Practical Guidelines for Repair of Partial Mastectomy Defects Using the Breast Reduction Technique in Patients Undergoing Breast Conservation Therapy (2008)

Sir: Despite the many advances that have occurred in reconstructive breast surgery, most patients who undergo breast conservation therapy—breast conserving surgery followed by radiation therapy—do not have repair of the resultant defect. Unfortunately, many breast surgeons and patients have hopes of secondary correction after breast conservation therapy, but the cosmetic outcomes are often disappointing, and these complicated reconstructive procedures are associated with a high rate of complications. Dr. Munhoz states his preference for a superiorly based pedicle technique as opposed to our preference for an inferiorly based pedicle technique. These types of disagreements in techniques and timing are exactly what have created this current situation of confusion for reconstructive breast surgeons with regard to how to approach the care of these patients. Despite the subjective preference of Dr. Munhoz for a superiorly based pedicle, we have provided clear data-driven explanations of our findings with new techniques that limit complications and optimize cosmetic outcome. It is important to mention that our preference for cosmetic breast reduction surgery is usually a superiorly based parenchymal pedicle with a vertical skin reduction pattern; however, our clinical experience and data indicate that this method is not reproducibly amenable to repair of a partial mastectomy defect, except for those located in zone 5 of the breast. In addition, as indicated in our study,1 superiorly based pedicles have the highest complication rates and tend to have poor cosmetic outcomes. Superiorly based pedicles are designed to descend inferiorly over time to fill the lower pole of the breast (Fig. 1). Unfortunately, when a patient undergoes radiation therapy soon after the repair, as in the case of breast conservation therapy, this process is interrupted and tends to not occur, with a resultant dead space in the dependent inferior region of the reconstructed breast. In addition, the lack of inferior descent of the breast parenchyma into the lower poles of the reconstructed breast leads to a repaired breast that often lacks inferior projection and has excessive superior fullness. If this repair is attempted after radiation therapy, it is associated with a very high rate of complications.1Fig. 1.: (Above, left) Preoperative view of a 52-year-old woman with a T2N0 tumor in zone 5 of the right breast with markings for a vertical skin resection pattern and a superiorly based parenchymal pedicle. (Above, right) Intraoperative view of the access incision used by the breast surgeon to perform the tumor resection with the dimensions of the resultant defect. (Below, left) Intraoperative view during closure of vertical skin resection pattern after creation of superiorly based parenchymal pedicle. (Below, right) Postoperative view after immediate repair with superiorly based parenchymal pedicle. Over the next several weeks, breast parenchyma will need to descend to fill the pole of the breast.Dr. Munhoz also mentions several studies with high rates of postoperative breast conservation therapy margins and local regional recurrence of breast cancer in patients who underwent breast conservation therapy. In our series,1 only 7 percent of patients had positive tumor margins after undergoing immediate repair following partial mastectomy. This rate is lower than the positive margin rates reported in patients who do not undergo repair (approximately 16 percent)2 because the defect sizes in those patients are generally smaller (mean, 245 g versus 60 g, respectively). In addition, our experience1 indicates that the majority of patients for whom repair is planned because of larger anticipated defects will proceed to completion mastectomy with immediate breast reconstruction rather than additional reexcision. Attention to tumor margins before rearrangement of the breast parenchyma is critical. If there is concern during surgery regarding the adequacy of the tumor margins, the partial mastectomy wound is closed primarily without any tissue rearrangement. After confirmation of negative margins on review of the permanent sections, repair of the defect is performed within several weeks of the partial mastectomy, which should not cause delay in the start of radiation therapy. Furthermore, the basic rule of thumb has been and remains that 10 percent of patients who undergo breast conservation therapy will develop a recurrence in 10 years. These rates are consistent and even lower than our findings of a 5 percent incidence of locoregional recurrence after a mean follow-up of 3 years. I would also like to remind Dr. Munhoz that there are many methods in reconstructive surgery to achieve the same goal. However, our study was a data-driven evaluation which, based on its results, led to the development of this standardized approach to repairing partial mastectomy defects in different regions of the breast, a strategy that has been lacking in the breast reconstruction literature. In addition, the outcomes of this study have allowed us to achieve our ultimate objective, which is to further the development of safe and innovative techniques that are reproducible and relatively straightforward to perform so that more surgeons may be encouraged to repair partial mastectomy defects before radiation therapy, so that fewer patients will have severe breast deformities after undergoing breast conservation therapy, requiring more extensive reconstructive procedures that most of these patients are not interested in undergoing. Steven J. Kronowitz, M.D. University of Texas M. D. Anderson Cancer Center Houston, Texas [email protected]