Reduction and Mastopexy Techniques for Optimal Results in Oncoplastic Breast Reconstruction

Abstract

Breast conservation therapy has emerged as an important option for select cancer patients as survival rates are similar to those after mastectomy. Large tumor size and the effect of radiation create cosmetic deformities in the shape of the breast after lumpectomy alone. Volume loss, nipple displacement, and asymmetry of the contralateral breast are just a few concerns. Reconstruction of lumpectomy defects with local tissue rearrangement in concert with reduction and mastopexy techniques have allowed for outstanding aesthetic results. In patients who have a reasonable tumor- to breast-size ratio, this oncoplastic surgery can successfully treat the patient's cancer while often improving upon preoperative breast shape. Specific surgical guidelines in reduction and mastopexy help achieve predictable aesthetic results, despite the effects of radiation, and can allow for a single surgical procedure for cancer removal, reconstruction, and contralateral symmetry in one stage.

Historical Data

Breast cancer is the most common malignancy affecting women in the United States, and the second leading cause of cancer mortality in women, with a current rate of more than 230,000 new cases annually. One in eight women will develop breast cancer during her lifetime.¹ Considering these statistics, plastic surgeons must be well versed in current reconstructive options.

Although mastectomy rates are on the rise, many newly diagnosed breast cancers are still treated with breast conservation techniques. Improvements in mammography and neoadjuvant therapies have helped with early identification and downstaging of breast cancers, increasing the number of patients who are candidates for breast conservation therapy.^{2 3 4} Early identification and adjuvant treatments have helped revolutionize the surgical approach to breast cancer from the radical operations once championed by Halsted.^{5 6} In 1985, the Early Breast Cancer Trialists' Collaborative Group were among the first to establish the equivalency of mastectomy and breast conserving therapy (BCT).² These observations were supported by trials performed by the National Surgical Adjuvant Breast and Bowel Project (NSABP), securing the equivalency in survivorship between mastectomy and BCT.

In addition to oncologic success and decreased patient morbidity, utilization of breast conservation techniques has many other advantages. Women who have undergone breast conservation are more likely to have a better body image, feel more comfortable naked and with physical intimacy, and have fewer complications of scarring, numbness, and asymmetry.⁷ A quality of life survey by Curran et al demonstrated significant benefits in cosmesis, body image, and treatment satisfaction in patients treated with breast conservation techniques.⁸

To achieve an aesthetic shape and symmetric result in the setting of breast conservation, oncoplastic breast reconstruction techniques are being utilized more frequently. An oncoplastic approach allows for resection of larger tumors without jeopardizing breast aesthetics, nipple position, and sensitivity.⁹ For larger tumors or those located in a less ideal location, poor cosmetic results often occur after lumpectomy and radiation therapy alone (Fig. 1). Techniques to avoid such deformities include reshaping breast tissue (volume displacement), volume replacement, and often shaping the contralateral breast for symmetry, to obtain the best cosmetic outcome.^{7 10 11} Local tissue rearrangement, mastopexy, and reduction techniques can allow for volume correction and for the nipple to be relocated to a more aesthetic position, at the same time as tumor removal.¹²

Fig. 1.

Patient who underwent lumpectomy without oncoplastic surgery and a cosmetically unfavorable result.

Patient Selection and Surgical Planning

Patients who are candidates for breast conservation surgery should be considered for oncoplastic breast reconstruction when the expected defect will have a displeasing aesthetic result. It is our opinion that in most cases tumor excision and breast reconstruction should be performed in a team approach. At our institution, the breast surgeon/surgical oncologist perform the tumor extirpation, and the plastic surgeon performs the reconstruction concomitantly. We have found that communication and preoperative planning by the team allows for predictable, aesthetic outcomes, with margin positivity occurring less than the national average.

Criteria for breast conservation are relative and should be judged based on tumor- to breast-size ratio.¹³ Traditionally, BCT was only offered for patients with lesions below 4 to 5 cm, although now it is increasingly being used for larger lesions as long as it is possible to remove the tumor and keep enough breast volume for a cosmetically acceptable result.¹⁴ Also, the effect of neoadjuvant therapy on tumor size, decreasing the tumor- to breast-size ratio, allows more patients who were not initially candidates to undergo BCT.¹³ In our opinion, most tumors more than 1 cm in size can benefit from some degree of reconstruction, whether it is simple local tissue rearrangement to prevent dimpling or full mastopexy with local tissue rearrangement. The procedure choice lies in the goals of the patient and will be discussed at length in the following sections.

The preference of the senior author is to offer oncoplastic procedures to patients who have a relatively small tumor to breast size, those who are especially motivated to save their breast, and for patients who would have a suboptimal result with either an implant or autologous-based total breast reconstruction. In patients with particularly large breasts, a concomitant reduction mammoplasty or mastopexy allows improvement on preoperative shape and asymmetry. For these patients, oncoplastic procedures can be the “silver lining” to their cancer diagnosis, often improving on their preoperative shape and size.

Patients who are not candidates for oncoplastic procedures are those unable to have BCT, such as pregnant patients unable to have radiation or those who cannot have radiation because they were previously irradiated. Multifocal tumors requiring mastectomy, those with a large tumor to breast ratio, and although our team occasionally employs a central lumpectomy, tumors behind the nipple remain a relative contraindication.

Surgical Approaches

As stated previously, oncoplastic techniques can be subcategorized into volume displacement or volume replacement procedures. Volume displacement is best for patients with medium- or large-sized breasts regardless of ptosis, but may be considered for small-breasted women who do not want mastectomy and total breast reconstruction.¹¹ Contralateral procedures, to match the operated breast may include reduction mammoplasty, mastopexy, or augmentation. Contralateral procedures can either be done in the immediate setting or in a delayed fashion after allowing the operated breast to have reached its final shape, usually after radiation therapy.¹³ In our experience, however, certain reconstructive guidelines that will be discussed in the sections to follow allow for successful shaping of the contralateral breast at the time of ipsilateral tumor removal and reconstruction, thereby avoiding a second surgery and a period of significant asymmetry.

Incision Planning

The incision itself depends on the size and location of the tumor and what type of oncoplastic reconstruction is planned. Of great importance is diagnostic imaging, to fully understand the extent of resection required. For those patients who are candidates for lumpectomy, incisions should be placed in a cosmetic fashion. In our experience, this is commonly within the often-utilized Wise or circumvertical lift incisions. Occasionally, tumors located far from the nipple–areolar complex (NAC) will require separate incisions from standard plastic surgical approaches, even when lifting or reduction is planned.^{2 7} In these cases, care and communication must be utilized to maintain skin perfusion and optimum contour. Please see Table 1 for commonly used incision patterns.

Table 1. Mastopexy incision patterns.

Incision pattern	Image	Clinical indications
Crescent mastopexy		Tumors above but not involving the NAC2
Batwing mastopexy		Lesions near or deep to the NAC, can be used for lesions larger or more medial and lateral than can be removed with crescent mastopexy12
Hemi-batwing		Similar to batwing, but for either a medial or lateral tumor12
Grisotti advancement/B-flap		Central quadrant tumors2 13
Triangle resection		Inferior breast lesions2
Inframammary resection		Posterior lesions located near the chest wall in breast with glandular ptosis2
Periareolar mastopexy		Periareolar lesions in patients with mild to moderate ptosis2 12
Vertical mastopexy		For lesions in large breasts that would benefit from reduction, skin excision patterns can be altered to accommodate the tumor.2 12
Wise pattern

Abbreviations: NAC, nipple–areolar complex.

Breast Reduction and Mastopexy Techniques with Local Tissue Rearrangement

In our practice, the most frequently used techniques for oncoplastic surgery are reduction mammoplasty and mastopexy in concert with local tissue reconstruction of the lumpectomy defect. As mentioned previously, contralateral operations can be done concomitantly or in a delayed fashion, although we advocate for performing contralateral procedures during the initial operation. Others prefer to delay symmetry procedures for 6 months, allowing for stabilization of the effects of radiation.

Other than the ability to decrease the morbidity of macromastia and reduce asymmetry in patients with breast hypertrophy,¹⁰ reduction mammoplasty has been shown to reduce risk of cancer in proportion to the amount of tissue removed,¹⁵ and those with smaller breasts are at decreased risk for radiation toxicity.¹⁶ Breast reductions can allow for a large volume of tissue removal, enhancing the chance of having negative margins. The ability to remove more tissue can allow large tumors to be removed using breast conservation techniques.¹¹ For women with large breasts, other advantages include those of traditional reduction mammoplasty such as reduction of upper body pain, improvement in clothing fit, and reduction of shoulder grooving from bra straps.¹¹

Traditional Wise pattern or vertical breast reduction techniques are chosen depending on the degree of reduction/lifting required.^{2 12} Location of the tumor must be considered when the skin excision pattern is delineated. The nipple can either be preserved on a pedicle or excised with the specimen if central lumpectomy is required for tumor removal. If the nipple is to be preserved, lesion location also dictates the choice in vascular pedicle for the NAC.^{2 12} For superior lesions, an inferior pedicle is an ideal choice and is also a good choice for lower lateral or medial lesions.^{2 12 13} For inferior lesions, a superior or superomedial pedicle can be chosen.¹² The skin around the nipple is de-epithelialized to allow transposition of the nipple to its new location and the breast reduction is continued in the usual fashion depending on the skin excision pattern and pedicle choice (Figs. 2 3 4).²

Fig. 2.

Patient who had a vertical skin pattern excision. (A) Preoperative markings. (B) Intraoperative exposure. (C) Preradiation. (D) Final result at 9 months after radiation therapy.

Fig. 3.

Traditional Wise-pattern markings and tumor identified with wire localization.

Fig. 4.

Patient with left upper-outer quadrant breast cancer. (A) Preoperative anterior view. (B) Preoperative lateral view. (C) One year after radiation, anterior view. (D) One year after radiation, lateral view, showing reasonable symmetry in a single surgical intervention.

Criticisms of utilizing the local tissue rearrangement with reduction at time of lumpectomy remain around the ability to achieve cancer-free margins. Positive margins after a concomitant breast reduction can offer a challenge; however, the team approach allows for immediate access to oncologic tumor bed for accurate and complete re-excision when needed. Clips left in the tumor bed mark the area of initial excision, and working together during the re-excision, the plastic surgeon can lead the oncologic team to the location of the tumor.

Planning for the Effect of Radiation on Reduction/Mastopexy

Radiation is essential after BCT, as it decreases the local recurrence rate significantly. Although timing of oncoplastic lumpectomy reconstruction in relation to radiation has been a topic of discussion in the literature, most centers currently agree that lumpectomy and concomitant reconstruction prior to radiation is safe and in the patients' best interest. Some argue that rearranging tissue prior to radiation alters anatomy and clouds the area in need of radiation boost. Our team, however, routinely clips the area of resection so that after rearrangement the appropriate region can undergo radiation boost therapy. Radiation oncologists and surgical oncologists have found this method acceptable for both margin identification and localization on X-ray for boost radiation. Further, combining the procedure into one avoids a second anesthetic, avoids the ruddy/stiff nature of the tissue after the healing process begins, and allows the patient one period of recovery prior to radiation.

Although performing oncoplastic reconstruction in the immediate setting clearly has some benefit, challenges remain regarding accounting for the effects of radiation over time. The effects of radiation are progressive and irreversible. Over time, the radiated breast will tighten, become more “perky,” and shrink in size. Although it is impossible to predict with precision to what degree a breast will shrink and tighten, we have several guidelines that have helped our center achieve consistent and predictable results.

When performing an oncoplastic reconstruction with reduction or lifting procedure and concomitant contralateral breast lift or reduction, it is imperative that the reconstructive surgeon remembers the effects of the planned radiation therapy and the cosmetic implications on both the affected breast and the nonaffected breast. Without consideration, symmetry in the long term will be impossible. We routinely leave the vertical limb (the distance from the inframammary fold [IMF] to the nipple) 1 cm longer on the breast that is to be radiated. This breast will not go through the natural process of ptosis and if left at the same height as the contralateral breast, long-term symmetry is lost. Along the same vein, we leave the contralateral breast that will not undergo radiation, with a vertical limb that is approximately 1 cm shorter than the affected breast. This side will “relax” with time and not suffer the tightening consequences of radiation. Following this guideline during the initial oncoplastic breast reconstruction allows for prediction (to the best of our ability) of the tightening effects of radiation, thereby allowing for appropriate postoperative nipple position over the long term.

As described, radiation therapy will indeed “shrink” the breast over the course of radiation treatment and the ensuing months after completion. Historically, plastic surgeons would completely delay reduction or lifting of the contralateral breast for 6 or more months after treatment of the ipsilateral affected breast. This can leave patients with a significant deformity and severe asymmetry, which can be challenging both emotionally and physically in clothes. To avoid such a situation and to avoid a second surgery, we simply plan preoperatively to leave the breast that will undergo radiation one-half to one-cup size larger than the nonaffected breast. Although cup size is indeed a nonspecific term, we have found that ∼150 to 200 cc larger on the side to undergo radiation allows for a very predictable and reliable symmetry in the long term for most patients. Though no two breasts are ever “perfectly symmetric,” the patients have been quite satisfied and none has asked for revision. One important point, however, is that in the patient undergoing mastopexy alone, contralateral reduction is often required on the nonaffected breast. Because the patient's goal may not be consistent with a reduction in size, the effects of radiation limit us and this must be disclosed preoperatively.

Although reconstruction at the time of lumpectomy is always our goal, we routinely see patients who have undergone lumpectomy and radiation without reconstruction and who now have a significant deformity. These patients complain of divot at the location of lumpectomy, nipple deviation, breast size asymmetry, and so on. In treatment of these deformities, we employ a very similar concept of surgical intervention. It has been our experience that the radiated breast will not undergo the traditional “settling” process. This breast almost behaves as though “what you see on the operative table is indeed what you get.” For this reason when lifting a previously radiated breast and performing contralateral symmetry procedures, one must be mindful of the differences in tissue.

When reducing or lifting a breast that has previously undergone radiation, we prefer to leave the pedicle to the nipple as large as possible—certainly larger than the normal 7-cm reduction pedicle. This improves vascular supply and decreases the risk of insult to the nipple. Further, the mastopexy flaps on the radiated breast must be thicker than normally created, usually at least 1.5 cm in thickness, again to avoid wound-healing complications. Finally, we inset the NAC in the exact position we ultimately would prefer it to lie. Instead of planning on the breast settling, we have found that the previously radiated breast does not settle and should be placed at the level at which you prefer it, long term. The contralateral reduced or lifted breast should have a shorter IMF to nipple distance than the radiated side, usually by 1 cm, as this side will indeed settle. Fig. 5 shows an example of a previously radiated breast undergoing a reduction with an example of the intraoperative measurements.

Fig. 5.

Patient status post right lumpectomy and radiation. (A) Preoncoplastic surgery at time of referral. (B) Intraoperative view showing measurements. Note distance of inframammary fold to the nipple–areolar complex on radiated side is purposefully placed 1 cm longer to account for settling of the contralateral nonradiated breast. (C) Final postoperative result.

In our practice, following these specific guidelines have allowed for predicable results in the complex setting of radiation. The differences in tissue must be considered, as should the effects of the upcoming or previously performed radiation, as traditional breast dynamics are indeed altered.

Local Tissue Rearrangement without Reduction/Mastopexy

Local tissue rearrangement without reduction or mastopexy is most commonly utilized for patients with minimal to no nipple ptosis and those who are pleased with their current breast size. Several techniques exist, however, in our hands, the most commonly utilized intervention in these patients is local breast advancement flaps. Once the tumor is removed, the breast parenchyma is elevated off of the pectoralis major muscle and advanced to fill the defect. The tissue from both sides of the defect is then rearranged to eliminate the cavity.² In our experience, local rotational breast flap closure in these smaller breasted patients without nipple ptosis utilizing 2–0 polydioxanone (PDS) plication of the breast pillars allows for bolstering of shape, filling of dead space, and avoidance of NAC displacement after radiation therapy.

Central Lumpectomy

This technique is used to resect lesions involving or just posterior to the NAC. The NAC and a cone of tissue are removed down to the level of the pectoralis fascia, or as deep as required by the oncologic scenario. Then, an inferior skin-glandular flap is rotated to fill the defect, making a smaller, but naturally shaped breast amenable to nipple reconstruction months after completion of radiation.² Often the scars of such a resection are similar to vertical or traditional Wise-pattern reduction, depending on the postoperative size goals.

Other Techniques

Rarely performed in our practice and beyond the scope of this article, local and regional flaps can be utilized to fill the defect caused by lumpectomy. For patients with small breasts or those requiring a large volume of replacement, local fasciocutaneous flaps, myocutaneous flaps, and free flap techniques can be utilized.^{9 17} However, we prefer to save these larger options for total breast reconstruction, as utilization of these techniques “burns a bridge” in the case of cancer recurrence.

Fat grafting has emerged as an important adjunct in oncoplastic surgery.¹⁸ For women with smaller breasts, contour defects after partial mastectomy can be managed using fat grafting techniques.¹⁹ Questions remain, however, as to whether fat grafting into a tumor bed can affect the recurrence rate as well as the ability of breast radiologists to interpret changes after fat grafting on screening mammography.¹⁸ In our practice, we prefer to utilize fat grafting for small defects in the setting of autologous or implant based total breast reconstruction, as these issues no longer are relevant.

Outcomes and Complications

Breast conservation has known emotional and psychological benefits over mastectomy. Patients who undergo oncoplastic procedures maintain the feel, color, and texture of their native breast. Rowland et al compared patients who underwent lumpectomy versus those who underwent mastectomy and those who underwent mastectomy and reconstruction. The lumpectomy patients had less postoperative symptoms, but also had less negative effects on body image and felt more attractive than women in the other two groups.²⁰ Studies consistently show high patient satisfaction with cosmetic appearance after oncoplastic reconstruction. Those who were not pleased, however, thought their breasts were too small for their body habitus.¹⁴ We find that preoperative education regarding the effects of radiation therapy on breast size and appearance greatly improves patient satisfaction, as expectations are set appropriately.

Common complications after breast conservation therapy and oncoplastic reconstruction include hematoma, wound-healing difficulty, fat necrosis, and seroma formation. Wound-healing problems, especially at the “T” junction in the reduction and mastopexy cohort, can delay starting postlumpectomy radiation therapy. In general, radiation therapy should be started within 9 weeks of lumpectomy. Therefore, plastic surgeons should be aggressive in treating these patients with re-excision of wound and closure in a timely fashion to avoid delay in treatment.

The complication of positive margins after lumpectomy remains a challenge for the surgical team. In a prospective series of 90 oncoplastic patients out of Helsinki, 16.2% required completion mastectomy.¹⁰ In our practice, however, the complication of positive margin after lumpectomy and oncoplastic reconstruction is less than the national average and only one patient required completion mastectomy due to inability to obtain negative margins. When margin positivity does arise, working as a team allows ease of access to tumor bed, accurate re-excision, and maintenance of aesthetic result.

Conclusion

Long-term survival rates of patients undergoing breast conservation therapy and oncoplastic reconstruction are comparable to those who undergo traditional mastectomy.¹⁰ In patients who have a reasonable tumor- to breast-size ratio, lumpectomy and reconstruction with local breast tissue and lifting and/or reduction can successfully surgically treat the patient's cancer while often improving upon preoperative breast deformity or asymmetry. Further, following predictable surgical guidelines in reducing or lifting breasts prior to unilateral radiation therapy allows for successful reconstruction of both breasts in a single stage.