Oncoplastic Techniques for the Lower Hemisphere of the Breast

Introduction

Two decades have passed since the NSABP and Milan randomized controlled trials reported 20-year outcomes confirming that women with early-stage breast cancer may safely choose to keep their breasts without compromising survival. Breast-conserving therapy (BCT) has become the standard approach for most women with early breast cancer limited to one quadrant. Breast-conserving surgery not only achieves the same overall survival, when paired with sentinel node biopsy, it is an outpatient surgery with shorter overall recovery. Still the upper and lower poles of the breast tolerate BCT differently. The lower hemisphere of the breast has routinely been problematic; it is associated with delayed posttreatment retraction labeled the “bird’s beak deformity” ( Fig. 41.1 ). Over the last several years, breast cancer surgical technique has adopted the breast reshaping approaches more traditionally employed by plastic surgeons. Thus the field of breast surgery has undergone an oncoplastic evolution.

As breast cancer survival rates improve, more research explores the survivorship consequences of breast cancer treatment. Nipple-sparing mastectomy (NSM) is increasingly employed for eligible women undergoing mastectomy with reconstruction, with no adverse oncologic outcome reported in a meta-analysis. However, compared with BCT, women undergoing NSM reported significantly less appearance satisfaction and less comfort being seen undressed, had decreased persistence of breast intimacy, and experienced a less pleasurable breast caress. In fact, NSM patients reported the highest rate of unpleasant sensations within the reconstructed breast. Additionally, breast-specific sensuality is less negatively impacted in women undergoing BCT compared with mastectomy with reconstruction. Furthermore, more durable outcomes have been described for BCT, with survivors reporting higher breast satisfaction, psychosocial, and sexual well-being scores compared to mastectomy with reconstruction. Therefore, NSM does not provide an adequate substitute for BCT-eligible women.

While beyond the scope of this chapter, sexual dysfunction in survivorship is well described. Though anatomically a modified sweat gland, the breast has roles in female self-identity and sexual function, well beyond the relatively short time period of lactation. Breast-specific sensuality tries to assess how the treated breast functions for women in survivorship. Breast deformity is associated with appearance dissatisfaction, which has a strong correlation with sexual dysfunction. Thus oncoplastic breast surgery (OBS) prioritizes a comprehensive oncologic resection followed by reevaluation of the resultant shape, and proceeds with reshaping at the index operation to achieve a favorable cosmetic outcome.

The IOM report formalized the current era of survivorship by mandating that all oncology clinicians describe and manage the late and long-term outcomes of their component of cancer therapy. Therefore, the responsibility to manage the long-term effects of scars and deformities associated with oncologic resection rests with the surgeon. Incision placement and consequences of resection should be included in the surgical consent process, which seem to be lacking based on a nationwide study of survivors.

Finally, recalling the interdisciplinary aspect of breast cancer therapy, with extended surgical dissections, the breast surgeon must clearly identify the tumor bed for the radiation oncologist. While surgical clips have been used historically, newer methods have emerged with improved tumor bed targeting.

Preoperative Evaluation

Breast Size, Form, and Shape

Breast ptosis has primarily been considered cosmetic. However, for the breast cancer surgeon, ptosis provides an opportunity for skin envelope reduction, facilitating tumorectomy defect elimination. Regnault categorized degrees of ptosis. Yet, for the breast surgeon, the most valuable aspect of assessing and planning to correct breast ptosis is identifying the targeted location of the nipple-areolar complex (NAC). The eponymous Pitanguy’s point is defined as the location on the anterior skin surface of the breast where the lowest point of inframammary fold (IMF) projects with the patient in the seated/standing position. By resting one’s finger at the IMF without undue upward pressure and palpating that finger through the anterior breast skin ( Fig. 41.2 ), or by marking a horizontal line between both IMFs and then tracing that line onto the anterior breast surface, the ideal NAC location is delineated. Identifying Pitanguy’s point preoperatively allows the surgeon to recenter the NAC intraoperatively, enabling skin envelope reduction and wound defect closure. We recommend performing a partial mastectomy with reduction mammaplasty in appropriately selected patients. Fig. 41.3 shows the algorithm for reconstructive options with and without ptosis/macromastia.