Combined Partial Breast Reconstruction: an Extreme Oncoplastic Procedure for the Lateral Breast

   

Matthew Binks^1*, Paul Chen^1,2

Received: November 23, 2024 | Published: December 5, 2024

Copyright^©2024 genesis pub by FRACS BM et al. CC-BY-NC-ND 4.0 DEED. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives 4.0 International License. This allows others distribute, remix, tweak, and build upon the work, even commercially, as long as they credit the authors for the original creation.

Abstract

The Wise pattern therapeutic mammoplasty has facilitated breast conserving surgery in the face of large breast cancers. With extended and secondary pedicles, big cancers can be removed from the upper pole of large and ptotic breasts in inner, central or outer quadrants. However, mastectomy has traditionally been required when resection volumes exceed the capacity of this procedure. By utilising the addition of a lateral intercostal artery perforator (LICAP) flap to an extended pedicle therapeutic mammoplasty, we describe two cases in which breast conservation was achieved in this circumstance.

Keywords

Breast conserving surgery; Radiotherapy; Therapeutic mammoplasty; Oncoplastic surgery.

Introduction

Breast conserving surgery with adjuvant radiotherapy has seen great improvements in surgical outcomes for breast cancer sufferers in recent decades [1,2]. The benefits are manifold and vital to a woman’s sense of self, her psychosocial health and her sexual health [3,4].

However, the deformity incurred by poorly planned or executed local excision and subsequent radiotherapy can have the opposite effect on a woman’s wellbeing [5-7]. In decades past, excision of greater than 20% of the breast volume would invariably lead to debilitating deformity.

With the recent emergence of oncoplastic surgery - the use of plastic surgery techniques to reconstruct the breast following tumour excision - resection of much larger breast volumes has become feasible [8].

Not only are such resections possible, but by correcting ptosis and reducing excess volume, they often lead to a more aesthetically pleasing and functional breast, which can also tolerate adjuvant radiotherapy with fewer sequelae [9-11].

The Wise pattern therapeutic mammoplasty with or without extended or secondary pedicles, has made resection of very large tumours possible and safe. Even so, resection of large tumours in the outer quadrants may exceed the capacity of an isolated therapeutic mammoplasty to reconstruct [12,13].

The LICAP flap has proven a versatile means of replacing lost volume in the outer quadrants of small breasts [14-16]. Supplied by perforators from the intercostal vessels, axillary subcutaneous tissue is mobilised and used to fill defects in the lateral breast. In our paper, we describe a case report of two patients with large lateral tumours who avoided mastectomy by the integration of Wise pattern therapeutic mammoplasty and LICAP volume replacement.

Case 1

MB, a 49-year-old woman, presented with a self-detected right breast mass. She had no history of breast disease and her family history was significant only for a great grandmother who suffered from breast cancer in her 70s.

MB wore a DD bra and the lesion manifested as a thickening of the lateral breast. The lesion was causing dimpling and tethering of the overlying skin. There were no abnormal axillary lymph nodes to palpation.

Mammogram, ultrasound and MRI were performed and showed multifocal disease of the right breast. Biopsies confirmed multifocal invasive ductal carcinoma spanning much of the lateral breast (Figure 1).

Figure 1: Preoperative photograph highlighting lateral extent of multifocal disease and preoperative markup.

MB underwent a wide local excision of the disease via a Wise pattern incision with an extended superomedial pedicle. The reconstruction was completed with the addition of a LICAP flap to provide further lateral bulk. The specimen weighed 295g.

Histopathology confirmed the presence of two invasive ductal carcinomas of 35mm and 37mm, respectively. The lateral and superficial margins were close and the deep margin was involved by a satellite lesion. One of two sentinel nodes was involved by a 3.5mm deposit with extranodal extension and lymphovascular invasion.

MB returned to theatre for a re-excision of margins (6g total) and a completion axillary dissection. MB recovered well and underwent adjuvant chemotherapy and radiotherapy (Figure 2).