European Journal of Plastic Surgery

, Volume 41, Issue 2, pp 157–164 | Cite as

Oncoplastic resection of breast cancers located in the upper-inner quadrants: a safe and effective surgical technique

  • Daniele Bordoni
  • Pierfrancesco Cadenelli
  • Nicola Rocco
  • Matteo Ornelli
  • Ariel Tessone
  • Giuseppe Falco
  • Cesare Magalotti
Original Paper
  • 126 Downloads

Abstract

Background

The combination of breast conserving surgery (BCS) together with plastic surgery techniques (oncoplastic breast surgery) is a useful surgical tool matching the radical oncological excision while preserving breast cosmesis. Upper-inner quadrant resections represent a challenge for breast surgeons. The aim of this study was to identify a reproducible technique to repair upper-inner quadrant defects with oncoplastic glandular reshaping in order to obtain a satisfactory aesthetic outcome together with a radical excision of the breast cancer.

Methods

During the period from March 2014 to March 2016, 32 patients with an upper-inner quadrant’s breast cancer were treated at our Department. Post-operative complications, negative margins of resection rates and cosmetic outcome (both patient-reported and surgeon-reported) were assessed.

Results

At a mean follow-up of 14 months (range 6–24), the complication rate was 25% (wound dehiscence, seroma formation, hematoma, marginal skin necrosis and partial NAC necrosis). Surgical margins of resection were negative in all procedures, and the overall satisfaction with the cosmetic outcome assessed by the patient was considered excellent in 17 cases (53.1%) and in 19 cases (59.4) when assessed by the surgeon.

Conclusions

The proposed technique represents a valuable and reproducible solution for the challenging reshaping that follows upper-inner quadrantectomies due to its low complication rates, high free margins of resection rates and excellent cosmetic outcomes.

Level of Evidence: Level IV, therapeutic study.

Keywords

Oncoplastic breast surgery Breast cancer Surgical technique 

Introduction

More than 70% of early breast cancer patients can be treated by partial breast resection achieving survival rates comparable with those of patients undergoing mastectomy [1, 2, 3, 4]. A limited number of breast conserving surgery (BCS) in the presence of a disease on surgical margins of resection requiring reoperation was necessary in 20–30% of the cases [5]. Moreover, a conventional wide local excision may result in major breast distortion causing a negative impact on women’s quality of life [6].

The combination of BCS with plastic surgery techniques (oncoplastic breast surgery) is a useful surgical tool matching the radical oncological excision while preserving breast cosmesis [7, 8, 9]. Different series revealed that an oncoplastic approach could dramatically reduce re-excision rates when compared with standard BCS [10], and limitations of the oncoplastic approach, as Clough et al. described in their atlas, are mainly related to the excision volume and tumour location [11].

Glandular resections of upper-inner quadrants represent a challenge for breast surgeons. Silverstein proposed a batwing excision pattern achieving good results [12]. Other authors reported their experience with a Wise skin pattern and an infero-medial nipple-areola complex pedicle [13, 14].

The aim of this study was to identify a reproducible technique to repair upper-inner quadrants’ defects with oncoplastic glandular reshaping in order to obtain a satisfactory aesthetic outcome together with a radical excision of the breast cancer.

Patients and methods

During the period from March 2014 to March 2016, all women candidates for upper-inner quadrant’s lumpectomy (therapeutic mammaplasty) for breast cancer and contralateral reshaping (mastopexy or reduction mammaplasty) were included in the study. The series included women diagnosed with unifocal lesions located at the upper-inner quadrant regardless of breast dimension. BRCA positive women and patients with skin-tumour distance less than 1 cm or with recurrent cancer were excluded from the study.

This study was approved by our institutional review board (Santa Maria della Misericordia Hospital Ethical Committee # 2015/316834), and appropriate informed consent was obtained from all patients for the surgical procedures performed in the present study and for personal images use and publication.

Ultrasound examination, mammography, MRI and subsequent vacuum-assisted breast biopsy were performed on all patients. All patients underwent a multidisciplinary approach, involving medical and surgical oncologists, plastic surgeons, breast radiologists and radiation oncologists.

In order to perform breast conserving surgery, we localized the lesions the day before surgery using Tc99-MAA (Technetium 99 m macro-albumin aggregated); the sentinel lymph node was localized preoperatively by injecting Tc99m-nanocoll. All specimens underwent frozen sections in order to perform immediate re-excisions when needed. Positive margins were defined as the presence of cancer cells when less than 1 mm from the specimen’s margin. Mammographic microcalcification clusters radical excisions were confirmed by radiographic examination of the surgical specimen. All patients received post-operative radiotherapy (50 Gy on the breast). Post-operative complications, negative margins of resection rates, and cosmetic outcome (both patient-reported and surgeon-reported) were assessed, and the mean time of follow-up was 14 months (range 6–24). Patients’ characteristics are presented in Tables 1 and 2.
Table 1

Patients’ comorbidities

Comorbidities

No. of patients (%)

Tobacco

12 (40)

Diabetes

2 (6.3)

Obesity

2 (6.3)

Overweight

10 (31.3)

Hypertension

8 (26.7)

Dyslipidemia

5 (15.7)

Table 2

Patients’ characteristics and complications

Case

Age

BMI

Breast base width (cm)

Breast height (cm)

G/NAC distance (cm)

Tumour breast location

Radiologic tumour size (cm)

Histological type of tumour

Margins (<1 mm)

Margins (1–10 mm)

Stage T

Stage N

Stage M

Complications tumour side

Complications contralateral side

Re-operation

Overall follow-up (months)

1

46

22.7

15

14

25

UIQ

1.0

IDC

T1b

N0

Mx

24

2

52

24.2

17

14

22

UIQ

2.7

ILC + IDC + DCIS

T2

N1

Mx

22

3

52

24.2

18

14

23

UIQ

1.9

DCIS

Tis

N0

Mx

22

4

68

26.1

20

14

27

UIQ

1.3

IDC

T1c

N0

Mx

Wound dehiscence

Wound dehiscence

22

5

61

26.2

19

13

23.5

UIQ

1.8

ILC

T1c

N0

Mx

22

6

53

23.2

16

11.5

23

UIQ

1.4

ILC

T1c

N0

Mx

21

7

33

23.4

18

14

24

UIQ

3.0

IDC

T2

N0

Mx

Seroma

Seroma drainage

21

8

47

26.4

17

12.5

26

UIQ

3.2

ILC

+

T2

N1

Mx

19

9

50

25.2

18.5

12

25

UIQ

2.4

IDC

+

T2

N0

Mx

18

10

39

22.5

15

11

23

UIQ

1.5

IDC

T1c

N0

Mx

18

11

65

23.1

16

10

23.5

UIQ

0.7

ILC + IDC + DCIS

T1b

N0

Mx

17

12

60

27.0

19

13

26

UIQ

2.4

IDC + DCIS

T2

N0

Mx

17

13

56

24.3

17

11

25

UIQ

1.8

IDC

T1c

N2

Mx

Hematoma

Hematoma drainage

16

14

65

28.1

17.5

10.5

25

UIQ

0.8

IDC

T1b

N0

Mx

15

15

51

23.6

16

11

23

UIQ

0.5

IDC

T1b

N1

Mx

14

16

38

21.5

12

10

22

UIQ

2.3

IDC

+

T1c

N0

Mx

14

17

65

22.4

19

12

25.5

UIQ

2.8

SCC

+

T2

N0

Mx

Reoperation for local recurrence

14

18

50

24.9

17

10

24

UIQ

2.0

IDC

T1c

N0

Mx

13

19

24

20.4

14

11

22

UIQ

1.2

IDC

T1c

N0

Mx

12

20

55

23.3

17

14

26

UIQ

0.9

ILC

T1b

N0

Mx

11

21

55

22.1

18

12

28

UIQ

0.6

IDC

T1c

N0

Mx

11

22

35

20.9

14

12

23.5

UIQ

2

IDC

T1c

N0

Mx

10

23

60

24.6

16

11

23

UIQ

0.8

ILC

T1b

N0

Mx

9

24

44

22.8

16

11

22

UIQ

2.0

MC

T1c

N0

Mx

8

25

47

21.5

15

11

22

UIQ

1.8

DCIS

Tis

N0

Mx

Wound dehiscence

Wound dehiscence

8

26

60

25.0

17

11

26

UIQ

2.5

IDC

T2

N0

Mx

Partial NAC necrosis + seroma

Wound dehiscence

8

27

66

29.3

19

16

27

UIQ

1

DCIS

Tis

N0

Mx

Wound dehiscence

7

28

54

30.1

17

11

26

UIQ

0.5

DCIS

T1b

N0

Mx

Wound dehiscence

Wound dehiscence

7

29

45

26.3

20

11

30

UIQ

1.5

IDC

T1c

N0

Mx

7

30

55

22.5

16

12

25

UIQ

0.9

ILC

T1b

N0

Mx

Marginal skin necrosis

Marginal skin necrosis

6

31

70

29.0

16

12

24

UIQ

2.6

IDC

T2

N0

Mx

6

32

47

32.7

19

14

34

UIQ

0.7

IDC

T1b

N0

Mx

6

UIQ upper-inner quadrant, IDC invasive ductal carcinoma, ILC invasive lobular carcinoma, DCIS Ductal carcinoma in situ, SCC squamous cell carcinoma, MC mucinous carcinoma

Surgical technique

All patients marked the day before surgery. The skin reduction approach was vertical or inverted T according to breast volume.

The incision was performed with the patient in a supine position and arms abducted to 90°, and all the skin within the pre-operative markings was removed. The skin overlying the cancer was then undermined in a mastectomy fashion (3–4 mm flap thickness), and a wide excision reaching the pectoralis major muscle fascia was performed. Different faces of the specimen were marked by stitches and a frozen section was performed in order to proceed in the case of re-excision. If the area to be excised consisted in a cluster of microcalcifications, a radiographic examination of the specimen was performed to determine the radicality of the excision. Surgical clips were placed in the tumour bed following the excision.

Subsequent total skin undermining was performed in the lateral and inferior quadrants in order to completely detach the gland from the skin. A dermo-glandular flap was then rotated in order to replace the loss of substance at the upper-inner quadrant and fixed with a 2/0 absorbable monofilament suture to the remaining superficialis fascia of the upper-inner quadrant. Then, the lower portion of the remaining inner quadrants were sutured, when necessary to the flap. The Nipple-areola complex was rotated and fixed in the desired planned position, after performing irrigation with saline solution, and accurate haemostasis suction drains were positioned (Figs. 1 and 2).
Fig. 1

Case 1 a Pre-operative drawings. b Intra-operative view: the skin overlying the tumour is undermined in a mastectomy fashion (3–4 mm flap thickness), and a wide excision of the tumour down to the pectoralis fascia is performed (yellow circle). c Intra-operative view: the de-epithelialized dermo-glandular flap is rotated to fill the defect in the upper-inner quadrant (yellow arrow). d Intra-operative view: the flap is fixed with 2/0 absorbable monofilament sutures to the remaining superficialis fascia in the upper-inner quadrant. e Immediate post-operative result. f Six-month post-operative result (after radiotherapy)

Fig. 2

Case 2 a Pre-operative drawings. b Intra-operative view: the skin overlying the tumour is undermined in a mastectomy fashion (3–4 mm flap thickness), and a wide excision of the tumour down to the pectoralis fascia is performed (yellow circle). c Intra-operative view: the de-epithelialized dermo-glandular flap is rotated to fill the defect in the upper-inner quadrant (yellow arrow). d Intra-operative view: the flap is fixed with 2/0 absorbable monofilament sutures to the remaining superficialis fascia in the upper-inner quadrant. e Immediate post-operative result. f Six-month post-operative result (after radiotherapy)

The sentinel node biopsy or axillary lymph node dissection was always performed by mastoplasty skin incision. Contralateral symmetrisation was always performed during the same surgical procedure. Antibiotic therapy was administered to all patients until drainage was removed.

Results

Thirty-two patients with an upper-inner quadrant’s breast cancer treated at our Department with therapeutic mammaplasty, and immediate contralateral symmetrisation were included in the study.

Patients’ median age was 52 years (range 24–70), median body mass index (BMI) was 24.7 kg/cm2 (range 20.4–32.7) and radiological mean tumour size was 1.6 cm (range 0.5–3.2). Patients’ baseline characteristics are presented in Tables 1 and 2.

Surgical margins of resection were negative in all the cases. The mean follow-up was 14 months (range 6–24). During this period, one patient with squamous cell carcinoma was re-operated for a local recurrence.

All patients included in the study received post-operative radiotherapy. Adjuvant chemotherapy was administered to nine patients (28.1%); neo-adjuvant chemotherapy was administered to one patient. Hormonal therapy was provided to 25 patients (78.1%). Oncological data is presented in Table 3.
Table 3

Oncological data

Oncological status

N (%)

Histology

 IDC

17 (53.1)

 ILC

6 (18.8)

 DCIS

4 (12.5)

 SCC

1 (3.1)

 MC

1 (3.1)

 ILC + IDC + DCIS

2 (6.3)

 IDC + DCIS

1 (3.1)

Chemotherapy

 Adjuvant

9 (28.1)

 No CHT

3 (9.4)

 Neoadjuvant

1 (3.1)

 Radiotherapy

32 (100)

 Hormonal therapy

25 (78.1)

T

 is

3 (9.4)

 1a

0 (0)

 1b

9 (28.1)

 1c

12 (37.5)

 2

8 (25)

 3

0 (0)

 4

0 (0)

N

 0

28 (87.5)

 1

3 (9.4)

 2

1 (3.1)

 3

0 (0)

M

 X

32 (100)

 0

0 (0)

 1

0 (0)

Grade

 I

4 (12.5)

 II

18 (56.2)

 III

10 (31.3)

Markers

 ER

25 (78.1)

 PgR

20 (62.5)

 Ki-67 (>30%)

7 (21.9)

 Ki-67 (5–30%)

9 (28.1)

 HER2

6 (18.8)

Eight patients (25%) experienced post-operative complications, such as wound dehiscence, seroma formation, hematoma, marginal skin necrosis and partial NAC necrosis. All complications (except two cases) were conservatively treated (Table 2).

The cosmetic outcome was assessed by patients and surgeons following radiotherapy (Table 4). The overall satisfaction with cosmetic outcome assessed by the patient was considered excellent in 17 cases (53.1%) and in 19 cases (59.4) when assessed by the surgeon.
Table 4

Cosmetic outcome assessment

Cosmetic outcomes N (%)

Self-estimation

Surgeon-estimation

Excellent

Good

Fair

Poor

Excellent

Good

Fair

Poor

Breast symmetry

9 (28.1)

17 (53.1)

6 (18.8)

0 (0)

19 (59.4)

11 (34.4)

2 (6.2)

0 (0)

NAC symmetry

11 (34.4)

10 (31.3)

9 (28.1)

2 (6.2)

16 (50)

5 (15.6)

8 (25)

3 (9.4)

Breast shape

12 (37.5)

11 (34.4)

8 (25)

1 (3.1)

18 (56.2)

8 (25)

6 (18.8)

0 (0)

Scarring

10 (31.3)

8 (25)

10 (31.3)

4 (12.4)

13 (40.6)

10 (31.3)

7 (21.9)

2 (6.3)

Overall satisfaction

17 (53.1)

7 (21.9)

7 (21.9)

1 (3.1)

19 (59.4)

9 (28.1)

4 (12.5)

0 (0)

Discussion

Oncoplastic breast surgery, combining breast conservation with surgical techniques deriving from cosmetic surgery, represents the most valuable approach for wide local resection in medium to large breasts. Resections larger than 10–15% of the total breast volume treated with standard breast conserving surgery represent the main cause of final breast deformity (15). On the contrary, aesthetic skin incisions followed by tissue displacements maintain or improve the natural gland contour often achieving a better breast symmetry [16].

Oncoplastic breast surgery dramatically reduces the number of mastectomies compared to radical oncological rates. Positive or close margin rates are reduced when compared with standard breast conserving surgery, leading to a reduction of re-operations [17, 18]. Upper-inner quadrant is known to be the most challenging breast cancer location to be treated from a cosmetic point of view: Grisotti and Calabrese defining this area “no man’s land” [19]. When the defect is small, a reliable glandular rotation flap can be adopted, but when dealing with large excisions, also well-trained surgeons can risk unsatisfactory aesthetic results. Few surgical approaches were proposed to avoid the deformity deriving from huge tumour resections from the upper-inner quadrants.

An interesting surgical procedure was described by Anderson and colleagues for upper-inner excisions less than 20% of breast volume: the so-called “batwing” excision pattern is easy and effective but determines a scar located in the upper breast pole [12].

Cutress and colleagues proposed a modification of the Wise pattern breast reduction for upper-inner and upper-outer quadrants, with a resection of the skin overlying the tumour and moving the same skin amount from the inframammary fold in order to preserve the nipple to inframammary fold distance [20].

Lee and colleagues presented the so-called “fish hook” approach. This interesting method allows the surgeon to avoid contralateral symmetrisation but leading to a large visible scar [21].

We propose an easy mastoplasty technique that fully respects a woman’s neckline while maintaining a pleasant breast shape. NAC malpositioning or asymmetry is not observed with our technique due to the large skin undermining that completely detaches the breast parenchyma from the overlying skin.

Fitoussi and colleagues stated that the huge undermining could lead to increased rates of seroma, fat necrosis and bleeding, and the NAC transposition may cause partial or total necrosis [22]: we did not experience a significant increase of seroma, hematoma, fat necrosis nor NAC necrosis.

The possible delay for adjuvant therapy, either radio or chemotherapy, caused by a longer wound healing time can be avoided with an accurate patient selection, avoiding smokers, diabetics or women affected by peripheral vascular disease for this surgical procedure. Some authors suggest to postpone contralateral breast symmetrisation after radiotherapy due to the risk of volume modification in the radio treated breast [23]. We agree that fat necrosis or edema may derive from radiotherapy, but we noted higher patients’ satisfaction levels when performing contralateral symmetrisation at the same surgical time. Literature supports the concept that partial mastectomy with oncoplastic techniques is associated with low rates of reoperation for positive margins with good cosmetic results [12].

Our low rate of close margins is also justified by the presence of the pathologist in the operating room, advising the surgeons when obtaining close margins with frozen sections and allowing intra-operative further resections.

The proposed technique represents a safe and effective solution for the challenging reshaping that follows upper-inner breast cancer wide excision with low complication and re-interventions for positive margins rates and good cosmetic results.

Notes

Compliance with ethical standards

Conflict of interest

Daniele Bordoni, Pierfrancesco Cadenelli, Nicola Rocco, Matteo Ornelli, Ariel Tessone, Giuseppe Falco, Cesare Magalotti declare that they have no conflict of interest.

Funding

The authors received no funding for this study.

Ethical approval

For this type of study, formal consent is not required.

This article does not contain any studies with animals performed by any of the authors.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Financial disclosures

None of the authors has a financial or non-financial interest in any of the products, devices or drugs mentioned in this manuscript.

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Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  1. 1.Department of SenologyAsur Marche Area Vasta 1, Santa Maria della MisericordiaUrbinoItaly
  2. 2.Department of Plastic Surgery, Hand Surgery and MicrosurgerySan Gerardo HospitalMonzaItaly
  3. 3.Department of Clinical Medicine and SurgeryUniversity of Naples “Federico II”NaplesItaly
  4. 4.Department of Plastic and Reconstructive SurgeryPolytechnic University of MarcheAnconaItaly
  5. 5.Department of Plastic and Reconstructive Surgery, The Talpiot Medical Leadership ProgramSheba Medical CenterRamat GanIsrael
  6. 6.Breast Surgery UnitIRCCS-Arcispedale Santa Maria NuovaReggio EmiliaItaly

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