multifocal disease

and the extent of the tumors cranially, a wide tissue

resec-tion was necessary and resulted in a poor cosmetic result with a defect in the upper quadrant and the position of the

nipple being too high ( c , d ) The patient is shown 3 years

after surgery and radiation No further surgery is planned yet

Fig 8.4 Hemibatwing quadrantectomies were used for

this patient with a tumor in the upper inner periareolar

quadrant of the right breast and upper outer periareolar

quadrant of the left breast

8 Batwing (Omega) Quadrantectomy