Reply (2009)

Sir: Certainly in the ideal world, only patients with large breasts would have breast conservation therapy; however, this is not the case. In the real world, patients with small breasts do receive breast conservation therapy. However, when trying to establish general principles of reconstructive surgery in breast conservation therapy, it is important to consider the implications of performing breast conservation therapy in small-breasted patients. Delivering radiation therapy to a small breast can necessitate the need for a flap and negate the use of a breast implant due to the healing difficulties associated with radiation therapy and capsular contracture, respectively. Many small-breasted patients tend to be thin with limited autologous tissue options. So if a poor outcome results after a failed attempt at primary repair of a partial mastectomy defect, the small-breasted patient is left in a precarious position for any subsequent breast reconstruction. Radiation therapy may limit the use of the often-preferred option in these patients, breast implants, and the exclusion of the breast implant option in this patient population can be very detrimental and may “cripple” any further attempts at reconstruction if required in the future. In addition, attempted secondary reconstruction in these patients is often associated with poor cosmetic outcomes due to an insufficient volume of autologous tissue and the need to replace the contracted breast skin with an unnatural appearing, mismatched skin island from a locoregional or distant flap. Therefore, it is imperative that any reconstructive management algorithm for breast conservation therapy be based on the most reliable method to minimize a deformity,1 rather than creating a possible situation that may require the clinician to have to resort to extreme measures for secondary repair. Neoadjuvant chemotherapy has become an excellent tool to limit the morbidity of mastectomy, especially the need to resect breast skin. It has also been shown to safely increase the eligibility of patients with large tumors for breast conservation therapy by reducing the tumor size, making them amenable to the use of partial mastectomy, instead of mastectomy.2 These benefits are not only for patients with large tumors but also can be seen in small-breasted patients. Despite the reduction in the tumor size that can occur with neoadjuvant chemotherapy, small-breasted patients may still not have enough remaining tissue to recreate a reasonable breast mound, especially since radiation therapy further reduces the volume of the repaired breast due to radiation-induced fat necrosis of the adipose component of the breast. Again, this point emphasizes that it is imperative that primary attempts at repair of partial mastectomy defects must be performed with a high degree of certainty to avoid the need for complicated secondary surgery. Preservation of the breast skin has been responsible for the great improvements in breast reconstruction over the last 20 years. As we continue to learn more about the effects of radiation therapy on the breast skin, it has become apparent that minimizing dermal scarring is essential. Placement of extirpative incisions on the breast skin overlying a breast tumor is often not required. Few patients even have involvement of the overlying breast skin and many of these concepts will probably become antiquated over the ensuing years. If possible, extirpative incisions should not be placed directly on the breast skin, especially in patients who will receive radiation therapy, as described in the technique of breast remodeling. This term “breast remodeling” is often misused, instead of being used as described by the author as the specific circumstance when the entire breast skin envelope is freed from the underlying breast parenchyma so that a parenchymal defect can be plicated without tethering of the overlying skin.1 The freed skin envelope then “remodels” to the recontoured “breast” mound. As previously mentioned, one of the significant benefits of breast remodeling is that it avoids scar formation directly on the breast skin envelope, which subsequently avoids the often contracted and tethered deformity that occurs to a breast skin scar due to the effects of radiation therapy on the scarred dermis, which often requires skin replacement, even when no breast skin was resected as part of the partial mastectomy. Because breast remodeling avoids this contracted skin deformity, it “sets the stage” for subsequent autologous fat grafting after radiation therapy, to correct any deformity or breast size mismatch that may have resulted from radiation therapy. Despite the many potential benefits of autologous fat grafting, even autologous fat grafting cannot overcome a contracted breast skin scar. Steven J. Kronowitz, M.D. Department of Plastic Surgery University of Texas M. D. Anderson Cancer Center 1515 Holcombe Boulevard Houston, Texas 77030 [email protected]