|Year : 2015 | Volume
| Issue : 4 | Page : 827-832
Reduction mammoplasty in conservative breast surgery in the early stage of breast cancer
Mohamed Ahmed Megahed1, Shawky Shaker Gad1, Hossamabdalkader Al Efol1, Ahmed Sabry El-Gammal1, Mohamed Kamel Hamed Faris MBBCh 2
1 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Shbin Elkom, Egypt
2 Department of General Surgery, Ministry of Health, Zagazig, Sharkia, Egypt
|Date of Submission||21-Sep-2014|
|Date of Acceptance||24-Dec-2014|
|Date of Web Publication||12-Jan-2016|
Mohamed Kamel Hamed Faris
Zagazig, Sharkia, 44718
Source of Support: None, Conflict of Interest: None
The aim of this study is to evaluate the application and clinical outcomes (oncological and cosmetic) following oncoplastic conservative surgery using bilateral reduction mammoplasty in conjunction with breast conservation therapy for esthetic purposes.
Breast cancer is the most common malignancy in women worldwide. Until recently, breast surgery could provide only two options for early-stage breast cancer: either modified radical mastectomy or segmental excision, followed by radiation, but the latter causes breast deformities. Reduction mammoplasty is used as a conservative breast surgery with excision of a large volume of tissue without compromising the cosmetic outcome.
Patients and methods
We studied 17 patients with breast cancer, aged 30-65 years (mean 48.4 years). Patients had been operated on by the reduction mammoplasty technique at Menoufia University Hospital in 2012 and later. Patients were followed up at regular intervals 2 years or more after the operation had been carried out.
Reduction mammoplasty is a good technique for conservative breast cancer surgery at its early stage, with fewer complications and better cosmetic results. All specimens showed free resection margins with an average size of 2.4 cm. No recurrence was detected. Postoperative complications were encountered in seven patients in the form of wound infection, seroma, partial skin slough, and asymmetry. Long-term follow-up results are awaited to support the more widespread use of this surgical technique in the definitive treatment of early-stage breast cancer.
Oncoplastic breast surgery is now being used widely as a better substitute for the management of early-stage primary breast cancer with proved safety and efficacy.
Keywords: breast cancer, oncoplastic breast surgery, reduction mammoplasty
|How to cite this article:|
Megahed MA, Gad SS, Al Efol H, El-Gammal AS, Faris MK. Reduction mammoplasty in conservative breast surgery in the early stage of breast cancer. Menoufia Med J 2015;28:827-32
|How to cite this URL:|
Megahed MA, Gad SS, Al Efol H, El-Gammal AS, Faris MK. Reduction mammoplasty in conservative breast surgery in the early stage of breast cancer. Menoufia Med J [serial online] 2015 [cited 2020 Feb 27];28:827-32. Available from: http://www.mmj.eg.net/text.asp?2015/28/4/827/173599
| Introduction|| |
The breast is the most common site of cancer in women worldwide  . According to the National Cancer Institute, breast cancer in Egypt accounts for about 35% of the total malignancies among Egyptian women  .
Until recently, breast surgery could only provide two options for patients with primary breast cancer: either a modified radical mastectomy or a segmental excision, followed by radiation. Integration of plastic surgery techniques at the time of tumor excision has provided a third option. This new combination of oncologic and reconstructive surgery is referred to as oncoplastic surgery (OPS)  .
Oncoplastic breast surgery allows surgeons to extend the indications for breast-conserving surgery (BCS) without compromising the oncologic goals or the esthetic outcome. Thus, avoidance of mastectomy and consequent reduction of psychological morbidity are the principal goals when applying oncoplastic techniques  .
In women with macromastia, performing breast reduction in conjunction with the oncologic surgery enables breast cancer treatment (BCT) and can lead to excellent cosmetic results. The reduction surgery allows better appearance and reduces the volume of the lung and thoracic structures in the irradiation field  .
Preserving the woman self-image by preserving her breast normal look greatly improves the patient's adherence to the treatment, and may also result in increased disease-free survival, for the psychological repercussion on the immune system  .
| Patients and methods|| |
This study included 17 patients with early-stage breast cancer who were treated in 2012 or before and were followed up for at least 2 years after surgery at regular intervals.
All female patients with localized and early-stage breast cancer and huge breasted female between 30 and 65 years old were included in this study.
All patients were subjected to the following:
- Thorough clinical examination: local or general.
- Radiological evaluation: mammography and ultrasound.
- Pathological evaluation: fine-needle aspiration fine needle aspiration (FNA) or Tru-Cut biopsy.
- Complete counseling of patients who were candidates for the study.
- Surgical techniques:
- Reduction mammoplasty techniques: superior pedicle mammoplasty, inferior pedicle mammoplasty.
- Postoperative excision biopsy:
All specimens were sent for a definitive pathological examination to assess tumor type, size, grade, safety margins, in-situ component, hormone receptor status, and axillary lymph nodes status, malignant metastasis, and capsular invasion or rupture.
- Postoperative radiotherapy.
All patients were discharged from the ward 48 h after the operation with suction drain and with proper administration of antibiotics. Follow-up was performed after the first week and then in the second week.
All patients were followed up for a period from 6 months to 2 years every 3 months in the first year and then every 6 months in the next year by clinical examination, mammography and breast ultrasonography, and metastatic evaluation by chest radiograph, and abdominal ultrasound every 6 months and bone scan annually.
Reduction mammoplasty techniques
Inferior pedicle mammoplasty
The skin markings were as follows: a central midline was drawn from the sternal notch to the umbilicus. The size of the tumor and the area of breast tissue planned to be resected with the tumor were marked on the skin.
A vertical line was drawn from the midclavicular point to the nipple and was extended through the nipple to the inframammary fold and on the thoracic wall, the new position of the nipple was marked with this point projected anteriorly on the midclavicular line. Medial and lateral markings were drawn on the breast, continuing the vertical axis line on the thoracic wall.
An inverted V was drawn with its peak at the future nipple position. The two lines of the V were drawn. Resection of the tumor was performed en bloc including the pectoralis fascia and both lateral and medial breast quadrants.
The inferior pedicle was prepared with a sufficient width and thickness for the vascular supply. It was transferred superiorly into the defect but not sutured to the fascia or the breast parenchyma, ensuring that the pedicle was not rotated and blood supply was not compromised. Axillary dissection was either performed through the mammoplasty incisions or through a separate axillary incision, followed by wound closure with suction drain.
Superior pedicle mammoplasty
The skin markings were identical to those described for the inferior pedicle. The resection, however, was located in the lower pole. It began with de-epithelialization of the area surrounding the NAC. The Nipple areola corner (NAC) was then dissected away from the underlying breast tissue on a superior dermoglandular pedicle. The inframammary incision was then completed, followed by wide undermining of the breast tissue off the pectoralis muscle. The undermining was started inferiorly and then performed superiorly beneath the tumor while encompassing the medial and lateral aspects of the breast as well as the NAC. The tumor was removed en bloc with a large margin of normal breast tissue and overlying skin as determined by the preoperative markings. Mobilization of the breast tissue was performed from the pectoralis muscle. Once the resection was completed, the breast was reshaped by reapproximation of the medial and lateral glandular columns toward the midline to fill in the defect, followed by NAC recentralization, suction drains, axillary dissection, and wound closure.
| Results|| |
In this work, we studied the outcome of applying OPS techniques in seventeen patients with early-stage primary breast cancer managed in Menoufia University Hospital throughout the period from September 2012 to March 2014.
According to the selection criteria for OPS, in terms of tumor location, size in relation to the breast, and breast density, patients underwent various procedures: nine (52.95%) patients underwent inferior pedicle mammoplasty and eight (47.05%) patients underwent superior pedicle mammoplasty ([Table 1]).
The time of operation ranged from 150 to 210 min, median 180 min, and the blood loss ranged from 250 to 500 ml, median 375 ml ([Table 2]).
All specimens showed free resection margins with an average of 2.4 cm; the least resection margin obtained was 0.4 cm as a deep margin in a patient with invasive ductal carcinoma, grade II, who received postoperative radiotherapy and hormonal therapy, and had received close follow-up, and yet, no recurrence was detected.
The largest resection margin was 8.5 cm at the deep margin ([Table 3]).
Cases were followed up for a period of 6 months to 2 years; no in-breast local recurrences were detected during this period ([Table 4]).
The cosmetic appearance was scored according to both the surgeon and the patient as follows: surgeons scored the cosmetic result in most patients (nine cases, 52.9%) as excellent, five (29.4%) as good, two (11.7%) as fair, and one (5.8%) as poor.
In terms of patients, not all enrolled cases could be contacted, but those cases who were asked were satisfied with the fact that their breasts were not amputated preserving their body image with complete tumor removal ([Table 5]).
Postoperative complications were encountered in the form of wound infection and raw areas, especially in the inframammary fold, in three (17.6%) patients; two of these patients were diabetic. Seroma (5.8%) was present in one patient.
Minimal (partial) skin slough occurred in one (5.8%) patient and was managed conservatively. Nipple areola complications occurred in one (5.8%) patient in the form of partial slough and this was managed conservatively. Asymmetry was observed in only one (5.8%) patient and a second operation was performed to correct this asymmetry ([Table 6] and [Figure 1] and [Figure 2]).
| Discussion|| |
OPS includes the set of techniques used along with oncological techniques for the prevention or correction of breast deformities caused by surgical cancer treatment. The goals of modern breast cancer surgery include the cure of the patient, preserving the breast as much as possible, and satisfying the woman.
The aim of local treatment of breast cancer is to achieve long-term local disease control with the minimum local morbidity. With the advancements made in radiotherapy, breast conservative surgery has become firmly established in the last two decades, with equivalent survival rates as mastectomy, which has been proven by several studies and systematic reviews. One of these reviews analyzed data from six randomized-controlled trials that compared BCT with mastectomy. This review analyzed data of 3006 women and found no difference in the risk of death at 10 years  .
In another systematic review, nine randomized-controlled trials involving 4981 women were included in the analysis. A meta-analysis of these trials found no significant difference in the survival rates over 10 years; there was also no difference in the rate of local recurrence  .
BCS has its limitations and drawbacks; the major drawback of BCS is unfavorable cosmetic results, which may be found in up to 30% of patients  . Breast tissue deformities are encountered immediately after surgery or develop over time. They are because of the amount of breast tissue excised, the size of the breast (tumor to breast size ratio), whether or not the skin is resected with the tumor, the localization of the tumor in the breast, orientation of surgical incisions, and postoperative radiation therapy  .
Thus, OPS has been developed as a new approach to allow wide excision for BCS without compromising either the natural shape of the breast or the oncological safety, and its oncologic efficacy in terms of margin status and recurrence compares favorably with traditional BCS  .
Many comparative studies such as those carried out by Schrenk and colleagues ,, have reported the advantages of the use of oncoplastic techniques such as resection of larger breast volumes, wider free margins obtained more frequently, and fewer patients in need for reoperations.
In this work, we studied the outcome of applying OPS techniques in 17 patients with early-stage primary breast cancer managed in Menoufia University Hospital throughout the period from September 2012 to March 2014.
All tumor locations were presented in the study and were managed successfully by several oncoplastic techniques as follows:
Nine (52.95%) patients underwent inferior pedicle mammoplasty and eight (47.05%) patients underwent superior pedicle mammoplasty.
Volume displacement techniques performed in the study were superior and inferior pedicle-based mammoplasty, utilized for the lower pole, and upper inner and upper pole masses, respectively, all of which yielded large resection volumes ranging from 100 to 480 g, with a least resection margin of 0.4 cm and the largest size of 8.5 cm at the deep margin. No recurrence has been detected in these cases to date.
Superior pedicle mammoplasty is considered a standard technique for cosmetic breast reduction/mastopexy. In OPS, it allows excision of breast tumors located in the inferior and central pole of the breast, as well as the medial or lateral quadrants, when the traditional skin incision patterns are modified  .
Also, the inferior pedicle reduction mammoplasty is frequently used for defect reconstruction following partial mastectomy because of its relative safety and reproducibility. It enables resection and reconstruction of tumors located in any breast quadrant, except the inferior central quadrant  .
The duration of operation ranged from 150 to 210 min, median 180 min, and blood loss ranged from 250 to 500 ml, median 375 ml. This is almost comparable to or slightly higher than that reported in the study by Nos et al.  as the mean operative time was 2.5 h (150 min), including axillary dissection and symmetrization of the contralateral breast.
It has been reported that OPS requires a longer duration of operation than standard BCS; the mean duration is at least twice that for regular BCS. Concomitant contralateral symmetrization was an important factor requiring longer operative time  .
Specimen sizes ranged from 90 to 550 cm, mean value 247 cm, with tumor sizes ranging from 0.7 to 5 cm, mean 2.9 cm. This is higher than that reported by Kaur et al.  and Giacalone et al.  ; in their study, it was shown that the amount of breast tissue excised during OPS is higher than that excised during a standard quadrantectomy.
Axillary lymph nodes were positive for malignancy in nine (52.95%) patients, and negative in eight (47.05%) cases.
For resection margins, all specimens in our research showed free resection margins with an average of 2.5 cm; the least resection margin obtained was 0.4 cm as the deep margin in a patient with invasive ductal carcinoma, grade II, who received postoperative radiotherapy and hormonal therapy and underwent close follow-up; yet, no recurrence was detected. The largest resection margin was 8.5 cm at the deep margin in an excised upper outer quadrant tumor.
All our specimens showed adequate free margins, and none of our cases showed local recurrences, but this might also be because of the relatively short duration of follow-up.
Clough et al.  reported a local recurrence rate of 9.4% with a mean follow-up of 3.8 years. Raja et al.  reported a recurrence rate of 3% with a mean follow-up of 5 years. Most authors define a positive margin as less than 1 mm and a close margin as less than 2 mm of normal breast tissue between the resection margin and the next cancer cell ,, .
Postoperative complications were encountered in seven (41.2.5%) cases in the form of wound infection and raw areas, especially in the inframammary fold, which were observed in three (17.6%) patients; two of these patients were diabetic. Seroma was present in one (5.8%) patient. Minimal (partial) skin slough occurred in one (5.8%) patient and was managed conservatively. Nipple areola complications such as partial slough occurred in one (5.8%) patient and this was managed conservatively; these complications resulted in delay in chemotherapy and radiotherapy.
Asymmetry is considered a complication from the cosmetic point of view; this was observed in one patient between two (5.8%) breasts and a second operation was needed and performed to achieve better symmetry.
This was a slightly higher ratio compared with the study of Nos et al.  , in which 10 of 50 (20%) patients developed early minor complications: seven patients developed skin slough that required secondary healing; two patients developed local sepsis that drained spontaneously; and one patient developed wound dehiscence related to limited glandular necrosis. In the latter three patients, the healing process took more than 2 months, resulting in delayed radiotherapy  .
The cosmetic appearance was scored according to both the surgeon and the patient taking into account the preservation of the normal breast shape despite the large volume of resection obtained with wider free resection margins.
The surgeon used a scale wherein the overall result was rated from 1 to 5 (5 = excellent; 4 = good; 3 = fair; 2 = mediocre; 1 = poor). This overall result took into account the global aspect of the two breasts, considering breast shape and size, scars, nipple-areolar complex position and shape, breast symmetry, and postirradiation sequelae. Patient satisfaction was also assessed. This cosmetic evaluation was first carried out before radiotherapy and then every year afterwards  .
In this study, cosmetic appearance was scored as follows: nine (52.9%) as excellent, five (29.4%) as good, two (11.7%) as fair, and one (5.8%) case as poor.
Not all enrolled patients could be contacted, but those who were asked were satisfied with the fact that their breasts were not amputated preserving their body image with complete tumor removal. Most of our patients were young; thus, the cosmetic outcome was a very important factor for them.
| Conclusion|| |
Oncoplastic surgical techniques allowed for more resection volumes, excision of larger masses, wider resection margins with satisfactory cosmetic results, and correction of asymmetry after tumor excision.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]