BREAST

Surgical techniques in In terms of patient factors, smokers, patients with high body
mass index (BMI) and diabetic individuals are at increased risk of

breast cancer: an wound dehiscence, wound infections and loss of implant or

autologous-based reconstructions. Complications such as these

overview may delay the start of any proposed adjuvant treatments. Finally,
one needs to consider a patient’s psychological suitability, lifestyle
and the likely impact of recovery time on family and employment.
Hirah Rizki A key component of planning surgery is considering which
Jajini S Varghese oncological treatments the patient has already received and
which adjuvant treatments may be necessary. For example, a
patient who has incurred adverse reactions to their neoadjuvant
Abstract chemotherapy, with neutropenic complications and hospital ad-
missions with opportunistic infections, may be best served with a
With advancements in oncology and oncoplastic training, the options
simple short operation thereby limiting their anaesthetic time,
for treating breast cancer have expanded exponentially over the past
in-patient hospital stay and reducing their risk of complications.
two decades. In particular, surgical techniques have advanced to the
At present, the effects of neoadjuvant or adjuvant chemotherapy
point where oncological safety and aesthetic outcomes are now the
on wound break down, infections and implant loss remain un-
pillars of contemporary breast surgery. Studies have demonstrated
clear. However, the effects of adjuvant radiotherapy on the breast
that by using oncoplastic techniques, breast conservation has
are well documented. We know radiotherapy to an implant-
become an alternative for many patients who would otherwise un-
based reconstruction can result in higher rates of implant loss
dergo mastectomy. Nonetheless, a considerable cohort of patients
and higher rates of capsular contracture. In addition, following
will still require, or request, a mastectomy. Surgical options range
breast conserving surgery (BCS), radiotherapy can cause peau-
from a simple wide local excision, therapeutic mammoplasty or vol-
ume replacement techniques with a local flap, to mastectomy with
d’orange, oedema and overall stiffening of the tissues which may
lead to increased asymmetry and reduced patient satisfaction.
whole breast reconstruction using autologous tissue or a prosthetic
In terms of the tumour itself, one should consider its size, its
implant. Deciding between surgical options involves careful consider-
site and if the overlying skin or the nipple areolar complex has to
ation of tumour characteristics, patient comorbidities and the potential
be removed in order to achieve clear margins. When there is skin
effects of neoadjuvant and adjuvant treatments. The key message for
tethering to the tumour, inflammatory breast cancer or when the
surgeons is to ensure the chosen surgery does not compromise onco-
cancer lies very close or behind the nipple areolar complex
logical outcomes and provides an excellent aesthetic outcome with
(NAC), then the overlying skin/NAC needs to be excised.
timely healing to prevent delays in commencing adjuvant oncology
In this article we cover the key points and considerations
treatments. In this article, we discuss techniques for breast conserva-
when deciding the optimum surgery for patients with breast
tion surgery and reconstructive options after mastectomy. In addition,
cancer.
we detail the safety and influence of neo-adjuvant and adjuvant treat-
ments on surgery. Breast conservation surgery
Keywords Breast cancer; breast conservation surgery; breast
Evolution
reconstruction; mastectomy; oncoplastic breast surgery; therapeutic
Historically, a simple mastectomy has been the surgical treat-
mammoplasty
ment of choice for breast cancer up until the 1970s when land-
mark trials from Veronesi and Fisher paved the way to
performing breast conservation surgery.1,2 Results from their
Introduction randomized control trials confirmed equivalence in overall
survival between mastectomy and BCS with radiotherapy with
In order to plan breast cancer surgery, one needs to consider 20-years of follow-up data subsequently published in 2002.
several factors including, patient comorbidities, tumour However, a 1% increase in recurrence rates was noted in the BCS
characteristics, potential effects of neoadjuvant and adjuvant arm but with no adverse impact on overall survival. Underpin-
treatments on the planned surgery and finally any genetic pre- ning their conclusion was achieving clear margins.
dispositions the patient may have. Underpinning surgical deci- By the early 1990s, Audretsch3 suggested integrating plastic
sion making is patient choice and their attitudes towards risk. surgery techniques with breast-conserving surgery. Conceptu-
Familial and genetic risk factors will influence both the patient ally, this approach was referred to as ‘oncoplastic surgery’.
and the surgeon’s choice for surgery. Oncoplastic surgery was not invented to extend unnecessary
margins but to reduce re-excision rates, reduce distortion after
breast conserving surgery and to lower the rate of mastectomies.
The overarching aim was to provide safe oncologic treatment
Hirah Rizki MBBS BSc FRCS(Gen Surg) is a Consultant Oncoplastic through careful preoperative planning and the incorporation of
Breast Surgeon at the Imperial College Healthcare NHS Trust, plastic surgery techniques in order to obtain good oncologic
London UK. Conflicts of interest: none declared. control with favourable cosmetic results. Over time, surgical
Jajini S Varghese MBBS MPhil PhD(Cantab) FRCS(Plast) is a Plastic techniques have advanced to the point where oncological safety
Surgeon and Consultant Oncoplastic Breast Surgeon at the Royal and aesthetic outcomes are now the pillars of contemporary
Free NHS Trust, London UK. Conflicts of interest: none declared. breast surgery. Oncoplastic training for breast surgeons is widely

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 BREAST

available and it is now commonplace for the full spectrum of Oncological safety of BCS
oncoplastic techniques to be delivered by most breast surgeons. In 2014 Houssami et al. published the results of their systematic
ABS, BASO and BAPRAS have published guidelines for surgeons review and meta-analysis wherein they showed a positive margin,
undertaking oncoplastic breast surgery to ensure uniformity in defined as ink on invasive cancer or DCIS, is associated with at
practice (Box 1). least a two-fold increase in ipsilateral breast tumour recurrence.
Studies have demonstrated that by using oncoplastic tech- This increased risk in local recurrence is not nullified by delivery of
niques, breast conservation has become an alternative for pa- a radiotherapy boost, systemic therapy or favourable tumour
tients who would have otherwise had a mastectomy. However, biology. In addition, they showed that wider margins widths do not
knowledge of risk factors for poor outcomes and poor satisfac- significantly lower this risk.4 Therefore, ensuring adequate margin
tion with conventional BCS is needed in order to determine excision is key to undertaking oncoplastic breast surgery (OPS).
which patients to offer these techniques to as not every patient is In the USA there has been general acceptance of ‘no tumour
suitable for BCS owing to anatomical and tumour characteristics. on ink’ as a minimum margin mandate for invasive disease and

List of quality indicators set out by ABS and BAPRAS

1. Breast reconstruction is discussed with all suitable patients requiring a mastectomy
Target: Breast reconstruction is discussed in >90% of all suitable patients requiring a mastectomy
2. When a referral for OPBS is made from one MDT to another MDT, full clinical, radiological and histopathological information is made available at
the time of the referral and reciprocated with a clear plan for ongoing care responsibility
Target: Full information is available in 100% of patients referred and following treatment
3. The oncological and reconstructive management is discussed at the MDM
Target: The oncological and reconstructive strategy is discussed at the MDM in 100% of patients suitable for OPBS
4. Medical photography (preoperative and postoperative) is part of the clinical record
Target: Medical photography is offered in 100% of BR patients
5. Patients have access to a BCN or equivalent key worker with expertise in OPBS
Target: Access to a key worker with expertise in OPBS and psychological assessment is available in 100% of patients
6. Patients receive information in a format and level of detail that meets their individual needs
Target: Information about the risks and benefits of breast reconstruction/oncoplastic procedures are provided to 100% of patients undergoing OPBS
7. Clinical specialist and psychological reviews take place at key points
Target: Review by the clinical specialist occurs in 100% of cases
8. Physiotherapy services should be available for patients undergoing OPBS
100% availability of physiotherapy services
9. Implant loss at 3 months following BR is assessed and audited (over 12-month period)
Target: Complications leading to implant loss occur in <5% of cases at 3 months
10. Flap loss following BR is assessed and audited (over 3-year period)
Target: Total free flap loss occurs in <5% of cases. Pedicled Flap Loss occurs in <1%
11. Unplanned return to theatre following BR/OPBS is assessed and audited
Target: Unplanned return to theatre occurs in <5% of cases for non-free flap IBR, and <10% of cases for free-flap IBR
12. Unplanned re-admission is assessed and audited for BR/OPBS
Target: Unplanned readmission occurs in less than 10% of cases within 3 months
13. Postoperative complications, return to theatre and length of stay are audited
Target: There is a regular audit and discussion of all patients with postoperative complications
14. Patients’ are invited to report their satisfaction with BR/OPBS using validated outcome measures
Target: At 18 months, > 90% of BR/OPBS patients are invited to report their satisfaction with BR/OPBS using validated outcome measures
15. Margins should be clear following OPBS/BR and this should be assessed and audited (over a 12-month period)
Target: Excision margins should be monitored in 100% of cases
16. Eligible patients are invited to take part in local and national clinical trials of OPBS/BR
Target: Screening for eligibility for clinical trials and national audits occurs in 100% of OPBS/BR patients
17. Implant-based breast reconstruction patient details should be entered into the Breast Implant Registrya
Target: 100% of implant -based breast reconstruction patient details are entered into the Breast Implant Registry
18. Flap-based breast reconstruction patient details should be entered into the UK National Flap Registrya
Target: 100% of flap-based breast reconstruction patient details are entered into the UK National Flap Registry
19. ERAS should be adopted by all units to reduce length of stay
Target: All units should adopt ERAS methodology
a
Where access to registry exists.

Box 1

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 BREAST

2 mm for DCIS. This was debated by ABS at their annual meeting tumours are accessed through scars placed in the periareolar
in 2015 and a minimum of 1 mm was agreed for radial margins position or along the peripheral borders (IMF, lateral breast fold)
for invasive disease. For DCIS, ABS guidelines recommend a and the vertical limb (Figure 1). Key to this approach is adequate
1 mm minimum margin; internationally, however, a 2 mm mobilization of the skin envelope off the breast. We feel this is
margin is generally accepted as the minimum for pure DCIS as best achieved with the tumour in situ and mobilizing with breast
reflected in the SSO-ASTRO guidelines from 2016. DCIS margins tissue in the mastectomy plane several centimetres radially will
wider than 2 mm have shown no benefit in reducing local allow the skin to be re-draped comfortably at the end of the
recurrence rates. procedure. The cavity is obliterated by approximating the breast
Management of a positive anterior margin following breast- pillars. This helps reduce seroma formation and improve
conserving surgery remains a cause for debate amongst breast the final aesthetic outcome, without leaving a visible deficit at
surgeons with a paucity of data to guide practice. It has been the site of the cancer. To avoid puckering of the skin, oppose the
suggested that involvement of the anterior margin carries less breast pillars with sutures located deep in the breast tissue, not
significance than the radial margin in terms of risk of local superficially. The skin will also pucker, and the aesthetic result
recurrence. Where re-excision has been performed for a positive will be sub-optimal if not enough of the gland has been mobilized
anterior margin after BCS, residual disease has only been iden- before closure.
tified in 4e11%.5 OPS does not routinely involve excising skin Mammoplasty is the generic term used to describe the refa-
over the breast cancer. Excision of this anterior margin will, for shioning and reshaping of the breast parenchyma. The procedure
the majority of OPS procedures, compromise aesthetic outcomes. can be divided into three components; a skin reduction pattern,
The national re-excision rate of radial margins in the UK is planned excision of parenchyma with the tumour and a pedicle
17.2%.6 This has implications when selecting the best surgical supporting the blood supply to the NAC. These can be considered
approach for patients. Re-excision of margins after a complex as separate entities when planning a mammoplasty procedure.
oncoplastic procedure can result in poor patient satisfaction with Multiple mammoplasty techniques have been described and as a
the final aesthetic result and increased morbidity. Oncoplastic general principle, we try and keep things as simple as possible to
techniques are now used in up to a third of patients undergoing reduce complications and avoid delays in commencing adjuvant
BCS. The use of oncoplastic techniques have been described to treatment. Below, we briefly discuss a few options based on the
allow for larger resection volumes, good long-term survival tumour to breast volume and ptosis of breast and highlight
outcomes and improved quality of life. Overall, no long-term some of the principles of planning and scar placement. Figure 2
differences in recurrence rates and survival has been reported illustrates how the surgical plan can change for tumours in the
between simple BCS and OPS paving the way to safely embark same quadrant, in different breasts.
on OPS.
However, complications after breast conservation surgery, Small tumour in non-ptotic breast: A periareolar incision
such as wound break down and infections, can lead to delays in usually gives very good access and the breast parenchyma
commencing adjuvant radiotherapy. A recent UK-based study around the tumour is approximated to obliterate the space. A
showed 89.4% of patients received timely radiotherapy. How- round block mastopexy can be utilized in small tumours located
ever, delays in radiotherapy are associated with decreased
overall survival versus timely radiotherapy.7 A similar study
showed postoperative complications were seen in 37.5% of the Breast incisions
patients after OPS but in only 8.2% of these patients the adjuvant
radiotherapy had to be delayed as a result.8

Overview of techniques of breast conservation

surgery
As a general principle, BCS can be broadly divided into volume
displacement and volume replacement techniques. A few key
factors help to decide which surgical method is best and they
include, the tumour to breast volume ratio, ptosis, position of
tumour and patient preference for symmetrizing surgery on
contralateral breast. Very broadly, Clough describes that when
less than 20% of the breast volume needs to be removed then
volume displacement can be employed, where 25e50% of the
breast needs removing then a volume replacement method is
generally used. In some instances, breast conservation is not
feasible by either method and therefore in order to achieve the
optimum oncological outcome, a mastectomy is required.
The simplest approach to BCS is to remove the tumour with
clear margins by placing an incision directly over the cancer. If
this is planned, especially when overlying skin needs to be
removed for oncological clearance, the incision is best placed in
Langers lines. In modern oncoplastic approach, the majority of Figure 1

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 BREAST

in any quadrant in a breast with a moderate degree of ptosis shape of the breast is created by suturing the gland and does not
(see Figure 2b). This was described by Benelli, where two rely on the skin envelope to achieve the desired aesthetic result.
concentric periareolar incisions are placed and the intervening There is a tendency for the NAC to ‘ride a little high’ in the
area is de-epithelised. Full-thickness incision is placed on the vertical technique. Consequently, the NAC should be marked
outer edge and the entire skin flap is undermined. The blood slightly lower than when performing a Wise pattern mammo-
supply to the NAC is through the breast parenchyma and there- plasty. As described by Lejour, the skin of the inferolateral,
fore robust. Excising the tumour in a pie/pizza slice pattern and inferior, and inferomedial aspects of the breast is undermined
then approximating the breast pillars will help achieve a better with creation of pillars medially and laterally which are opposed
breast contour than a circular excision of the cancer. This tech- to recreate the lower pole.
nique is reliable, easy to learn with low morbidity and excellent Employing a Wise pattern mammoplasty is best in large
cosmesis in the right patient. A round block does raise the breasted women with a moderate to significant degree of ptosis
position of the NAC slightly and sometimes women request/are (see Figure 2d). The Wise pattern both reduces the breast volume
offered a contralateral mastopexy to achieve symmetry. and lifts the position of the breast. The most vulnerable points in
the Wise pattern are at the T-junction and the nipple. Depending
Larger tumour in a non-ptotic, small-medium breast: In these on the tumour location, different pedicles to support the vascu-
cases, the tumour to breast ratio while not necessitating a mas- larity of the NAC are planned. For tumours located in the lower
tectomy, exceeds the glandular volume available to fill the defect pole of the breast, maintaining the blood supply of the breast on
(see Figure 2a). This is where local perforator flaps can be a superior-medial pedicle is recommended. For medially, later-
safely employed to provide volume replacement. Local flap re- ally or superiorly placed tumours an inferior pedicle can be used.
constructions are based on a named perforating vessel or This is the most robust pedicle. With the inferior pedicle tech-
collection of vessels therefore flaps and understanding the nique, the blood supply to the nipple and areola remains
anatomy is key to undertaking these procedures. These opera- generous, coming mainly from the deep blood supply through
tions may be carried out in a single or two-stage procedure. In the the 4th intercostal perforator with the added benefit of excellent
two-stage approach the initial operation involves excising the postoperative sensation of the nipple, areola and the skin of the
tumour and ensuring clear margins are achieved. Two weeks breasts. The superomedial pedicle relies on the perforators
later the local perforator flap is inserted to fill the defect. branching off the internal mammary arteries and provides
The lateral intercostal artery perforator (LICAP) flap or lateral excellent blood supply to the nipple. These perforators run in the
thoracic artery perforator (LTAP) flap are commonly utilized of superficial subcutaneous tissue approximately 1 cm deep to the
laterally placed breast cancers. The thoracodorsal artery perforator skin, toward the nipple. This superficial location allows for
(TDAP) is particularly useful to fill larger defects in this region. A undermining of the distal pedicle and/or dermal scoring to assist
medial intercostal artery perforator (MICAP) flap or an anterior in rotation without jeopardizing vascularity. Less commonly
intercostal artery perforator (AICAP) flap are used to fill defects in employed pedicles with the Wise pattern mammoplasty are the
the lower pole of the breast. Before embarking on a local perforator central mound and lateral pedicles.
flap, the patency of the perforating vessels can be checked in clinic
using a handheld Doppler. CT angiograms and MRI scan are also
increasingly being used to delineate the vascular anatomy for these TIPS: If at the end of the procedure the nipple appears ischaemic or
flaps. Intraoperatively, with the assistance of the Doppler the congested then it can be converted to a free nipple graft. To take the
vessels are identified and dissected just enough to ensure adequate tension of the T-junction at closure, additional skin can be left in the
mobilization of flap. They do not need to be completely delineated. central portion of the IMF, thereby converting the inverted T to a
The flap is then de-epithelialized and pivoted as a “turnover flap” Y-junction facilitating a tension free closure.
or “propelled” into the defect.

Larger tumours in larger breasts with grade 2/3 ptosis: These Tumour with planned excision of overlying skin: The Batwing
breasts would benefit from skin reduction and repositioning of approach is appropriate for women with tumours located in the
the NAC. The Le-Jour mammoplasty was first described by central or upper pole of the breast and overlying skin excision is
Madeline Lejour in the 1980s. This technique is best used for also required. This approach can be used to both lift the breast
lower pole centrally placed tumours at the 6 o’ clock position. It and reduce volume (see Figure 2e). Aesthetically, it is inferior
requires the patient to have moderate ptosis with good skin to other described mammoplasty techniques in terms of preser-
elasticity and a superior pedicle that will be 10 cm or less in vation of breast projection, scar pattern and correction of ptosis.
length (see Figure 2c). It utilizes a superior pedicle for the blood As mentioned before, scar placement over the breast mound is
supply to the NAC and creation of lower pole medial and lateral generally limited to times when overlying skin excision needs to
breast pillars to fill the defect left after tumour excision. The be done for oncological clearance. For direct excision of tumour

Figure 2 Wide range of surgical options available depending on factors which include: tumour to breast ratio, grade of ptosis, need for overlying
skin excision and patient preference for contralateral procedure. (a) Periareolar incision to access small tumour (<20%) eliminating the need for
contralateral procedure. When the tumour is larger (>20%), volume replacement through a local perforator flap may be indicated in a non-ptotic
breast. (b) Round block mammaplasty can give excellent access and can slightly lift the nipple areolar complex (NAC). (c) Vertical scar or Le Jour in
breasts with grade 2 ptosis and larger tumour (>20%). (d) Wise pattern in breasts with grade 2/3 ptosis and large breasts with larger tumours
(>20%). Tumours abutting the skin can be removed through (e) Batwing incision. (f) Vertical scar (with NAC removal). (g) Grisotti procedure where
a skin paddle can be placed after NAC removal.

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 BREAST

and overlying skin in inferior pole, the Lejour or vertical limb consideration when undertaking complex OPS on both the
mammaplasty, described above can be used. aesthetic and oncological outcomes. Oncologically adverse out-
comes are seen with delays in commencing adjuvant chemo-
Techniques for excision of tumour and NAC: When the NAC therapy with studies reporting a phase of accelerated growth of
needs to be excised, a simple central wide local excision can be the microscopic residual disease after initial surgical resection.
used in generously breasted women thereby avoiding a mastec- Delays are particularly detrimental among patients with triple-
tomy. When oncologically possible, we feel that this is best negative breast cancer. Therefore, careful consideration
approached through a vertical incision as this results in less regarding non-surgical treatments that may be required preop-
reduction of the breast projection (see Figure 2f). However, for eratively and postoperatively need to be made prior to embarking
the optimal aesthetic outcome, a Grisotti mammoplasty tech- on oncoplastic breast surgery as well as close liaison with the
nique can be employed whereby a circular skin island is mobi- wider multidisciplinary team.
lized from the lower power of the breast and placed at the site of
the previous nipple areola complex (see Figure 2g). This can be Mastectomy
followed with a nipple reconstruction and/or nipple tattoo. A
moderate degree of ptosis is required to perform this procedure, Evolution
the size and shape of the breast does not tend to significantly The rate of mastectomy procedures, where there is complete
alter. This approach helps maintain breast projection and avoid removal of breast tissue to treat breast cancer, has been decreasing
the blunting that is often seen on excising the NAC in isolation. all around the world. This has been influenced by a number of
factors including, the emergence of safety of breast conserving
Impact of adjuvant radiotherapy surgery (BCS), increasing utilization of neoadjuvant therapy to
Radiotherapy to the conserved breast can result in skin changes, downstage locally advanced disease and focused training of
fibrosis leading to stiffening of the gland, reduced rates of pa- surgeons in emerging oncoplastic techniques. In the UK, the 2020
tients satisfaction and increased asymmetry. NHSBSP audit reported only 16% of women with invasive breast
Several studies have explored the safety of omitting radio- cancer underwent mastectomy. However, mastectomy remains
therapy after BCS including the landmark BASO II trial.9 Even the appropriate treatment in several circumstances.
in these patients, with tumours of excellent prognosis, local
recurrence after BCS without adjuvant therapy was still very Indications for mastectomy
high. This was reduced to a similar extent by either radio-
Extensive, multifocal invasive or in-situ disease not
therapy or tamoxifen but to a greater extent by the receipt of amenable to BCS.
both treatments. Conversely, the PRIME II,10 a phase 3 ran-
Unfavourable tumour to breast size ratio.
domized controlled trial across 76 centres in four countries
Patient choice.
with over 1000 women, showed no statistical differences in
Inflammatory breast cancer.
regional recurrence, distant metastases, contralateral breast
Contraindications to radiotherapy e previous WLE þ
cancers, or new breast cancers. While radiotherapy reduced radiotherapy or previous mantle radiotherapy for lymphoma.
local recurrence from 4.1% to 1.3%, there was no difference in
Risk reducing mastectomy e high risk gene carriers or non-
OS at 5 years. carriers with >30% overall risk of breast cancer.
At present, the vast majority of patients undergoing BCS will
receive radiotherapy. The PRIMETIME study is currently Oncological safety
recruiting, aiming to utilize biomarkers to determine if radio- A mastectomy of any type never removes 100% of the breast
therapy can be safely omitted. But until more robust data and tissue. There has been considerable debate regarding the amount
guidelines are available, one should assume adjuvant radio- of residual breast tissue left behind after SSM or NSM and if this
therapy will be delivered and appropriately counsel the patients is reflected in the respective recurrence rates. Interestingly, local
as to its impact on the breast. recurrence rates after mastectomy (any type) have not changed
over the past five decades. A recent meta-analysis of observa-
Impact of neoadjuvant and adjuvant chemotherapy tional studies comparing SSM to Simple Mastectomy reported
Neoadjuvant chemotherapy can reduce the footprint of the breast comparable rates of local recurrences after breast cancer (3.8%
cancer, with complete pathological response seen in around 40% e10.4% after SSM and 1.7%e11.5% after Simple
of patients. Tumour shrinkage can change the surgical approach Mastectomy).12
from a mastectomy to breast conservation. In the NSAPB-B18 Prophylactic mastectomies were shown by Hartmann et al. in
trial, a significant increase in recurrence rates was reported in a large series with 14-year follow-up to be an effective method of
patients who were converted from mastectomy to BCS when risk reduction.13 Notably, most of these cases were NSM; how-
compared with those patients who had BCS as initially planned. ever, only 26 of these patients in the study were identified to
After 9 years, the rates of recurrence were 15.9% versus 9.9%, a have a BRCA mutation. It is estimated that a high-risk gene
difference that was no longer statistically significant after mutation carrier, with an overall 85% lifetime risk of breast
controlling for patient age and initial clinical tumour sizes.11 cancer, and 60% risk of second breast cancer can benefit from a
However, much debate remains regarding excising the footprint 90% risk reduction following a prophylactic SSM. However,
or the residual cancer with long-term follow-up data awaited. consciously leaving behind additional ductal tissue with an NSM
In terms of wound healing, neoadjuvant chemotherapy results can cause the patient and clinician pause, especially among
in increased rates of wound infections, an important BRCA carriers in which all somatic cells carry the genetic

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 BREAST

mutation. Data from two cohorts of BRCA mutation carriers planning is essential. It is important to document any scoliosis,
undergoing therapeutic or prophylactic NSM procedures showed shoulder droop or chest wall asymmetry as these will all affect
no new cancers at 43 months of follow-up and therefore it’s the final reconstruction results. The boundaries of the breast can
acceptable to offer this to patient. Sakurai et al. reported a low be marked to avoid inadvertent breach during the procedure with
rate of NAC recurrence (3.7%) in 788 patients who underwent particular attention to the inframammary fold (IMF) and the
NSM. There was no difference in local recurrence between NSM lateral limits. Any asymmetry in the height of IMF is also docu-
and non-NSM cohorts (8.2% vs 7.6%, p ¼ 0.81).14 mented and pointed out to the patient in the preoperative
In a lot of centres, in addition to imaging using MRI to assess setting as this may become obvious after the reconstruction. It
clearance of tumour from NAC, intraoperative frozen section is important to mark both breasts even when planning for uni-
analyses from retro areolar tissue allows for reassurance lateral mastectomy and reconstruction and have them both
regarding safety of sparing the NAC. Lohsiriwat et al. performed prepped and draped during procedure to allow for assessment of
a pathological study in mastectomy specimens and showed symmetry during reconstruction.
sensitivity of retro areolar frozen section examination of 88.2% The incision used depends on whether skin reduction is
and a negative predictive value of 93.3%, which can be inter- required (in grade 2 or 3 ptotic breasts). In a non-ptotic, or grade
preted to mean that when the frozen section test yields a negative 1 ptotic breast with medium volume and when the nipple cannot
result it is unlikely that the definite histopathology should have be conserved due to oncological concerns, the most common
been positive.15 However, not every centre has access to such incision is an ellipse centred around the nipple, orientated either
service. vertically or horizontally (Figure 3). Through this incision the
mastectomy flaps are raised along the plane defined by the sus-
Techniques of mastectomy pensory ligaments of Cooper, carefully preserving the vascularity
Simple mastectomy: In this procedure, the nipple areolar com- through the subdermal plexus and subcutaneous layer. The skin
plex (NAC), skin and breast parenchyma are all removed. The is gently lifted with skin hooks initially and lighted retractors can
patient is marked standing up and the sternal notch, midline and be used for the deeper portions. Hand manoeuvres provide
breast contours are drawn including the IMF. The skin incision counter traction to help visualize the plane better. The dissection
most commonly used is an ellipse which includes the NAC and is carried up to the clavicle superiorly, IMF inferiorly, sternum
the lower margin is designed to sit just above the IMF. The width medially and the anterior border of latissimus dorsi laterally.
of the ellipse depends on the vertical elasticity of the skin en- Once the dissection between the skin and parenchyma is com-
velope. The aim is to create skin flaps that close without tension, plete, the gland is taken off the chest wall, leaving the pocket
thereby reducing risk of skin necrosis and wound dehiscence. At ready for reconstruction. Meticulous haemostasis is performed
the same time, it’s important to avoid residual, redundant skin to throughout the procedure while preserving the subdermal
allow the external prosthesis to sit comfortably. This can be vascularity.
challenging in obese women as there will be lateral fullness, When autologous reconstruction is performed, the defect
which will become more apparent after the procedure. Surgical through which the mastectomy was performed is replaced with
techniques to manage skin and soft tissue fullness include dog- skin from the autologous flap. In cases of implant-based recon-
ear excisions and liposuction. Ideally these issues are identified struction, the elliptical incision is closed into a line.
in the first sitting and addressed; however, residual tissue excess In larger, ptotic breasts (grade 2/3), a wise-pattern skin
may exist, and its important women are counselled regarding reduction incision pattern allows for creation of a smaller pocket.
potential need for further tidy up procedures.
The only absolute indication for this procedure is inflamma-
tory breast cancer where immediate reconstruction is not offered. Tips: The use of a dermal flap from the inferior mastectomy skin can
Other indications include, patients not medically fit to undergo protect the underlying reconstruction in case of a T-junction break-
immediate reconstruction and patient choice. In some circum- down. This can be planned in high-risk women. Another technique
stances, the patient and surgeons may opt for delayed recon- commonly used is a ‘V’ extension from the inferior mastectomy skin
struction particularly in the presence of aggressive cancer where to reduce the tension at the T-junction and reduce the risk of break-
any delay to adjuvant therapy due to wound complications need down.
to be avoided.

TIPS: Skin staples can be used to temporarily hold skin edges The lateral flap is the most vulnerable with this design due to the
together allowing the surgeon to tailor mark a tension free closure division of the Lateral Thoracic artery during mastectomy.
and remove excess tissue.
Nipple-sparing mastectomy: In this procedure, breast paren-
chyma is removed while preserving the skin envelope and nipple
areolar complex. This is commonly offered to women with small
Skin-sparing mastectomy: In skin-sparing mastectomy (SSM), to medium volume (A or B cup size) with no or grade 1 ptosis.
the procedure is performed to allow for careful dissection of all of There are several contra-indications to the preservation of NAC,
the parenchyma while preserving almost all of the skin and the including clinical or radiological evidence of NAC involvement,
subdermal vascular supply with the subcutaneous tissue. SSM is or a tumour within 2 cm of NAC thereby increasing the risk of
always planned with immediate reconstruction and accurate extension to the nipple, Paget’s disease of nipple and bloody

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 BREAST

Incisions for skin-sparing mastectomy Incisions for nipple-sparing mastectomy

Figure 3 Figure 4

discharge. The incision is most commonly placed in the IMF,

particularly for smaller breasts. Another incision that allows for less invasive surgery through avoidance of a donor site, shorter
procedure, shorter hospital stays and potentially quicker recovery.
It can be replaced with autologous reconstruction at a later date if
the results are not satisfactory. However, patients should be
Tips: Nipple delay is procedure where the nipple and surrounding
adequately counselled regarding expectations, especially with re-
skin is released from underlying parenchyma for around 5 cm,
gard to the need for multiple surgeries in the future. While it is
2 weeks before the definitive NSM. This has shown to increase the
possible to achieve excellent symmetry in bilateral procedures, in
subdermal supply to the nipple and allows nipple to accommodate to
unilateral reconstruction, there may be asymmetry, and this can
the new blood supply and thereby improve survival of NAC. A ret-
be addressed with symmetrizing contralateral mastopexy or
roareolar biopsy can also be done at the same time. Lateral place-
reduction. Women need to be aware that rates of revisional sur-
ment of the IMF scar can allow for preservation of the blood supply
geries can be as high as 50%. Need for further surgery could be
through the superficial branch of the superior epigastric artery that
due to the effect of aging, weight gain and pregnancy resulting in
supplies the inferior aspect of skin flap. This can improve the blood
further asymmetry or due to implant failure through capsular
supply to the mastectomy flap.
contracture, displacement or rupture. There are several risk factors
that can increase the risk of reconstructive failure such as smok-
ing, obesity, radiation therapy, diabetes and older age. None of
good access while being aesthetically pleasing is a vertical inci- these are contraindications but the patient must be made aware of
sion that extends from the NAC to the IMF which may also allow the higher risk profile and they are better prepared and make
some skin removal if indicated (Figure 4). changes if possible, such as cessation of smoking which can
reduce wound complications by threefold.
Reconstruction post mastectomy Implant-based reconstruction can be done in one stage
The positive impact of immediate reconstruction on body-image, through the use of a fixed volume implant (DTI) or can be staged
self-esteem and quality of life after breast cancer treatment has through the placement of a partially filled expander first which is
been well-documented. The National Institute for Health and the expanded in the clinic. Once the desired volume is achieved,
Clinical Excellence (NICE) in the UK published guidelines rec- the inflated expander is exchanged for a definite implant at
ommending that reconstruction should be offered to all women another date. Implants can be placed in the pre-pectoral pocket
with breast cancer at the initial surgical operation, if the patient is or in the sub-pectoral pocket. The use of acellular dermal matrix
medically fit for the longer anaesthetic. To ensure this is per- or synthetic mesh has increased and provides cover to the whole
formed without causing any delay to adjuvant oncological implant in the pre-pectoral pocket and as a sling to cover the
therapy, the surgeon needs to develop an understanding of the lower pole in the subpectoral pocket. The exact benefits of each
impact of adjuvant and neoadjuvant treatment on reconstruction of these approaches are not very clear and hence there is a trial
outcomes. This will allow for informed and shared decision currently being set-up to generate robust evidence for each of
making with patients and appropriate counselling regarding these practices and support informed consent.
expectations.
Autologous reconstruction of the breast mound using autolo-
Implant-based reconstruction is the most common form of gous tissue can be achieved in a variety of ways depending on
breast reconstruction in the UK. This procedure offers the patients patient preferences in terms of desired breast size, donor site

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 BREAST

and scar location and the availability of donor sites. Most flaps the setting of radiotherapy is to decrease the complications of
can be used in an immediate or delayed setting. Delayed flaps implant-based reconstructions and thus it would be counter-
will typically need more skin to create the skin envelope while productive to use an implant.
in immediate reconstruction the focus is on reliable healing to
access adjuvant treatment in a timely manner if indicated. Impact of adjuvant radiotherapy
Depending on patient wishes, contralateral adjustment can be The indications for radiotherapy post mastectomy have recently
performed in a single stage or as a second stage. been expanded. Radiation therapy, although essential for
The most commonly used flaps in reconstruction are the locoregional control of breast cancer, adds significantly to the
deep inferior epigastric artery (DIEP) flap as a free flap. complexity of breast reconstruction and the optimal form and
Pedicled flaps such as the latissimus dorsi flap remain attached timing of reconstruction has been a topic of debate. Like in all
to their blood supply, whereas in free tissue transfer the blood cases of breast reconstruction, the reconstruction can be autol-
supply of the flap is cut and anastomosed to vessels at the ogous or prosthetic. The question is in the setting of radiation
donor site. Free DIEPs spare the rectus abdominus muscle and therapy, is one superior to the other?
subsequently have fewer donor site bulges and hernias as Regardless of the reconstructive technique used, patients
compared to TRAM flaps. Because they are supplied by the receiving radiotherapy have higher rates of complications and
dominant deep inferior epigastric system, they also have less lower patient satisfaction with cosmetic results. Literature consis-
fat necrosis, wound complications and hospital stays. Other tently recommends immediate reconstruction with autologous
than the abdomen, possible donor sites are from the thighs, tissue if chest wall radiotherapy is anticipated. A systematic review
buttocks and back (Figure 5). If there is a paucity of donor by Berbers et al. identified subgroups of patients according to the
sites or the volume of the flap is smaller than what is needed, timing and type of reconstructions; autologous after radiotherapy,
hybrid reconstruction combining both autologous and pros- implant after radiotherapy, autologous before radiotherapy and
thetic reconstruction have been described. Most surgeons now permanent implant before radiotherapy. Implant failure was
prefer to augment the flap with fat rather than place an significantly higher among women that underwent implant
implant. The whole concept of autologous reconstruction in reconstruction after radiotherapy (OR:3.03 [1.59e5.77]).16

Diagrammatic representation of some common pedicled and free flaps

LD

DIEP TRAM

SGAP

IGAP TMG

LD, latissimus dorsi; SGAP, superior gluteal artery perforator; IGAP, inferior gluteal artery perforator;
DIEP, deep inferior epigastric perforator; TMG, transverse myocutaneous gracilis; TRAM, transverse
rectus abdominis myocutaneous.
Figure 5

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 BREAST

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 BREAST

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