Upper Hemisphere Oncoplastic Surgery

Introduction

The application of oncoplastic breast surgery techniques in upper hemisphere breast conservation surgery (BCS) affords optimal oncologic and aesthetic outcomes via case-by-case tailored procedures. The goal of this chapter is to provide breast surgeons with multiple reproducible techniques for performing oncoplastic surgery (OPS) in the upper hemisphere. Although the upper hemisphere is often thought of as a “less than ideal” or “less forgiving” location for surgery, multiple OPS techniques are available. The inherent necessity of a breast surgeon to have an armamentarium of OPS techniques is not only a reflection of the variety of breast shapes and sizes, tumor sizes, and tumor locations, but also the increased eligibility of patients for BCS and the demonstrated benefit of OPS. A variety of reproducible OPS techniques, including full-thickness resection and anatomically ideal incision placement, are accessible to the breast surgeon. Multiple techniques to address large-volume OPS resection in any location within the upper hemisphere include modified Benelli also known as modified round block mastopexy, racquet mastopexy, skin-sparing mastopexy, and modification of the Wise pattern for upper outer and upper inner breast tumors. Several OPS classification systems have been proposed, including bilevel classification, four main categories classification, lower level, upper level, and highest level classification, and a system based on difficulty of the tissue/skin rearrangement and volume of resection level 1 through 4. To further demonstrate the feasibility of performing OPS as a breast or general surgeon, a recent study found no statistical difference in the risk of postoperative complications when surgery was performed by either of the two specialty services (plastics or breast surgeon).

The Tailored Upper Hemisphere Ops Procedure

All oncoplastic breast surgery cases are tailored to the individual patient. Assessment starts with radiographic review of size and location of the lesion. Next a clinical examination provides information on breast shape, size, and contour. Radiographic and/or clinical assessment will demonstrate whether overlying skin needs to be excised. Glandular density and patient preference are taken into account. At this point you can decide on one of two basic categories: lumpectomy or mastopexy. This decision is derived from the ratio of tumor to breast and the location of the tumor within that specific breast (shape and size). Of course, there are many permutations, but for sake of ease, we will divide possible OPS for the upper hemisphere into an algorithm differentiating skin-sparing and non–skin-sparing, lumpectomy and mastopexy, and a middle category of tissue transfer rearrangement, nipple-areolar complex (NAC) recentralization, and application of a mastopexy in smaller lumpectomies ( Fig. 40.1 ).

The majority of BCS procedures performed on a day-to-day basis by breast surgeons involve tumor volumes of <20% without a need for NAC recentralization. In this instance, a lumpectomy via an anatomically ideal incision is the optimal choice when overlying skin does not need to be removed. If overlying skin excision is required, a non–skin-sparing lumpectomy is performed. The tenets of OPS, as delineated in Chapter 39 , are applicable whether an anatomically ideal incision is utilized or skin involvement necessitates an overlying skin envelope incision. Tissue transfer rearrangement and/or NAC recentralization may be required in addition to the lumpectomy when the tumor volume nears closer to 20% or to accommodate the native shape and size of the breast. A mastopexy is generally utilized with tumor volume ≥20%. A mastopexy may also be utilized in smaller resections located in the upper or upper inner quadrants to accommodate a more evenly distributed tissue reapproximation or ease of lesion excision.

Lumpectomy via an Anatomically Ideal Incision

This procedure involves ascertaining that the tumor is <20% of the breast volume and can be accomplished via an anatomically ideal incision with appropriate working space and visualization using available instruments ( Fig. 40.2 ). Incision choice should be sensible to your skill set and tailored to the patient on a case-by-case basis ( Fig. 40.3 ).

The incision is brought down through the dermis into the sub-q space, and dissection toward the lesion is undertaken in the superficial plane (through Cooper’s ligaments, same as when performing a mastectomy), the posterior plane (either anterior or posterior to pre-pec fascia), or mid-parenchyma (directly through the glandular tissue). Choice of dissecting plane is assessed on a case-by-case basis depending on incision placement, tumor location, tumor size, and plan of reapproximation of surrounding parenchyma after tumor excision and prior to closure ( Fig. 40.4 ). While dissecting toward the lesion, extend the plane both left and right as well as past the point of targeted excision. This maneuver both creates a space to work in as well as mobilizes tissue for eventual reapproximation. Once the lesion is excised, orient the specimen. Mark the tumor bed. Reapproximation of the created defect decreases the chance of seroma formation and eliminates the created defect. If the area of excision is within an area that has significant overlying or underlying parenchyma, you are likely able to reapproximate the defect at this time with the previously mobilized tissue. If the tumor bed is in an area with varying parenchyma thickness or equal to the size of tumor excised, you will want to mobilize another plane, that is, the superficial plane, posterior plane, or both planes, to facilitate adequate tissue reapproximation. (See below OPS lumpectomy with tissue transfer rearrangement for extensive mobilization.) The tumor bed and created defect are closed with multiple interrupted 3-0 vicryl on multiple levels. The sub-q is reapproximated with interrupted 3-0 vicryl, and the dermis is closed with a running 4-0 monocryl.

Lumpectomy via an Anatomically Ideal Incision and Tissue Transfer Rearrangement

The addition of tissue transfer rearrangement is indicated when the tumor volume excised or location of tumor excision necessitates additional tissue mobilization to eliminate the created defect and can be incorporated to any incision in any location in the upper hemisphere ( Fig. 40.5 ). It is helpful to consent all patients undergoing a lumpectomy for possible tissue transfer rearrangement. Extensive mobilization can be undertaken in the superficial plane, posterior plane, or both planes extending into surrounding quadrants. Reapproximation of tissue should be easy and without tension.

Considerations in an OPS Lumpectomy via Anatomically Ideal Incision

OPS is nuanced; some additional input that may be helpful is delineated below.

Incision choice

Incision choice is made on an individual case-by-case basis by assessing: location and size of tumor, skin involvement, glandular density, and ease and feasibility of performing the desired procedure through the incision ( Fig. 40.6 ). A circumareola incision with or without NAC recentralization may also be utilized for multicentric lesions.

Dissection plane

There are options for the initial dissection plane. Dissection planes include superficial (through Cooper’s ligaments), mid-parenchyma, and posterior plane (pre-pec, above or below pre-pec fascia). While dissecting toward the targeted lesion, it is helpful to expand the plane, especially when in the superficial or posterior plane, past the point of dissection. This accomplishes two things: creates a space to work in, and takes advantage of the tension to start mobilizing tissue that will be used to reapproximate the created defect without overlying puckering or defect. Extended mobilization should be undertaken when you anticipate need, that is, in a breast with thin parenchyma (A cup) or in a location of thinner parenchyma (potentially anywhere in the upper pole, upper inner quadrant, closer to the superior border of the breast, far lateral, or medial border). In these instances, extensive tissue transfer mobilization is employed. At times, such as when utilizing an axillary, low axillary, transverse mid-axillary line, or lateral breast incision, an adaptation to planes of initial dissection and mobilization is helpful. In these instances, a back-and-forth superficial and posterior plane dissection/mobilization technique prior to removal of the lesion is oftentimes easiest, as the tension afforded by the intact glandular tissue expedites the mobilization that will be required for glandular reapproximation after tumor excision (Step 1 in Fig. 40.4 ).

Troubleshooting NAC malposition

NAC recentralization can be performed at the same time by utilizing two offset concentric circumareola incisions with deepithelialization

of the intervening skin. In an instance where a nonareola incision was utilized and there is concern regarding potential malposition, the NAC position can be corrected. NAC recentralization via two offset circumareola incisions with intervening skin deepithelialization regardless of incision placement may be helpful.

Exposure

Good exposure is key in performing OPS. Appropriate instruments of appropriate length and functionality including smoke evacuation and light are necessary (Step 1 in Fig. 40.7 ). Exposure can also be facilitated in case of pendulous breasts with an ioban drape (Step 2 in Fig. 40.7 ).

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