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ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 1  |  Page : 210-215

Superior pedicle reduction mammoplasty for lower quadrants breast cancers


Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission25-Jul-2021
Date of Decision14-Aug-2021
Date of Acceptance15-Aug-2021
Date of Web Publication18-Apr-2022

Correspondence Address:
Tarek M Rageh
Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_133_21

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  Abstract 


Objective
To present a new technique to reconstruct the lower-quadrant breast cancer excision defects with superior pedicle-reduction mammoplasty reshaping in order to obtain a satisfactory esthetic outcome together with a safe oncological outcome.
Background
The application of oncoplastic surgery into breast-conservation surgery affords many procedural options to achieve the acceptable esthetic results as well as oncological safety outcome. Lower-quadrant breast cancer radical excision with a high satisfactory esthetic outcome represents a challenge for breast surgeons.
Patients and methods
During the period from May 2018 to March 2021, 23 patients with a lower quadrant's breast cancer were operated. Postoperative complications, resection margins, and cosmetic outcome were assessed.
Results
At a mean follow-up of 12 months, the complication rate was 17.39% (two cellulitis and two margin-skin necrosis). Surgical margins of resection were negative in all cases. The overall satisfaction was considered excellent in 21 (91.3%) patients, good in two (8.69%) patients, and fair in one (4.34%) patient.
Conclusions
This technique represents a good solution for the reshaping that is needed following lower-quadrant breast cancer as regards oncological safety outcome and excellent cosmetic results.

Keywords: lower-quadrant breast cancer, Oncoplastic breast surgery, superior pedicle flap


How to cite this article:
Rageh TM, Elsisi AA, Alhanafy MK. Superior pedicle reduction mammoplasty for lower quadrants breast cancers. Menoufia Med J 2022;35:210-5

How to cite this URL:
Rageh TM, Elsisi AA, Alhanafy MK. Superior pedicle reduction mammoplasty for lower quadrants breast cancers. Menoufia Med J [serial online] 2022 [cited 2024 Mar 28];35:210-5. Available from: http://www.mmj.eg.net/text.asp?2022/35/1/210/343097




  Introduction Top


Breast cancer is the most popular malignant disease among Egyptian females and has ∼38.8% of all total diseases among Egypt's female population [1].

Modified radical mastectomy has a psychological upset phase on breast cancer patients, which adversely affects patients' quality of life [2]. This led to the innovation for alternative techniques, especially with the advances in radiotherapy, hormone therapy, chemotherapy, and pathology [3].

Oncoplastic breast surgery (OBS) has increased in popularity with the achievement of safe oncological outcome and a highly acceptable esthetic result [4]. As these methods become more accepted, there is a necessity for surgeons to be more familiar with the indications and experience needed to make the oncoplastic technique safe [5]. These techniques are constantly being refined and upgraded as surgeons try to introduce new techniques with better cosmetic results while always keeping in mind the oncologic safety of the technique [6].

Oncoplastic surgery techniques are classified into 'level I, level II and level III' procedures. Level-I OBS is performed when less than 20% of breast volume is designed to be excised. Level II is performed when 20–50% of breast volume is designed to be excised and tissue displacement performed to repair the defect. Level III was performed when more than 50% of breast tissue is excised and tissue-replacement technique is performed to repair the defect [7]. The choice among different oncoplastic techniques is determined mostly by the site of the tumor, degree of resection of breast features such as size, shape, and density of glandular tissue prior to surgery, and the desires of the patient [8].

In early-stage unifocal breast cancer, breast-conserving surgery (CBS) followed by radiation therapy is the recommended choice. Although in some patients, lesions are difficult to excise without the hazard of cosmetic distortion or inadequate edge clearance [9]. Additional factors affecting poor cosmesis after CBS are tumors located in esthetically sensitive areas such as the central, medial, and inferior quadrants [10].

We aim to evaluate the superior pedicle-reduction mammoplasty in the lower-quadrant breast cancer as regards surgical results, oncological safety outcome, and patient satisfaction.


  Patients and methods Top


This is a prospective study, conducted on 23 consecutive female patients presenting with operable breast cancer located at lower-breast quadrants treated by superior pedicle-flap oncoplastic technique.

This study was carried out from May 2018 to March 2021 in the Surgery Department, Menoufia University Hospital, Egypt. Patient's informed consent was taken and the study was approved by the faculty ethical committee.

Diagnosis of breast cancer was by full medical history, clinical examination, pathological evaluation, and investigations for exclusion of distant metastasis.

Inclusion criteria: pathologically proven unilateral lower-quadrant breast cancer, unifocal breast cancer, T1 and T2 breast cancer, and T3 breast cancer that dawnstaged to T1 or T2 after neoadjuvant chemotherapy. Patient candidates for breast-conserving surgery and oncoplastic reconstruction.

Exclusion criteria: distant metastasis, T4 breast cancer, lesions of less than 1.5 cm from the nipple, and diffuse microcalcification or multicentric breast cancer. Patients were not convinced with the proposed procedure after adequate explanation. Patients refusing postoperative adjuvant radiotherapy or radiotherapy are contraindicated.

Technique: (a) Patient marking: drawings were done on a standing patient after localization of the tumor lower-quadrant site: lower central tumor [Figure 1]a, lower outer quadrant [Figure 1]b, and lower inner quadrant [Figure 1]c. The first step is to draw the midline. Then draw the midclavicular line that usually passes by the nipple and equally divides the breast into two halves. The new areola is placed on this axis, at a 20–22-cm distance from the sternal notch. This distance is chosen according to breast volume, breast ptosis, and skin elasticity and it was at least 10 cm from the midline. The contours of the per-areolar deepithelialization are drawn. The vertical limb of excision marking is at least 7 cm and it can be estimated by assessing the amount of skin to be removed [Figure 1]A,[Figure 1]B,[Figure 1]C. The inner and outer contours were defined by estimating the vertical scar between 4 and 6 cm. The objective is to make a wide excision that largely removes the tumor, while reshaping the breast to have an optimal cosmetic result. Finally, contralateral breast-reduction drawing was done in nine patients when immediate contralateral breast reduction is planned. Delayed contralateral breast reduction was done in 14 patients as shown in [Figure 1]d.
Figure 1: (a) Central tumor preoperative markings. (b) Lower lateral tumor markings. (c) Lower inner tumor markings. (d) Delayed contralateral breast markings. (e) Periareolar deepithelialization. (f) Tumor excision.

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Skin incision and breast-tissue resection: periareolar deepithelialization of the superior pedicle started from the upper border of the areola to the new site of positioning the new areola and 1–2 cm all circumferential [Figure 1]e. The breast is then incised vertically and horizontally above the submammary fold. The nipple–areola pedicle is created thin enough to avoid venous necrosis. Prepectoral detachment represents the dissection's deep limit. To complete tumor excision, the breast is incised laterally to reduce breast volume. The tumor-operative bed is clipped to facilitate postoperative-directed radiotherapy [Figure 1]f.

Superior pedicle dermal-free glandular-reduction mammoplasty: the intervention is completed by placing the nipple–areola complex (NAC). Inner and outer excisions are adjusted to tumor-resection limits and breast reduction/modeling. It is simple to center the resection on the tumor and use the adjacent gland to reshape the breast [Figure 2]a,[Figure 2]b,[Figure 2]c. Symmetrization of the contralateral breast was performed simultaneously or delayed [Figure 2]d.
Figure 2: (a) Harvesting the superior pedicled areolar flap. (b) Intraoperative results. (c) Postoperative results. (d) Intraoperative results. (e) Postoperative results. (f) Postoperative results.

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Axillary dissection: axillary clearance was performed in all cases with axillary-palpable lymph nodes through the same or separate incision. sentinel lymph node (SLN) and axillary mapping was done if needed.

Postoperative management: all patients were called for regular visits at the postoperative first week and postoperative second week for assessment of the wound complications. All patients were advised for regular visits every month for 12 months at the outpatient clinic for assessment of locoregional recurrence. All patients received postoperative radiotherapy for local control of the disease. In addition, high-risk-group patients with positive lymph nodes received adjuvant chemotherapy for systemic control of breast carcinoma.

Surgical outcome measures: all patients were assessed for operative time, postoperative resection-margin assessment, and postoperative morbidity – wound dehiscence, hematoma, seroma, infection, and NAC necrosis. Cosmetic-outcome assessment – breast symmetry, NAC symmetry, scarring, and overall satisfaction. A four-point Likert score (Harvard scale) was used to assess the cosmetic outcome as excellent, good, fair, or poor [Figure 2]e and [Figure 2]f.

Statistical analysis

All data were statistically analyzed using Statistical Package of Social Science (SPSS). Quantitative data were expressed as a mean ± SD, while qualitative data were expressed as frequency and percentages.


  Results Top


Superior pedicle-reduction mammoplasty was used to treat 23 patients with breast cancer located at the lower quadrants of the breast. The age of the patients varied from 31 to 43 years. The mean age for our study was 37.5 ± 6.27. Three patients were found to have medical comorbidities, three patients have diabetes mellitus, and one patient was found to have hypertension. Operative time mean time was 115 min (range, 90–150 min). Nine patients had immediate contralateral breast reduction and 14 patients had delayed contralateral breast symmetrization. There were four (17.39%) postoperative complications, two (8.69%) cellulitis, and two (8.69%) patients had marginal skin necrosis. Surgical margins of resection were negative in all cases. All patients received postoperative radiotherapy, 17 patients received chemotherapy, and 19 patients received hormonal therapy. Two patients received neoadjuvant chemotherapy [Table 1].
Table 1: Patients characteristics and operative data

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Tumor was located in the lower outer quadrant in 14 patients, in the lower inner quadrant in five patients, and was the central location (at 6 o'clock) in four patients. The tumor was invasive ductal carcinoma in 21 (91.3%) patients and invasive lobular carcinoma in two (8.69%) patients. The mean tumor size 1.5–3.5 cm and its distance from the NAC ranges from 2 to 4.7 cm. The distance from the NAC was variable among the cases of the study; the nearest tumor was 1.5 cm from NAC, the farthest was 4.6 cm from NAC with a mean distance of 2.84 cm. The T staging was T1 in 12 patients, T2 in nine patients, and T3 in two patients who received neoadjuvant chemotherapy preoperatively. The N staging was N0 in 12 patients, N1 in 11 patients, and N2 in 0 patients [Table 2].
Table 2: Patients tumor characteristics and operative data

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The cosmetic outcome was assessed by patients. Cosmetic-outcome assessment scale includes breast symmetry, NAC symmetry, scarring, and overall satisfaction. A four-point Likert score (Harvard scale) was used to assess the cosmetic outcome as excellent, good, fair, or poor. The overall satisfaction was considered excellent in 21 (91.3%) patients, good in two (8.69%) patients, and fair in one (4.34%) patient [Table 3].
Table 3: Esthetic result outcome

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  Discussion Top


A combination of breast-conservation surgery with postoperative radiotherapy is now a well-established surgical modality, with survival rate equivalent to modified radical mastectomy, besides the improved body image and quality of life [11]. The purpose of improving a breast cancer surgery and the patient quality of life has been achieved by the application of reconstructive techniques [12]. This new combination of CBS and reconstructive surgery is commonly referred to as oncoplastic surgery. This 'third pathway' allows the surgeons to extend the indications for breast-conservation surgery without compromise of oncologic safety or the esthetic outcome. It is a logical extension of the quadrantectomy technique described by Inas et al. [13], with immediate reshaping employed through oncoplastic surgery; major resections can now be achieved with enhanced cosmetic outcomes.

OBS is based on three basic principles: safe oncological resection, immediate breast reconstruction, and immediate symmetry of the other breast. This is achieved by several techniques based on tumor location, volume of glandular resection, and clinical evaluation of the patient into volume-displacement and volume-replacement procedures. The volume-displacement techniques use the remaining breast tissue, while the volume-replacement technique uses other autologous tissue to fulfill the insufficient breast tissue [14].

Oncoplastic surgery with the superior pedicle-reduction mammoplasty is useful for the treatment of tumor of the inferior quadrant of the breast from the 3 o'clock to the 9 o'clock position. Obtaining free surgical margins is an essential step in the procedure in order to reduce the cancer-recurrence rate. The recurrence rates are influenced by the tumor size, the tumor type, vascular invasion, multicentric disease, and the age of the patient. All our patients had the tumor in the lower outer, central, and lower inner quadrants of the breast. The Wise pattern is the most commonly used incision for reduction of mammoplasties, which offers the surgeon wide access to the breast parenchyma that allows skin excision in both vertical and horizontal dimensions and can be used with any pedicle [15].

In this study, the rate of postoperative complications was 17.39%. In a systematic review of OBS, early postoperative complication rate of 20% has been reported [16]. All oncoplastic surgery techniques are not the same and the extent of tumor resection and skin dissection varies with the kind of oncoplastic operative technique done. So, it will be hard to compare complications.

In this study, two (8.69%) cases got wound cellulitis, who were diabetic, which reflects the immune compromization with diabetes mellitus. These patients were treated conservatively and the patient improved within 7 days. Another two (8.69%) cases had marginal skin necrosis at the meeting of the vertical and submammary incision, it was discovered in the second week postoperatively. These patients were treated with topical reepithelialization products and daily dressing until full recovery. Fitoussi et al. [17] stated that the extensive undermining could lead to increased rates of seroma, fat necrosis, and hematoma, and the NAC transposition may cause partial or total necrosis. We did not experience any case of wound dehiscence, seroma or hematoma, or NAC necrosis due to wider flap base (8–10 cm) and due to less undermining of both the skin and the gland from the pectoralis major muscle.

We perform immediate contralateral breast reduction in nine (39.13%) patients and we noted higher patients' satisfaction when performing contralateral symmetrization at the same surgical time. We perform delayed contralateral breast reduction in 14 (60.86%) patients. Some authors suggest postponing contralateral breast reduction after radiotherapy due to the risk of volume reduction as a result of fat necrosis and edema derivation from radiotherapy [18].

In this study, none of the patients had any local recurrence during the first 6 months postoperatively, proving that we had performed a superior pedicle technique safely from the oncological point of view. Previous studies augment the fact that CBS with oncoplastic surgical techniques is associated with low rates of redo surgery for positive margins with acceptable cosmetic results [19]. These results show no involved margins due to two important factors: first, the tumor is excised under bimanual palpation guidance providing an open book for enough excision, thus resulting in an increased chance of achieving negative margins. The other factor is the presence of a pathologist performing frozen sections for the resected specimens, directing the operating surgeons when obtaining involved margins, allowing the same session intraoperative extended resections.

There is no delay for adjuvant therapy, either radiotherapy or chemotherapy in our patients because there is no delay in wound-healing time.

In this study, we were able to conduct an excellent cosmetic outcome in 20 (86.95%) patients, good cosmetic outcome in two (8.69%) patients, and fair cosmetic outcome in one (4.34%) patient, as these three patients noticed asymmetry of the two breasts in front of the mirror as they refused immediate contralateral breast reduction.

We define an easy oncoplastic technique that fully respects female needs while maintaining breast shape. NAC malpositioning or asymmetry is not observed with superior pedicle-flap technique.


  Conclusion Top


Superior pedicle-reduction mammoplasty is an easy approach designed for management of lower-quadrant breast cancer. The approach offers both high oncological safety and excellent esthetic outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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