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

Part 2 book “Oncoplastic breast surgery - A guide to clinical practice” has contents: Retroareolar breast cancer treated with central quadrantectomy, nipple-sparing mastectomy and immediate implant reconstruction with a mesh, nipple-sparing mastectomy and immediate implant-based reconstruction with a tiloop bra mesh,… and other contents.

Fig 34.5 ( a – f ) A 67-year-old patient underwent breast

conservation surgery using a B plasty for a 30 mm lobular

cancer (receptor positive, HER2 negative, Ki 67: 20 %,

G2) in the upper outer quadrant of the left breast The

sen-tinel node was positive, and an axillary dissection was

performed (2 positive lymph nodes out of 15) Re-excision

was necessary due to involved margins with intraductal

carcinoma in situ The breast was of medium size with no

ptosis and a good cosmetic result after quadrantectomy

( a , b ) A skin-sparing mastectomy with immediate

recon-struction with a latissimus dorsi fl ap and an implant was performed The fl ap was de-epithelialized except a skin

island as a substitute for the areola ( c , d ) The

postopera-tive cosmetic result 4 years after surgery was excellent with good size and ptosis of the reconstructed breast and

symmetry to the contralateral breast ( e , f ) Reconstruction

of the NAC was declined by the patient

34 Breast Conservation Surgery: The B Plasty, Involved Margins, Skin-Sparing Mastectomy

Peter Schrenk

P Schrenk , MD

Second Department of Surgery , Breast Care Center,

Akh – LFKK Linz , Linz , Austria

e-mail: peter.schrenk@liwest.at

35

35.1 The Patient

A 62-year-old woman was diagnosed (open

biopsy) with Paget carcinoma of the left nipple-

areola complex (NAC) Mammography and

breast MRI revealed suspicious microcalcifi

ca-tions 30 mm in size solely behind the nipple

Vacuum needle biopsy found intraductal

carci-noma in situ of intermediate grade Breast

con-servation surgery was suggested and planned as a

central quadrantectomy The patient had a large

and ptotic breast (Fig 35.1a–c )

35.2 Surgery

Central quadrantectomy was performed as part of

an inferior-based pedicle reduction

mammo-plasty with a resection volume of 1,150 g The

inferior pedicle was de-epithelialized except a

small skin island, which was used for

biopsy found one negative sentinel node

35.3 Clinical and Cosmetic

Outcome

The postoperative course was uneventful Permanent histology found a Paget carcinoma of the nipple and a 30 mm carcinoma in situ of high grade with wide clear margins of more than 5 cm

No postoperative radiation was suggested by the tumor board due to the wide resection margins Nine months after surgery, reconstruction of the NAC and a contralateral reduction with an inferior-based pedicle were done (Fig 35.3a, b ) Routine follow-up mammography 8 years after initial surgery revealed scattered suspicious microcalcifi cations in the upper inner quadrant of the left breast over a distance of 3 cm Vacuum needle biopsy confi rmed ductal carcinoma in situ high grade

Breast conservation surgery was suggested and planned as a vertical central quadrantectomy with resection of the (reconstructed) NAC or – in case the intraoperative radiogram of the speci-men reveals large free margins – as an inferior- based pedicle reduction mammoplasty with the reconstructed NAC as a skin island on the de- epithelialized inferior-based pedicle (Fig 35.4a–c )

The extension of the microcalcifi cations was

was circumcised and the inferior pedicle was de- epithelialized (Fig 35.4d ) Wide excision of the upper inner periareolar quadrant was done

Fig 35.1 ( a – c ) Preoperative view The 62-year-old

patient had a Paget carcinoma of the nipple and

intra-ductal carcinoma in situ of the left breast Central

quadran-tectomy was planned using an inferior pedicle reduction mammoplasty with a skin island for reconstruction of the NAC

Fig 35.2 ( a , b ) Intraoperative view Following central quadrantectomy, the inferior pedicle was de-epithelialized

leav-ing a skin island for reconstruction of the nipple

Fig 35.3 ( a , b ) Postoperative view The nipple was

reconstructed with a star fl ap technique; an inferior-based

pedicle reduction mammoplasty was performed for

sym-metrization ( a ) ( b ) Postoperative result after 4 years

Fig 35.4 ( a – g ) Follow-up mammography found

recur-rence of intraductal carcinoma in situ in the upper inner

quadrant of the left breast and extending to the NAC

A central quadrantectomy performed as an inferior

pedi-cle reduction mammoplasty with or without preservation

of the reconstructed NAC – depending on the

intraopera-tive specimen mammography and frozen section – was

planned ( a – c ) The extension of the microcalcifi cations was marked with two wires ( c ) The NAC was preserved

on the de-epithelialized inferior pedicle ( d ) and used for

reconstruction ( e ) Early postoperative view showed a smaller volume of the left breast but an otherwise good

Intraoperative mammogram of the specimen

(resection weight 350 g) found the microcalcifi

-cations completely removed with wide free

mar-gins and no involvement of the reconstructed

NAC, which was used for reconstruction

biopsy found two negative sentinel lymph nodes

Permanent histology found an intraductal

car-cinoma in situ of high grade of 35 mm with wide

clear margins The postoperative course was

complicated with delayed wound healing (small

necrosis of the skin of the neo-areola) managed

conservatively The fi nal postoperative result is

seen in Fig 35.4f, g

35.4 Comments of Author

quadrantectomy is safe and comparable to

mas-tectomy when postoperative radiation is applied

inferior- based pedicle, the NAC can be structed immediately with a skin island on the de-epithelialized pedicle This technique requires adequate breast volume with a medium- or large-size breast with at least moderate ptosis

recon-• Due to the large resection volume with wide clear margins, no radiation was suggested by the tumor board For the patient who had no prior radiation and the tumor recurrence was restricted to the upper inner periareolar region, reoperation quadrantectomy was done

• Figure 35.5a–f shows another patient with a central quadrantectomy using an inferior- based pedicle and reconstruct the NAC with a skin island from the inferior pedicle

• In order to obtain a more pronounced volume

of the breast, the medial and lateral pillars of the inferior pedicle may be mobilized and sutured together behind the inferior pedicle (Fig 35.6a, b )

g

Fig 35.4 (continued)

Fig 35.5 ( a – f ) A 54-year-old patient with bilateral

breast cancer The cancer in the right breast was located

retroareolarly and extended into the upper outer quadrant,

whereas the tumor in the left breast was in the upper outer

quadrant ( a – c ) A central quadrantectomy with an

inferior- based pedicle and reconstruction of the NAC with

a skin island was planned on the right breast, whereas due

to the location of the tumor, an inferior pedicle plasty was done on the left breast without resection of the NAC The patient underwent radiation on both breasts The postoperative result 3 years after surgery was rated as

mammo-excellent ( d – f )

35 Central Quadrantectomy and Reconstruction of the Nipple Areola Complex with an Inferior Pedicle

Fig 35.6 ( a , b ) Central quadrantectomy and

autoaug-mentation of the breast volume After resection of the

NAC, the lateral and medial pillars of the inferior pedicle

are incised ( a ), mobilized, and closed behind the central inferior pillar ( b ) to augment the breast volume

Second Department of Surgery , Breast Care Center,

Akh – LFKK Linz , Linz , Austria

e-mail: peter.schrenk@liwest.at

36

36.1 The Patient

A 36-year-old premenopausal woman was

diag-nosed with a small (11 mm) retroareolar cancer

of the left breast Mammography and breast MRI

revealed no further pathology in both breasts

Breast conservation surgery with resection of the

nipple-areola complex (NAC) and direct closure

of the defect was planned The breast was of

medium size with minimal ptosis (Fig 36.1 )

36.2 Surgery

Central quadrantectomy using a circumareolar

incision was done The NAC was completely

resected including the retroareolar tissue

includ-ing the pectoralis muscle fascia Sentinel lymph

node biopsy found two negative nodes The

breast tissue was mobilized and closed with two

purse string sutures

36.3 Clinical and Cosmetic

Outcome

The postoperative course was uneventful Final histology found an 11 mm invasive cancer of intermediate grade and positive hormonal recep-tor status Radiation therapy and endocrine treat-ment were suggested Although the left breast was slightly smaller than the right breast, both the patient and surgeon were satisfi ed with the cosmetic result (Fig 36.2a, b ) Reconstruction of the NAC was declined by the patient

Clinical follow-up, however, found an ing retraction of the scar in the retroareolar region (Fig 36.3 ) Radiologic fi ndings were unsuspi-cious Eight years following surgery, routine mammography revealed a small (4 mm) invasive cancer and intraductal carcinoma in situ (DCIS) behind the right nipple Breast conservation was suggested, but the patient decided to undergo a skin-sparing mastectomy in order to spare radia-tion Skin-sparing mastectomy was done using a circumareolar incision Sentinel node biopsy found one negative node Immediate reconstruc-tion was done with a latissimus dorsi muscle

increas-mobilization of the breast tissue and closure without tension

• Retroareolar breast cancer requires resection

of the NAC The mastectomy was performed using a circumareolar approach Reconstruction with a latissimus dorsi muscle is indicated in patients with a small- or medium-size breast and a moderate ptosis Whenever more volume

is required, this may be gained adding a cone implant

quadrantectomy is a horizontal elliptical sion, which may also be used in small breasts

with larger breasts, a T-like resection (Fig 36.6a, b ) The latter also allows correc-tion of ptosis and reduction of breast size.)

Fig 36.1 Preoperative view of a 36-year-old patient with

a retroareolar cancer of the left breast Drawings show two

possible incisions for a central quadrantectomy: elliptical

or circumareolar incision In this patient, the areola/tumor

was resected using a circumareolar approach

Fig 36.2 ( a , b ) Postoperative view 8 years following central quadrantectomy and closure with a purse string suture

The left breast was slightly smaller less than the right breast but with a good cosmetic result

Fig 36.3 Eight years after surgery, routine mammogram

found a small retroareolar cancer Skin-sparing

mastec-tomy through a circumareolar incision and immediate

reconstruction with a latissimus dorsi fl ap was planned

The left breast revealed a retraction of the scar in the

for-mer quadrantectomy area Drawings are shown for a

cir-cumareolar incision with a small areolapexy

Fig 36.4 Postoperative result after skin-sparing tomy and immediate reconstruction with a latissimus dorsi fl ap 4 years after surgery shows an excellent cos- metic result Following central quadrantectomy and radia- tion, the left breast revealed a retraction of the skin Reconstruction of the NAC was declined by the patient

mastec-a

b

Fig 36.5 ( a – d ): Pre ( a , b )- and postoperative ( c , d ) view

after central quadrantectomy using an elliptical excision

of the NAC The postoperative result showed adequate volume and symmetry

36 Retroareolar Breast Cancer Treated with Central Quadrantectomy

Fig 36.6 ( a , b ) Pre ( a )- and postoperative ( b ) view of a

70-year-old patient with a multifocal tumor retroareolarly

and above the nipple In order to include both tumors in

the resection, a T-like reduction technique was used The postoperative result was excellent; reconstruction of the NAC was declined by the patient

Part VIII Breast Conserving Oncoplastic Techniques: Medial Pedicles

© Springer-Verlag Vienna 2015

F Fitzal, P Schrenk (eds.), Oncoplastic Breast Surgery: A Guide to Clinical Practice,

DOI 10.1007/978-3-7091-1874-0_37

A 60-year-old woman underwent incisional

biopsy for a 25 mm mass in the upper inner

quad-rant of the left breast at another hospital

Histology revealed a dermatofi brosarcoma of

intermediate grade Breast MRI revealed no

fur-ther lesions in both breasts Mastectomy with

immediate reconstruction or breast conservation

was discussed with the patient, and she decided

to undergo a wide quadrantectomy

The breast was of large size and ptotic with

the nipple of the left breast slightly lower than

that of the right breast (Fig 37.1a–c )

37.2 Surgery

Due to the aggressive type of the cancer, a wide

quadrantectomy using a modifi ed reduction

mammoplasty with the basis of the T being in the

Following quadrantectomy (resection weight:

420 g), the gland was dissected off the major

pec-toral muscle to allow adequate mobilization and

closure of the defect without tension The skin

areola was recentralized (areolapexy) into the new center of the breast (Fig 37.2a–c ) Sentinel node biopsy was done through a separate incision

in the axilla and revealed 2 negative nodes

37.3 Clinical and Cosmetic

Outcome

Final histology found a 25 mm tumor with the closest margin being 12 mm in direction of the skin and with all the other margins being more than 20 mm The postoperative course was uneventful No radiation treatment or chemother-apy was suggested The cosmetic result 2 years after surgery was rated as good by both the sur-geon and the patient (Fig 37.3a, b ) The scar in the upper inner quadrant was slightly hypertro-phic, the right breast was larger than the left breast, but the patient declined symmetrization mastopexy

37.4 Comments of Author

• The tumor – dermatofi brosarcoma protuberans –

is an uncommon soft tissue sarcoma rarely seen

in the breast It is associated with a high local aggressiveness and signifi cant risk for local recurrence but with a low risk for metastases

P Schrenk , MD

Second Department of Surgery , Breast Care Center,

Akh – LFKK Linz , Linz , Austria

e-mail: peter.schrenk@liwest.at

c

Fig 37.1 ( a – c ) Preoperative view ( a ) The tumor was in

the upper inner quadrant (parasternal region) The scar

resulted from the previous incisional biopsy ( b , c )

Drawings for modifi ed reduction mammoplasty with the joist of the T in the parasternal region

P Schrenk

a b

Fig 37.3 ( a , b ) The postoperative result 2 years after surgery was rated as a good cosmetic outcome

c

Fig 37.2 ( a – c ) Intraoperative view ( a , b ) The upper inner

quadrant is resected with the shape of a T The periareolar

region is de-epithelialized and the nipple transferred into

the new center of the breast ( c ) Closure of the reduction

mammoplasty

The treatment of choice is radical excision with

wide margins The optimal width of the

mar-gins is discussed yet and is assumed to be

between 1 and 5 cm There is no indication for

radiation or chemotherapy Clinical follow-up

should diagnose locoregional recurrence as

early as possible

• The challenge of this case was the location of

the tumor in the upper inner quadrant, the size

of the tumor, and the aggressiveness with a

need for wide local excision Tumors in the

upper inner quadrant usually result in a poor

cosmetic outcome for less tissue is available

for reconstruction of the defect Furthermore, the defect and the scar are often visible in the neckline

There is no indication for neoadjuvant therapy in this type of tumor, and the surgical technique has to excise a large tissue specimen with an adequate cosmetic result The modifi ed T reduction mammoplasty allowed wide local exci-sion and – although the scar is seen in the medial quadrants – a good cosmetic result The incision used for diagnostic biopsy was included in the center of the resection specimen

chemo-P Schrenk

A 60-year-old postmenopausal woman presented

with a new microcalcifi cation in the right breast

dur-ing screendur-ing mammography Microcalcifi cations

were located at 1 o’clock mediocranial in the right

breast (Fig 38.1a, b ), and biopsy revealed

intra-ductal carcinoma However, breast MRI (Fig 38.2 )

showed at least two distinct lesions suspicious for

invasive cancer in the same area Thus, the clinical

stage was multifocal cT1cN0 In order to improve

cosmetic result, we decided to perform an

oncoplas-tic procedure using the Hall Findlay technique

described earlier (Fitzal 2007 )

38.2 Surgery

After preoperative drawings were done, the

nipple- areola complex was supplied by a lateral

pedicle (modifi ed Hall Findlay) After resection

of the tumor, the skin was closed again, however,

After closure of the vertical scar, the tension resulted in a hypoperfused area along the scar (Fig 38.3b ) We decided to use the vertical reduc-tion technique as the patient had no ptosis and with medium- to large-sized breast with a jugulo- nipple distance of 28 cm and a submamarian- nipple distance of about 9 cm Our primary intention was to remove the mediocranial quad-rant and fi ll the defect with the central and lower portion of the breast Moreover with the Hall Findlay technique, scars are avoided at the medial and inner quadrant (no man’s land)

38.3 (Clinical and Cosmetic)

Outcome

Final histological staging revealed mpT1c pN0(0/18) G3 Er- Pr- her2neu+++ KI67 20 % R0 (5 mm closest resection margin) Surgery yielded in good cosmetic outcome regarding symmetry and defect fi lling (Fig 38.4 ) However, the necrotic area along the vertical scar is easy visible This picture has been taken 1 month after surgery Necrosectomy at the surgical out-patient ward has already been performed for some areas at the medial part of the scar Necrosis

is the very most common complication after oncoplastic surgery The patient did not undergo

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

treated at the surgical outpatient ward for about

3 months by special breast cancer nurses and wound managers

Was the Problem

For tissue dissection, we use an electronic scalpel device In this case, we used the device to dissect between the skin and the breast parenchyma (Modus Swift 2 or 3 with 120–160 W) Investigations now show that using electronic devices close at the skin may increase skin dam-age by causing local ischemia In Fig 38.3b , the damage at the medial edge of the vertical skin may already be expected Another explanation may be too much tension on the tissue as seen in

diabetes or smoking increase the risk of wound edge necrosis

Fig 38.1 ( a , b ) Microcalcifi cations located at 1 o’clock mediocranial in the right breast

Fig 38.2 Breast MRI showing at least two distinct

lesions

F Fitzal

38.5 Comment/Possible Solution

If skin necrosis occurs after surgery we

recom-mend to wait until the necrotic tissue becomes

dry Thereafter, it is easy to perform

necrosec-tomy at the outpatient ward Dry bandages and

used Adaptic ® to cover the defect after

necrosec-tomy The wound healed within 3 months

(Fig 38.5 ), and the result after 4 years is shown

in Fig 38.6

Fig 38.3 ( a ) After resection of the tumor, the skin was closed again, however with strong tension on the edges ( b ) After closure of the vertical scar the tension resulted in a hypoperfused area along the scar

Fig 38.4 Surgery yielded a good cosmetic outcome

regarding symmetry and defect fi lling, but the necrotic

area along the vertical scar is easily visible

Fig 38.5 Healing of the necrotic area after 3 months and

4 years

Fig 38.6 Healing of the necrotic area after 3 months and

4 years

Reference

Fitzal FG, Nehrer D, Hoch O, Riedl S, Gutharc M,

Deutinger R, Jakesz M, Gnant (2007) An oncoplastic

procedure for central and medio-cranial breast cancer

Eur J Surg Oncol 33(10):1158–1163

F Fitzal

Peter Schrenk

39.1 The Patient

A 44-year-old premenopausal patient had

multi-ple suspicious microcalcifi cations in the upper

outer and upper inner quadrants of the left breast

found in routine mammography Vacuum needle

biopsy confi rmed a high-grade intraductal

carci-noma in situ The possible treatment options

(breast conservation surgery and radiation or

mastectomy and immediate reconstruction) were

discussed with the patient and she decided for

mastectomy The breast was of medium size with

moderate ptosis with the left nipple-areola

com-plex (NAC) slightly lower compared to that of the

right breast (Fig 39.1a, b )

39.2 Surgery

Nipple-sparing mastectomy was done through a

lateral incision Nipple coring was performed and

retroareolar frozen section biopsy revealed a

tumor-free specimen A subpectoral pocket was

dissected with the pectoralis major muscle

sepa-rated from its origins in the inframammary fold

and medially to the height of the nipple position

A 370 cc anatomical implant was inserted and covered in the inferior pole with an acellar der-mal matrix (ADM) which was fi xed to the muscle and to the inframammary fold with a running suture (2.0 vicryl) One drain was placed in the subpectoral pocket and another one in the mas-tectomy pocket Sentinel node biopsy found two negative sentinel nodes

39.3 Clinical and Cosmetic

Outcome

Final histology found a multicentric carcinoma in situ completely removed The postoperative course was uneventful No further treatment was suggested

The postoperative result was rated as excellent

by the patient and surgeon (Fig 39.2a, b )

39.4 Comments of Author

• The location of the incision for mastectomy largely depends on the breast size, the ptosis, the location of the tumor, and the preference

of the surgeon Although a nipple-sparing mastectomy is oncologically safe, the pros and cons have to be discussed with the patient, and the preference of the patient for a skin- sparing mastectomy has to be respected

P Schrenk , MD

Second Department of Surgery , Breast Care Center,

Akh – LFKK Linz , Linz , Austria

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

39

(Fig 39.3a–f ) Preserving the nipple carries

the risk of necrosis, and due to nipple coring,

the nipple is completely numb

• In case of a nipple-sparing mastectomy, the

location of the incision largely infl uences the

blood supply of the NAC A periareolar (infra-

carries a higher risk for nipple necrosis

com-pared to a lateral incision or an incision in the

Intraoperative frozen section analysis of the

retroareolar specimen is mandatory to exclude

cancer

• Acellular dermal matrices are more frequently used with implant breast reconstruction They are derived from porcine or bovine skin (peri-cardium) In several cleansing steps, the cellular components are removed, but the extracellular matrix is preserved This scaffold is infi ltrated with cells and blood vessels and incorporated in the host tissue Matrices allow reconstruction of larger breast volumes and breasts with more ptosis They keep the implant in place until a new scar tissue has built around the implant and act like an inner/biological bra They are either cross-linked (remain like an eggshell and non-absorbable foreign body with no cells migrating

Fig 39.1 ( a , b ) Preoperative view A 44-year-old patient had a multicentric carcinoma in situ in both the upper

quad-rants of the left breast The breast was of medium size with moderate ptosis

Fig 39.2 ( a , b ) Postoperative view after nipple-sparing mastectomy and immediate reconstruction with an implant

and a Strattice ® ADM

Fig 39.3 ( a – f ) Pre ( a – c )- and postoperative ( d – f ) view

of a 45-year-old patient with bilateral cancer The patient

preferred nipple resection and a bilateral skin-sparing

mastectomy and immediate implant reconstruction with Veritas® ADM was performed

39 Nipple Sparing Mastectomy and Immediate Implant Reconstruction with an Acellular Dermal Matrix

through the matrix) (Fig 39.7a, b ) or

non-cross-linked (cells migrate through the matrix and

form new tissue) (Fig 39.8a–c )

been proven although they are described to be

associated with a higher complication rate

(seroma, infection, wound necrosis,

recon-struction failure) and cost Long-term results

are available only from a few institutions

They may be of advantage in patients

receiv-ing postoperative radiation to avoid capsular

contraction and reconstruction failure due to

exposure of the implant

• The ideal patients for implant reconstruction

with a mesh are those with a small or medium

breast size with no or moderate ptosis However, also patients with larger breasts may

be reconstructed, but this carries a higher risk

of complications due to the weight of the implant on the tissue

• A supportive bra with a superior pole strap should be worn postoperatively for 6–8 weeks The suction drains are removed when the drainage is less than 20 cc for 24 h

• The most important issue is to preserve viable mastectomy fl aps Whenever the blood supply

is in question, this necessitates intraoperative excisions or conversion of the reconstruction to

re-a two-stre-age reconstruction, re-autologous tissue, or

a delayed reconstruction after wound healing

c

d

Fig 39.4 ( a – d ) Pre ( a , b )- and postoperative ( c , d ) view

of a 51-year-old patient with multicentric DCIS of the

right breast The breast was of medium size and with

moderate ptosis A nipple-sparing mastectomy was done

through an infra-areolar incision as well as immediate

implant reconstruction with a Protexa® ADM A olar incision with areolapexy to correct the ptosis would have carried a high risk for nipple necrosis The postop- erative result 2 years after surgery reveals excellent cos- metic outcome

Fig 39.5 ( a – g ) Preoperative view ( a – c ) of a 39-year-old

patient with a breast cancer in the left breast Due to a

positive result for BRCA 1 mutation, a bilateral nipple-

sparing skin-reducing mastectomy was done The breasts

were reconstructed with a 375 cc round high implant and

a Surgmend® bovine ADM ( d ) Postoperative view ( e – g )

reveals a good cosmetic result

Fig 39.5 (continued)

Fig 39.6 ( a – e ) Pre ( a , b )- and postoperative ( c – e ) view

of a 67-year-old patient with a breast cancer in the left

breast A nipple-sparing mastectomy and immediate

reconstruction with an implant and a Strattice® ADM was performed through an incision in the inframammary fold

39 Nipple Sparing Mastectomy and Immediate Implant Reconstruction with an Acellular Dermal Matrix

Fig 39.7 ( a , b ) Intraoperative view ( a ) and histological

examination ( b ) of a cross-linked ADM (Permacol®)

The cross-linked matrix provides stability of the implant

reconstruction but remains like a nonabsorbable foreign body

a

b

c

Fig 39.8 ( a – c ) Intraoperative view ( a ) and histological

examination ( b ) of a non-cross-linked ADM The matrix

is substituted with cells forming a stable tissue layer for

the implant In some patients, however, the non-cross- linked ADM remains as a foreign body is not substituted

by migrating cells ( c )

39 Nipple Sparing Mastectomy and Immediate Implant Reconstruction with an Acellular Dermal Matrix

A 48-year-old patient underwent skin-sparing

mastectomy for multicentric intraductal

carci-noma in situ of the left breast Immediate

recon-struction was done with an implant placed under

the pectoralis major muscle, which was covered

with a dermoglandular fl ap dissected from the

inferior pedicle Concomitantly, a contralateral

mastopexy with a superior-based pedicle was

per-formed for symmetry (Fig 40.1a–c ) Pathological

examination of the mastopexy specimen

inciden-tally found a multicentric intraductal carcinoma

in situ, which was not seen in the preoperative

mammogram The pathological result was

dis-cussed with the patient, and a nipple- sparing

mas-tectomy with immediate reconstruction with an

implant was planned The breast was of medium

size with moderate ptosis (Fig 40.1a, b )

40.2 Surgery

A nipple-preserving mastectomy using the

pre-vious scars from the mastopexy was performed

Intraoperative frozen section of the retroareolar

tissue showed no tumor, and the areola was preserved Immediate breast reconstruction was done with a 375 cc anatomical implant placed in the subpectoral position after release

of the insertions of the pectoralis major muscle and covered with an acellular dermal matrix

drains were used (submuscular and ous pocket) and the wound was closed in two layers

subcutane-40.3 Clinical and Cosmetic

Outcome

The postoperative course was uneventful Contrary to the frozen section, the fi nal patho-logical examination of the retroareolar specimen revealed tumor with the margins involved Resection of the nipple-areola complex was done under local anesthesia, followed by bilateral reconstruction of the nipple-areola complex 6 months later (Fig 40.2a, b ) The cosmetic result

6 months after nipple reconstruction was rated as excellent by both the surgeon and the patient (Fig 40.3a–c )

V Bjelic-Radisic , PD, PhD

Division Gynecology, Department of Obstetrics and

Gynecology , Medical University Graz , Graz , Austria

e-mail: vesna.bjelic-radisic@medunigraz.at

Fig 40.1 ( a – c ) The 48-year-old patient had a history of

prior mastectomy and immediate implant-based

recon-struction with a dermoglandular fl ap of the left breast

A superior-based pedicle mastopexy was performed on

the right breast for symmetrization Due to multicentric intraductal carcinoma in situ found in the mastopexy specimen, a nipple-sparing mastectomy was planned The breast was of medium size with moderate ptosis

Fig 40.2 ( a , b ) Postoperative result after bilateral

mas-tectomy and immediate reconstruction with implants Due

to tumor involvement of the nipple of the right breast, the

nipple-areola complex (NAC) was removed under local

anesthesia The incision for NAC resection is outlined on

the skin ( a ) Prior to resection of the nipple-areola plex ( b ) Six months after surgery

com-V Bjelic-Radisic

40.4 Comments of Author

• When the nipple is preserved during mastectomy,

an intraoperative frozen section of the

retroareo-lar tissue should be done to exclude cancer

A frozen section, however, cannot exclude

ret-roareolar tumor and when positive requires

resec-tion of the nipple in a second surgical procedure

• The use of ADM or dermoglandular fl ap with

implant-based breast reconstruction allows

ade-quate coverage of the implant in the inferior

pole after the pectoralis major muscle insertions

have been dissected Compared to an ADM, the

dermoglandular fl ap has the advantage of no

additional costs but carries a higher risk of

leav-ing breast tissue behind after mastectomy

• Nipple-sparing mastectomy after prior pexy is associated with a higher risk for nipple necrosis Whereas the nipple-areola complex may be preserved after a superior-based pedi-cle mastopexy (or reduction), this is hardly ever possible after an inferior-based pedicle mastopexy (reduction) for in these patients either too much breast tissue is left behind to ensure adequate blood supply with the risk of cancer recurrence or adequate oncological dissection of the inferior breast pedicle tissue endangers the blood supply of the nipple Therefore, when mastectomy is planned after inferior-based pedicle mastopexy (reduction), this should be done as a skin-sparing mastec-tomy (with removal of the nipple-areola complex)

Fig 40.3 ( a – c ) Postoperative view 6 months after bilateral reconstruction of the NAC shows an excellent cosmetic result

Peter Schrenk

41.1 The Patient

The 42-year-old premenopausal patient was

diagnosed with a palpable mass in the upper

inner quadrant of the left breast Core needle

biopsy found a high-grade, receptor-negative,

Her-2-neu 3+ invasive breast cancer

Mammography and breast MRI found the tumor

of a size of 25 mm with no other lesions in the

left or right breast; the axillary lymph nodes

were unsuspicious

Due to tumor biology, the size and location

of the tumor neoadjuvant chemotherapy was

planned The patient had a positive family

his-tory and genetic testing was suggested Sentinel

node biopsy prior to chemotherapy found a

micrometastatic node out of two sentinel lymph

nodes

Following completion of neoadjuvant

chemo-therapy the patient showed a clinically partial

remission Genetic testing found a BRCA 1

mutation and a bilateral mastectomy with

imme-diate implant reconstruction was planned The

breast was of small size and non-ptotic; the

nip-ple of the left breast was inverted since puberty

(Fig 41.1a–c )

41.2 Surgery

A bilateral nipple-sparing mastectomy was done through an incision in the inframammary fold (resection volume was 330 and 340 g) Reoperation sentinel node biopsy found three negative nodes in the left axilla and two negative nodes in the right axilla Nipple coring ensured adequate tissue resection behind the nipple region with the intraoperative frozen section examina-tion from the retroareolar region negative (and negative in the fi nal histology) A subpectoral pocket was created with the major pectoralis muscle being dissected off its origin in the infe-rior and inferomedial part of the breast A 250 cc round implant was implanted in the submuscular pocket and covered with a slow absorbable mesh (TIGR ® , Novus Scientifi c, Fig 41.2a ), which was

fi xed to the pectoralis major muscle caudally and cranially and the serratus fascia laterally with absorbable sutures (2.0 Vicryl) (Fig 41.2b, c ) One suction drain was placed subpectorally

41.3 Clinical and Cosmetic

Outcome

Final histology found scattered tumor cells in the upper inner quadrant of the left breast with a total size of 18 mm The postoperative course was uneventful

P Schrenk , MD

Second Department of Surgery , Breast Care Center,

Akh – LFKK Linz , Linz , Austria

e-mail: peter.schrenk@liwest.at

41

Trastuzumab was continued for 1 year The

postoperative result after 2 years showed a good

cosmetic outcome with two symmetric breasts

(Fig 41.3a–c )

41.4 Comments of Author

• In patients with a strong family history for

breast cancer and neoadjuvant chemotherapy

planned, genetic testing for BRCA 1 and 2

mutations should be done prior to the start of

chemotherapy With the result of the tests

available before the end of chemotherapy, the

surgery may be planned according to the test results and the patient’s request

mastectomy? Nipple-sparing mastectomy is oncologically safe provided that the tumor is

no closer than 2 cm from the nipple-areola complex (NAC) and there are no malignant microcalcifi cations close to the nipple In case

a nipple-sparing mastectomy is performed, intraoperative frozen section analysis of the retroareolar specimen is mandatory and the decision whether or not to excise the NAC depends on the intraoperative result When the

fi nal histologic examination reveals tumor, secondary resection of the nipple has to be

c

Fig 41.1 ( a – c ) Preoperative view The 42-year-old

patient with a tumor in the upper inner quadrant of the left

breast ( circle ) underwent neoadjuvant chemotherapy with

a partial clinical remission The breast was of small size and non-ptotic

performed Nevertheless, the patient’s choice

for a nipple preservation or not must be

respected

• Reoperation sentinel node biopsy is possible

and safe but is associated with a lower

iden-tifi cation rate and in case of a positive

senti-nel node prior to neoadjuvant chemotherapy

also with a higher false-negative rate

A micrometastatic sentinel node before

che-motherapy requires no axillary dissection

provided a remission of the tumor due to

chemotherapy but reoperation sentinel node

biopsy should be done to evaluate the axilla

after chemotherapy

• The TIGR ® matrix (Novus Scientifi c) consists

of 2 fi bers which are absorbed after 6 months

and 3 years, respectively The mesh is ally substituted with cells forming a new tis-sue which provides stability for the implant

shows another patient with skin-sparing tectomy and immediate implant reconstruc-tion with a TIGR ® matrix

mas-• The ideal patients for implant reconstruction with a mesh are those with a small or medium breast size and no or moderate ptosis Contraindications are when the expectations of the patient do not meet what is practicable and patients with a smoking history or obesity

• A supportive bra with a superior pole strap should be worn postoperatively for 6–8 weeks

41 Nipple-Sparing Mastectomy and Immediate Implant Reconstruction with a Mesh

The suction drain is removed when the

drain-age is less than 20 cc for 24 h

• The most crucial point is the viability of the

mastectomy fl aps When the blood supply of

the fl aps is in question, reconstruction

should either be delayed or converted to

expander or autologous reconstruction Avoiding electrocautery or too much trac-tion on the mastectomy fl aps during dissec-tion may avoid decrease of blood supply of the fl aps

c

Fig 41.3 ( a – c ) Postoperative result 2 years after surgery showed a good cosmetic result

a

c

b

Fig 41.4 ( a – c ) Histologic examination of the TIGRR

matrix 1 year following reconstruction Macroscopic

appearance of the matrix with the surface toward the skin

( a ) and implant ( b ) and microscopic view showing nants of the matrix incorporated within scar tissue ( c )

rem-41 Nipple-Sparing Mastectomy and Immediate Implant Reconstruction with a Mesh

d

Fig 41.5 ( a – f ) The 54-year-old patient had a

multicen-tric carcinoma of the right breast and skin-sparing

mastec-tomy with immediate implant-based reconstruction was

planned The breast was of medium size and ptotic ( a , b )

The implant was covered with a TIGR R matrix ( c )

Postoperative view after skin-sparing mastectomy and immediate implant reconstruction with a TIGRR matrix and concomitant reduction of the left breast showed an

excellent cosmetic result ( d – f )