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Oncoplastic and reconstructive surgery of the breast
The Breast 22 (2013) S100eS105
Contents lists available at SciVerse ScienceDirect
The Breast journal homepage: www.elsevier.com/brst
Original article
Oncoplastic and reconstructive surgery of the breast Moustapha Hamdi, MD, PhD a, b, * a b
Department of Plastic & Reconstructive Surgery, Brussels University Hospital, UZBrussel, Laarbeeklaan 101, B-1090 Brussels, Belgium Free University of Brussels, Brussels, Belgium
a b s t r a c t Keywords: Oncoplastic surgery Pedicled perforator flaps Theapeutic mammaplasty
Introduction: Oncoplastic surgery has been widely developed during the last decade. The combination of a large tumor resection performed by the breast surgeon and the immediate breast reconstruction by the plastic surgeon has numerous advantages. This technique provides safer resection with larger margins and immediate aesthetic results. Materials & methods: During the last decade, we have used an algorithm in oncoplastic surgery: Small and moderate size breast tumors (T1e2) are considered the best indications for conserving breast surgery. Depending on the breast size and tumor/breast size relation, determinesthe reconstructive technique is used. A glandular flap, as a part of breast reduction techniques, was raised from the breast itself to fill defects after tumorectomy in large-size breast. However, contralateral breast reduction is necessary to achieve breast symmetry. In the case of smaller breast size, partial breast reconstruction is performed using pedicled flaps (LD or muscle sparing LD, TDAP, LICAP, SAAP) harvested from the back and/or the axillary region. Adequate symmetry is obtained without operating on the contralateral breast. Adjuvant radiotherapy can be started after 4e6 weeks postoperatively. Results: In total 119 patients, in whom bilateral breast remodeling techniques and pedicled flaps were used in 26 and 93 patients respectively. In three cases, margins were involved with the tumor. Wider excision was done in two patients. Total mastectomy was performed in the third patient. With an average follow-up of 4 years, further surgery was indicated in only three patients because of fat necrosis. Converting to total mastectomy with immediate breast reconstruction with a DIEAP flap was necessary in one patient at 2 years after the initial partial breast reconstruction with a TDAP because of major fat necrosis. Aesthetic results and patient satisfaction are promising, however, longer follow-up is still required to confirm our 4-year-follow-up outcome. Conclusion: Oncoplastic surgery offers a better cosmetic outcome as partial breast reconstruction, using various techniques, when performed during the same procedure. In partial breast reconstruction, therapeutic mammaplasty techniques offer creative options for large and pendulous breast. On the other hand, perforator flaps, which spare latissimus dorsi muscle function, provide valuable method for small size breasts. Ó 2013 Elsevier Ltd. All rights reserved.
Introduction Breast conservation surgery (BCT) is the excision of a breast cancer with a tumor-free margin followed by adjuvant breast irradiation [1e5]. This treatment modality has increased in popularity among women with early breast cancers as it is proven to be oncologically sound with survival rates similar to that of
* Plastic Surgery Department, Brussels University Hospital, UZBrussel, Laarbeeklaan 101, B-1090 Brussels, Belgium. Tel,: þ32 2 47762 51; fax: þ32 2 477 62 50. E-mail address: [email protected]. 0960-9776/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.breast.2013.07.019
mastectomy, with associated aesthetic and psychological benefits. However, patient selection is very important and a relative contraindication is a woman with a large tumor in a small breast, in whom the aesthetic outcome of breast conservation surgery is poor [6]. In these situation, a surgical dilemma in BCT arises. On the one hand,the surgeon needs a wider excision to provide clear margins and better local control of disease, but on the other hand the surgeon wants to spare as much tissue as possible for defect closure and to make the resulting aesthetic outcome as favourable as possible [6,7]. To overcome this, oncoplastic techniques which redistribute the remaining breast parenchyma via breast advancement flaps or breast reduction patterns were employed,
M. Hamdi / The Breast 22 (2013) S100eS105
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Materials and methods
on oncologic and clinical experience factors. As for any conservative breast therapy, tumors up to 3 cm in diameter are considered most safely for quadrantectomy associated with postoperative radiotherapy. Larger tumors are still treated with mastectomy as a first choice [10]. However, the introduction of more efficient protocols of neo-adjuvant chemotherapy may allow a more conservative local approach to advanced tumors [10,11]. Many surgeons have suggested incorporating a reduction mammaplasty-type procedure during tumor resection in large native breast [8,9,12e15]. One of the anatomical contraindications for re-arrangement breast surgery is a large tumor/breast ratio. Smaller breasts require different pedicled flap reconstruction [16e18].
Indications of oncoplastic surgery
Surgical techniques
The approach to breast cancer has become multidisciplinary in modern breast units. Indications of oncoplastic surgery are based
To determine which reconstructive option is best suited for the patient, the size and location of the expected tumor resection and
along with reduction/mastopexy of the contralateral breast for symmetry [8,9]. Patients with larger tumor to breast ratios were not considered suitable candidates for this procedure and were treated with total mastectomy with or without reconstruction. Pedicled flaps expands the indications of breast conservation surgery to include women with larger tumor to breast volume ratio than was previously possible, while maximising aesthetic outcome [8,9]. The purpose of the manuscript was to report a personal experience with oncoplastic surgery techniques (Figs. 1 and 2).
Fig. 1. A 53 year old patient who presented with 2.5 cm diamter ductal cancinoma in the superolateral quadrant of the right breast. As the patient has large and ptotic breast, an oncoplastic surgical procedure allows large tumor resection with immediate partial breast reconstruction. A wide resection through therapeutic mammaplasty incision lines was planned with bilateral breast remodelage using breast reduction technique with medial pedicle. a, b: Surgical marking of the bilateral breast remodelling. The tumor location was outlined with dotted lines. The reconstruction was planned using a medial pedicle carrying the nipple areola complex (NAC) with a glandular extension to fill up the defect. c. The tumor resection (weight 120 g) was done through the peri-areolar incision line. This allowed 2-cm free margins of the tumor. d. The medial pedicle carrying the NAC (arrow) with the glandular extension (2 arrows). Further resection of the gland was (250 g). e. Preoperative views. f. Postoperative views with the outcome at 3 years after radiotherapy.
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M. Hamdi / The Breast 22 (2013) S100eS105
Fig. 2. A 48 year old patient undergoing a quadrantectomy for a tumor of Ductal Carcinoma over the junction of the superior quadrants of the right breast. A pedicled TDAP flaps was planned to fill the defect. a: Preoperative views shows the tumor location. b: The TDAP flap, which measured 18 8 cm, was marked over the lateral thoracic skin. The perforators (red circled) were located using a unidirectional Doppler. c: The quadrantectomy (measured 8 7 cm) was performed d: A perioperative view shows the perforator dissection from the latissimus dorsi muscle which is completely spared. The flap was completely deepithelialized and transferred to the breast defect. The skin was closed primarily. e: The preoperative views. f: The outcome of the reconstruction and the donor site 18 months postoperatively.(For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
M. Hamdi / The Breast 22 (2013) S100eS105 Table 1 Shows the different pedicles for therapeutic mammaplsty depending on the location of the breast defect. Location of the defect
Choice of pedicle
Inferior, infero-medial or infero-lateral Superior
Superior, supero-medial or supero-lateral pedicle Inferior or centro-inferior pedicle or Lateral Supero-lateral pedicle with an infero-central component to fill the defect Supero-medial pedicle with an infero-central component to fill the defect Inferior pedicle
Supero-medial Supero-lateral Central
the ratio of breast volume to resection volume must be appreciated [8e18]. Displacement techniques A large native breast has historically been a moderate contraindication for BCT, due to increased rates of radio-toxicity, as the large breast requires higher doses of radiation therapy to reach a therapeutic range. Many surgeons have suggested incorporating a reduction mammaplasty-type procedure during tumor resection. Benefits include a more aesthetic appearing postoperative breast, concealing the tumor resection incision within the breast reduction pattern, and decreasing radiation doses due to decreased breast size. The pattern can be rotated laterally or medially to fit the location of the tumor. The choice of the pedicle is related to the tumor location (Table 1). Good knowledge of the blood supply of the breast is essential to design different potential pedicles to carry the NAC or to reconstruct the defect [8e10,13e15]. Other regions of tumor excision, not normally removed with reductions, can also be reconstructed using a combination of breast reduction and creation of a glandular flap to fill the oncologic defect [14,19]. A similar mammaplasty technique is performed on the contralateral breast to match the size and shape of the tumor-affected breast. However, it is preferred to end-up with a tumor-affected breast 10% larger in size compared to the
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contralateral remodeled breast because one should expect some shrinking and volume changes of the reconstructed breast due to irradiation. Replacement techniques One of the relative anatomical contraindications for rearrangement breast surgery is a large tumor/breast ratio. Smaller breasts require different methods of reconstruction. Depending on the location and the size of the breast defect, different flaps can be used for partial mastectomy reconstruction. Small lateral defects (10% of breast size) can be closed with local fascio-cutaneous flaps using the subaxillary area as a transposition or a rotation flap as it was first described by Clough et al. [20] and more recently by Munoz et al. [21]. For defects up to 30% breast volume, the latissimus dorsi musculocutaneous flap is a common local option for lateral, central, and even medial defects [16,22,23]. Pedicled perforator flaps replace volume by recruiting wellvascularised tissues from around the breast. As the underlying muscles are not sacrificed in the elevation of these perforator flaps, donor site morbidity in terms of muscle function and seroma is kept to a minimum [17,18,24e28]. Almost all post-quadrantectomy defects can be reconstructed with pedicled perforator flaps. However, depending on the pedicle length, some flaps are more suitable for certain defects. Defects located at the infero-medial quadrant of the breast are difficult to reach using a pedicled perforator flap (Table 2) raised on the thoracodorsal or intercostal vascular pedicle axes [24,26]. However, some defects can still be considered for reconstruction with pedicled flaps based on the anterior thoracic vessels such as the intercostal or superior epigastric vessels [18,28]. Timing of reconstruction Reconstruction of partial mastectomies can either include delayed, immediate or immediate delayed procedures [8,9,29,30]. In delayed reconstruction, at least 6 months to a year is allowed to elapse after the last radiation therapy session, in order to evaluate the deformities of the breast and plan the appropriate
Table 2 The classification of pedicled perforator flaps and their indications. Flap
Source vessel
Location of perforator
Muscle component
Reach
TDAP
Thoracodorsal artery (vertical branch)
Within 5 cm posterior to the anterior border of the LD, 8e13 cm caudal to the axillary crease
e
Lateral, central and supero-medial quadrants
MS-TD 1
Thoracodorsal artery (vertical branch)
MS-TD 2
Thoracodorsal artery (vertical branch)
Lateral, central and supero-medial quadrants All breast quadrants
LICAP
Intercostal artery, costal segment, anterior to the LD
4 2 cm LD muscle posterior to split in LD muscle 5 cm width of LD muscle from its anterior border e
AICAP
Intercostal artery, rectus segment
e
SAAP
Serratus Anterior branch (vascular connection to intercostal artery in 21%) Superior Epigastric Artery
Inferior and infero-medial quadrants Lateral and central quadrants
SEAP
Mean distance of 3.5 cm from the anterior border of the LD muscle in the 4e8 ICS Rectus/sheath
Same as LICAP
e
Rectus muscle/sheath caudal to costal margin to the first tendinous intersection
e
Lateral quadrants
Notes
Preserves TDAP/MS-TD/LD for future use
Only in 21%
Inferior, central and medial quadrants
TDAP, thoracodorsal artery perforator; MSTD, muscle-sparing thoracodorsal; LICAP, lateral intercostal artery perforator;, AICAP anterior intercostal artery perforator; SAAP, serratus anterior artery perforator; SEAP, superior epigastric artery perforator.
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M. Hamdi / The Breast 22 (2013) S100eS105
reconstruction modality. In immediate reconstruction, the goal is to perform co-instantaneously tumor resection with oncologically appropriate margins and partial breast reconstruction. Immediate breast reconstruction offers many advantages over delayed breast reconstruction, such as a better aesthetic outcome due to the preservation of the three-dimensional breast skin envelope. Immediate delayed partial breast reconstruction is actually a two stage immediate surgical approach with delayed reconstruction (within a few days) until the results of the pathology report are known and the margins of the tumor excision are determined as sufficient or must be re-excised to clear margins before reconstruction. The final aesthetic outcomes are similar to those with immediate reconstruction [8,9,29,30]. Outcome During the last decade, 119 patients underwent oncoplastic surgery. The breast tumor and axillary lymph node surgery were done by different oncological surgeons meanwhile the reconstruction was performed by the author. The average age of the patients was 48 year old (range 31e69 years). Bilateral breast remodeling (displacement techniques) and pedicled flaps (replacement techniques) were used in 26 and 93 patients respectively. In three cases (2.5%) margins were involved with the tumor: two cases after pedicled TDAP flap and 1 case after remodeling techniques. Wider excision was done in two cases and skin-sparing mastectomy was required in the third patient because of all margins were involved with the tumor. Postoperative complications were limited to wound healings (4%), infection (2%), and hematoma (2%). When pedicled flaps were used, seroma in the donor site was only found in six cases of MS TDAP II flaps (5.5%). None of the preforator flaps were complicated with seroma in the donor site. With an average follow-up of 4 years (range 6 months to 10 years), 7 flaps (6.3%) were complicated with palpable fat necrosis. Further surgeries were required in 3 patients. One patient had excision of the fat necrosis with primary closure. The other two patients required a wide excision and reconstruction with pedicled skin flaps, however, mastectomy was required in the second patient because of the extended fat necrosis, and a free DIEP flap was then used for the breast reconstruction. In the group of breast remodeling, one patient had fat necrosis excision (3.8%). Local recurrence was found in two patients (1.7%). Both of whom were treated with a mastectomy. Discussion The combination of a quadrantectomy with an immediate partial breast reconstruction has been considered a decisive stage in the evolution of breast cancer surgery. This combination, often called “oncoplastic surgery”, allows a wider resection of the tumor with safe margins [10]. Moreover, good aesthetic results can be achieved because of the advantage of immediate reconstruction with supple, malleable non-irradiated tissue [8,9]. In our previous study, we have shown that during oncoplastic procedures larger resections can be made. A mean weight of 127 g of breast tissue was excised during oncoplastic procedures, compared to 86 g of breast tissue during breast conservative treatment [31]. In our study, larger tumors were treated with oncoplastic surgery while more DCIS was noted in the oncoplastic group comparing to the BCT group. We have shown that using oncoplastic surgery techniques, larger glandular excisions can be made [31]. The presence of DCIS at the surgical margin is associated with the identification of residual DSIC in 40e82% of re-excised specimens and is correlated with margin widths of: 41% at 1 mm, 31% at 1e2 mm and 0% with 2 mm of clearance [32]. A recent meta-
analysis concluded that a margin width was significant superior to lesser margins [7]. Oncoplastic techniques allow extensive resections with actual partial mastectomy specimens of more than 230 g, compared with institutional norms of about 40e50 g with the nononcoplastic approach [6]. Kaur et al. have demonstrated an oncological benefit in a comparative study in which positive margins were identified in 16% of breast cancer patients who had the oncoplastic approach versus 43% in patients with quadrantectomy [33]. A recent meta-analysis was performed by Losken et al. [34] in PubMed using key words “oncoplastic,” “partial breast reconstruction,” and “breast conservation therapy.” The three comparative groups included BCT with oncoplastic reduction techniques (Group A), BCT with oncoplastic flap techniques (Group B), and BCT alone (Group C). Comparisons were made on 3165 patients in the BCT with oncoplastic group (Groups A and B, 41 papers) and 5494 patients in the BCT alone group (Group C, 20 papers). Demographics were similar, and tumor size was larger in the oncoplastic group (2.7 vs 1.2 cm). The weight of the lumpectomy specimen was 4 times larger in the oncoplastic group. The positive margin rate was significantly lower in the oncoplastic group (12% vs 21%). Reexcision was more common in the BCT alone group (14.6% vs 4%), however, completion mastectomy was more common in the oncoplastic group (6.5% vs 3.79%). The average follow-up was longer in the BCT alone group (64 vs 37 months). Local recurrence was 4% in the oncoplastic group and 7% in the BCT alone group. Satisfaction with the aesthetic outcome was significantly higher in the oncoplastic group (89.5% vs 82.9%). Incorporating a reduction mammoplasty with partial mastectomy can potentially be a complex procedure. Recent literature, however, suggests that early complications are similar to mere reduction mammaplasty .The aesthetic outcome was considered good or very good in 81% of patients [15]. In Spear et al. review, none of the complications significantly interfered with healing, radiation, chemotherapy or the quality of the result [13]. The ability to adequately screen for tumor recurrence following oncoplastic procedures is important. Given the additional parenchymal manipulation, scar tissue or fat necrosis is not uncommon and might be suspicious on mammogram, magnetic resonance imaging, or physical examination. Further tissue sampling is often necessary to rule out tumor recurrence (up to 25%) [35]. This is easily accomplished with fine needle aspiration, core biopsy, or excisional biopsy. The addition of breast remodeling procedures does not seem to affect mammographic sensitivity, and qualitative changes are similar to those found following breast conservation therapy alone [36,37]. Epidermal inclusion cysts or areas of fat necrosis are often seen clinically or mammographically following breast reduction that are diagnostically amenable to fine needle aspiration or core biopsy. Mammographic reading following repair of a partial mastectomy defect using the latissimusdorsi myocutaneous flap is not impaired [37]. However, the need for additional imaging modalities (i.e., ultrasound, magnetic resonance imaging) is common. Previous studies showed actuarial 5-year local recurrence rates after oncoplastic surgery range from 8.5 to 9.4 percent [6,33,38]. Most reviews in the literature are of intermediate follow-up (up to 4.5 years), with local recurrence rates varying from 0 to 1.8 percent per year [38]. Nevertheless, it is not clear whether a larger resection would result in a better patient survival than the standard tumorectomy in the standard breast conserving surgery. In another review of literature, a total of 88 articles were identified for potential inclusion and reviewed in detail by the lead authors [39]. No randomized controlled trials were identified. Only 11 prospective observational or comparative studies fulfilled inclusion criteria and were selected. In these studies, 80% to 93% of the tumors were
M. Hamdi / The Breast 22 (2013) S100eS105
invasive. Tumor-free resection margins were observed in 78e93%, resulting in a 3e16% mastectomy rate. Local recurrence was observed in 0e7% of the patients. Good cosmetic outcome was obtained in 84e89% of patients. However, most studies showed significant weaknesses including lack of robust design and important methodological shortcomings, negatively influencing generalizability. The authors emphasized the need to for robust comparative studies, including both randomized controlled trials and welldesigned, multicenter prospective longitudinal studies [39]. Conclusion Breast conservation therapy has a proven track record for treating breast cancer whilst preserving uninvolved breast tissue. Oncoplastic surgery is a new multidisciplinary approach to breast cancer. It is oncologically safe due to larger tumor resections. Larger and ill-defined tumors are also treated with safe oncologic resections. The true value on local recurrence remains to be determined. Patients are more satisfied with outcomes when the oncoplastic approach is used. Oncoplastic surgery offers a better cosmetic outcome as partial breast reconstruction, using various techniques, is performed during the same procedure. In partial breast reconstruction, therapeutic mammaplasty techniques offer creative option for large and pendulous breast. On the other hand, perforator flaps which spare latissimusdorsi muscle function, provide valuable method for small size breasts. Disclosure The author has nothing to disclose. Conflicts of interest statement None declared. References [1] Jakesz R, Samonigg H, Gnant M, et al. Significant increase in breast conservation in 16 years of trials conducted by the Austrian Breast and Colorectal Study Group. Ann Surg 2003;237:556e64. [2] Fisher B, Dignam J, Wolmark N, et al. Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project. J ClinOncol 1998;16:441e52. [3] Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med Oct 17, 2002;347(16):1227e32. [4] Schwartz GF, Birchansky CA, Komarnicky LT, et al. Induction chemotherapy followed by breast conservation for locally advanced carcinoma of the breast. Cancer 1994;73:362e9. [5] Doridot V, Nos C, Aucouturier JS, Sigal-Zafrani B, Fourquet A, Clough KB. Breast-conserving therapy of breast cancer. Cancer Radiother 2004;8:21e8. [6] Clough KB, Lewis JS, Couturand B, Fitoussi A, Nac S, Falcou MC. Oncoplastic techniques allow extensive resections for breast-conserving therapy of breast carcinomas. Ann Surg 2003;237:26e34. [7] Dillon MF, Hill AD, Quinn CM, et al. A pathologic assessment of adequate margin status in breast conserving therapy. Ann Surg Oncol 2006;13(3): 333e9. [8] Hamdi M, Wolfli J, Van Landuyt K. Partial mastectomy reconstruction. Clin Plast Surg 2007:51e62. [9] Losken A, Hamdi M. Partial breast reconstruction: current perspectives. Plast Reconstr Surg 2009;124(3):722e36. [10] Audretsh WP. Fundamentals of oncoplastic surgery. In: Losken, Hamdi, editors. Partial breast reconstruction: techniques in oncoplastic surgery. St. Luis, Missouri: Q.M.P. Inc.; 2009. p. 3e26.
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[11] Cance W, Garey L, Calvo B, et al. Long-term outcome of neoadjuvant therapy for locally advanced breast cancer. Ann Surg 2002;236:295e302. [12] Petit JY, Garusi C, Greuse M, et al. One hundred and eleven cases of breast conservation treatment with simultaneous reconstruction at the European Institute of Oncology (Milan). Tumori 2002 JaneFeb;88(1):41e7. [13] Spear LS, Pelletiere CV, et al. Experience with reduction mammaplasty combined with breast conservation therapy in the treatment of breast cancer. Plast Reconstr Surg 2003;111(3):1102e9. [14] Mcculley SJ, Macmillan RD. Therapeutic mammaplastydanalysis of 50 consecutive cases. Br J Plast Surg 2005;58(7):902e7. [15] Munhoz A, Montang E, et al. Critical analysis of reduction mammaplasty techniques in combination with conservation breast surgery for early breast cancer treatment. Plast Reconstr Surg 2006;117(4):1091e103. [16] Dixon JM, Venizelos B, Chan P. Latissimusdorsi mini-flap: a technique for extending breast conservation. Breast 2002 Feb;11(1):58e65. [17] Hamdi M, Van Landuyt K, Monstrey S, et al. Pedicled perforator flaps in breast reconstruction: a new concept. Br J Plast Surg 2004 Sep;57(6):531e9. [18] Hamdi M, Van Landuyt K, de Frene B, et al. The versatility of the inter-costal artery perforator (ICAP) flaps. J Plast Reconstr Aesthet Surg 2006;59(6):644e52. [19] Kronowitz SJ, Kuerer HM, Buchholz TA, Valero V, Hunt KK. A management algorithm and practical oncoplastic surgical techniques for repairing partial mastectomy defects. Plast Reconstr Surg 2008 Dec;122(6):1631e47. [20] Clough KB, Kroll SS, Audretsch W. An approach to the repair of partial mastectomy defects. Plast Reconstr Surg 1999;104:409. [21] Munhoz AM, Montag E, Arruda E, et al. The role of the lateral thoracodorsal fasciocutaneous flap in immediate conservative breast surgery reconstruction. Plast Reconstr Surg 2006;117:1699. [22] Rainsbury RM. Breast sparing reconstruction with latissimusdorsiminiflaps. Eur J Surg Oncol 2002;28:891e5. [23] Losken A, Schaefer T, et al. Immediate endoscopic latissimusdorsi flap: Risk or benefit in reconstructing partial mastectomy defects. Ann Plast Surg 2004;53: 1e5. [24] Hamdi M. Pedicled perforator flap reconstruction. In: Losken A, Hamdi M, editors. Partial breast reconstruction: techniques in oncoplastic surgery. St. Luis, Missouri: Q.M.P. Inc.; 2009. p. 387. [25] Hamdi M, Van Landuyt K, Hijjawi JB, et al. Surgical technique in pedicledthoracodorsal artery perforator flaps: a clinical experience with 99 patients. Plast Reconstr Surg May 2008;121(5):1632e41. [26] Hamdi M, Spano A, Van Landuyt K, et al. The lateral intercostal artery perforators: anatomical study and clinical application in breast surgery. Plast Reconstr Surg Feb 2008;121(2):389e96. [27] Hamdi M, Decorte T, Demuynck M, et al. Shoulder function after harvesting a thoracodorsal artery perforator flap. Plast Reconstr Surg Oct 2008;122(4): 1111e7. [28] Hamdi M, Van Landuyt K, Ulens S, et al. Clinical applications of the superior epigastric artery perforator (SEAP) flap: anatomical studies and preoperative perforator mapping with multidetector CT. J Plast Reconstr Aesthet Surg Sep 2009;62(9):1127e34. [29] Kronowitz SJ. Immediate versus delayed reconstruction. Clin Plast Surg Jan 2007;34(1):39e50. [30] Kronowitz SJ. Delayed-immediate breast reconstruction: technical and timing considerations. Plast Reconstr Surg 2010 Feb;125(2):463e74. [31] Hamdi M, Sinove Y, DePypere H, et al. The role of oncoplastic surgery in breast cancer. Acta Chir Belg 2008 NoveDec;108(6):666e72. [32] Patani N, Khaled Y, Al Reefy Mokbel K. Ductal carcinoma in-situ: an update for clinical practice. Surg Oncol 2011;20:e23e31. [33] Kaur N, Petit JY, Rietjens M, et al. Comparative study of surgical margins in oncoplastic surgery and quadrantectomy in breast cancer. Ann SurgOncol 2005;12:539e45. [34] Losken A, Dugal CS, Styblo TM, Carlson GW. Meta-analysis comparing breast conservation therapy alone to the oncoplastic technique. Ann Plast Surg 2013 Mar 13. [Epub ahead of print]. [35] Losken A, Schaefer TG, Newell M, Styblo TM. The impact of partial breast reconstruction using reduction techniques on postoperative cancer surveillance. Plast Reconstr Surg 2009;124(1):9e17. [36] Mendelson EB. Evaluation of the postoperative breast. Radiol Clin North Am 1992;30:107. [37] Monticciolo DL, Ross D, Bostwick III J, Eaves F, Styblo T. Autologous breast reconstruction with endoscopic latissimusdorsi musculosubcutaneous flaps in patients choosing breast conserving therapy: mammographic appearance. Am J Roentgenol 1997;167:385e9. [38] Asgeursson KS, Rasheed T, McCulley SJ, Macmillan RD. Oncological and cosmetic outcomes of oncoplastic breast conserving surgery. Eur J Surg Oncol 2005;31:817e23. [39] Haloua MH, Krekel NM, Winters HA, et al. A systematic review of oncoplastic breast-conserving surgery: current weaknesses and future prospects. Ann Surg 2013 Apr;257(4):609e20.
Contents lists available at SciVerse ScienceDirect
The Breast journal homepage: www.elsevier.com/brst
Original article
Oncoplastic and reconstructive surgery of the breast Moustapha Hamdi, MD, PhD a, b, * a b
Department of Plastic & Reconstructive Surgery, Brussels University Hospital, UZBrussel, Laarbeeklaan 101, B-1090 Brussels, Belgium Free University of Brussels, Brussels, Belgium
a b s t r a c t Keywords: Oncoplastic surgery Pedicled perforator flaps Theapeutic mammaplasty
Introduction: Oncoplastic surgery has been widely developed during the last decade. The combination of a large tumor resection performed by the breast surgeon and the immediate breast reconstruction by the plastic surgeon has numerous advantages. This technique provides safer resection with larger margins and immediate aesthetic results. Materials & methods: During the last decade, we have used an algorithm in oncoplastic surgery: Small and moderate size breast tumors (T1e2) are considered the best indications for conserving breast surgery. Depending on the breast size and tumor/breast size relation, determinesthe reconstructive technique is used. A glandular flap, as a part of breast reduction techniques, was raised from the breast itself to fill defects after tumorectomy in large-size breast. However, contralateral breast reduction is necessary to achieve breast symmetry. In the case of smaller breast size, partial breast reconstruction is performed using pedicled flaps (LD or muscle sparing LD, TDAP, LICAP, SAAP) harvested from the back and/or the axillary region. Adequate symmetry is obtained without operating on the contralateral breast. Adjuvant radiotherapy can be started after 4e6 weeks postoperatively. Results: In total 119 patients, in whom bilateral breast remodeling techniques and pedicled flaps were used in 26 and 93 patients respectively. In three cases, margins were involved with the tumor. Wider excision was done in two patients. Total mastectomy was performed in the third patient. With an average follow-up of 4 years, further surgery was indicated in only three patients because of fat necrosis. Converting to total mastectomy with immediate breast reconstruction with a DIEAP flap was necessary in one patient at 2 years after the initial partial breast reconstruction with a TDAP because of major fat necrosis. Aesthetic results and patient satisfaction are promising, however, longer follow-up is still required to confirm our 4-year-follow-up outcome. Conclusion: Oncoplastic surgery offers a better cosmetic outcome as partial breast reconstruction, using various techniques, when performed during the same procedure. In partial breast reconstruction, therapeutic mammaplasty techniques offer creative options for large and pendulous breast. On the other hand, perforator flaps, which spare latissimus dorsi muscle function, provide valuable method for small size breasts. Ó 2013 Elsevier Ltd. All rights reserved.
Introduction Breast conservation surgery (BCT) is the excision of a breast cancer with a tumor-free margin followed by adjuvant breast irradiation [1e5]. This treatment modality has increased in popularity among women with early breast cancers as it is proven to be oncologically sound with survival rates similar to that of
* Plastic Surgery Department, Brussels University Hospital, UZBrussel, Laarbeeklaan 101, B-1090 Brussels, Belgium. Tel,: þ32 2 47762 51; fax: þ32 2 477 62 50. E-mail address: [email protected]. 0960-9776/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.breast.2013.07.019
mastectomy, with associated aesthetic and psychological benefits. However, patient selection is very important and a relative contraindication is a woman with a large tumor in a small breast, in whom the aesthetic outcome of breast conservation surgery is poor [6]. In these situation, a surgical dilemma in BCT arises. On the one hand,the surgeon needs a wider excision to provide clear margins and better local control of disease, but on the other hand the surgeon wants to spare as much tissue as possible for defect closure and to make the resulting aesthetic outcome as favourable as possible [6,7]. To overcome this, oncoplastic techniques which redistribute the remaining breast parenchyma via breast advancement flaps or breast reduction patterns were employed,
M. Hamdi / The Breast 22 (2013) S100eS105
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Materials and methods
on oncologic and clinical experience factors. As for any conservative breast therapy, tumors up to 3 cm in diameter are considered most safely for quadrantectomy associated with postoperative radiotherapy. Larger tumors are still treated with mastectomy as a first choice [10]. However, the introduction of more efficient protocols of neo-adjuvant chemotherapy may allow a more conservative local approach to advanced tumors [10,11]. Many surgeons have suggested incorporating a reduction mammaplasty-type procedure during tumor resection in large native breast [8,9,12e15]. One of the anatomical contraindications for re-arrangement breast surgery is a large tumor/breast ratio. Smaller breasts require different pedicled flap reconstruction [16e18].
Indications of oncoplastic surgery
Surgical techniques
The approach to breast cancer has become multidisciplinary in modern breast units. Indications of oncoplastic surgery are based
To determine which reconstructive option is best suited for the patient, the size and location of the expected tumor resection and
along with reduction/mastopexy of the contralateral breast for symmetry [8,9]. Patients with larger tumor to breast ratios were not considered suitable candidates for this procedure and were treated with total mastectomy with or without reconstruction. Pedicled flaps expands the indications of breast conservation surgery to include women with larger tumor to breast volume ratio than was previously possible, while maximising aesthetic outcome [8,9]. The purpose of the manuscript was to report a personal experience with oncoplastic surgery techniques (Figs. 1 and 2).
Fig. 1. A 53 year old patient who presented with 2.5 cm diamter ductal cancinoma in the superolateral quadrant of the right breast. As the patient has large and ptotic breast, an oncoplastic surgical procedure allows large tumor resection with immediate partial breast reconstruction. A wide resection through therapeutic mammaplasty incision lines was planned with bilateral breast remodelage using breast reduction technique with medial pedicle. a, b: Surgical marking of the bilateral breast remodelling. The tumor location was outlined with dotted lines. The reconstruction was planned using a medial pedicle carrying the nipple areola complex (NAC) with a glandular extension to fill up the defect. c. The tumor resection (weight 120 g) was done through the peri-areolar incision line. This allowed 2-cm free margins of the tumor. d. The medial pedicle carrying the NAC (arrow) with the glandular extension (2 arrows). Further resection of the gland was (250 g). e. Preoperative views. f. Postoperative views with the outcome at 3 years after radiotherapy.
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Fig. 2. A 48 year old patient undergoing a quadrantectomy for a tumor of Ductal Carcinoma over the junction of the superior quadrants of the right breast. A pedicled TDAP flaps was planned to fill the defect. a: Preoperative views shows the tumor location. b: The TDAP flap, which measured 18 8 cm, was marked over the lateral thoracic skin. The perforators (red circled) were located using a unidirectional Doppler. c: The quadrantectomy (measured 8 7 cm) was performed d: A perioperative view shows the perforator dissection from the latissimus dorsi muscle which is completely spared. The flap was completely deepithelialized and transferred to the breast defect. The skin was closed primarily. e: The preoperative views. f: The outcome of the reconstruction and the donor site 18 months postoperatively.(For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
M. Hamdi / The Breast 22 (2013) S100eS105 Table 1 Shows the different pedicles for therapeutic mammaplsty depending on the location of the breast defect. Location of the defect
Choice of pedicle
Inferior, infero-medial or infero-lateral Superior
Superior, supero-medial or supero-lateral pedicle Inferior or centro-inferior pedicle or Lateral Supero-lateral pedicle with an infero-central component to fill the defect Supero-medial pedicle with an infero-central component to fill the defect Inferior pedicle
Supero-medial Supero-lateral Central
the ratio of breast volume to resection volume must be appreciated [8e18]. Displacement techniques A large native breast has historically been a moderate contraindication for BCT, due to increased rates of radio-toxicity, as the large breast requires higher doses of radiation therapy to reach a therapeutic range. Many surgeons have suggested incorporating a reduction mammaplasty-type procedure during tumor resection. Benefits include a more aesthetic appearing postoperative breast, concealing the tumor resection incision within the breast reduction pattern, and decreasing radiation doses due to decreased breast size. The pattern can be rotated laterally or medially to fit the location of the tumor. The choice of the pedicle is related to the tumor location (Table 1). Good knowledge of the blood supply of the breast is essential to design different potential pedicles to carry the NAC or to reconstruct the defect [8e10,13e15]. Other regions of tumor excision, not normally removed with reductions, can also be reconstructed using a combination of breast reduction and creation of a glandular flap to fill the oncologic defect [14,19]. A similar mammaplasty technique is performed on the contralateral breast to match the size and shape of the tumor-affected breast. However, it is preferred to end-up with a tumor-affected breast 10% larger in size compared to the
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contralateral remodeled breast because one should expect some shrinking and volume changes of the reconstructed breast due to irradiation. Replacement techniques One of the relative anatomical contraindications for rearrangement breast surgery is a large tumor/breast ratio. Smaller breasts require different methods of reconstruction. Depending on the location and the size of the breast defect, different flaps can be used for partial mastectomy reconstruction. Small lateral defects (10% of breast size) can be closed with local fascio-cutaneous flaps using the subaxillary area as a transposition or a rotation flap as it was first described by Clough et al. [20] and more recently by Munoz et al. [21]. For defects up to 30% breast volume, the latissimus dorsi musculocutaneous flap is a common local option for lateral, central, and even medial defects [16,22,23]. Pedicled perforator flaps replace volume by recruiting wellvascularised tissues from around the breast. As the underlying muscles are not sacrificed in the elevation of these perforator flaps, donor site morbidity in terms of muscle function and seroma is kept to a minimum [17,18,24e28]. Almost all post-quadrantectomy defects can be reconstructed with pedicled perforator flaps. However, depending on the pedicle length, some flaps are more suitable for certain defects. Defects located at the infero-medial quadrant of the breast are difficult to reach using a pedicled perforator flap (Table 2) raised on the thoracodorsal or intercostal vascular pedicle axes [24,26]. However, some defects can still be considered for reconstruction with pedicled flaps based on the anterior thoracic vessels such as the intercostal or superior epigastric vessels [18,28]. Timing of reconstruction Reconstruction of partial mastectomies can either include delayed, immediate or immediate delayed procedures [8,9,29,30]. In delayed reconstruction, at least 6 months to a year is allowed to elapse after the last radiation therapy session, in order to evaluate the deformities of the breast and plan the appropriate
Table 2 The classification of pedicled perforator flaps and their indications. Flap
Source vessel
Location of perforator
Muscle component
Reach
TDAP
Thoracodorsal artery (vertical branch)
Within 5 cm posterior to the anterior border of the LD, 8e13 cm caudal to the axillary crease
e
Lateral, central and supero-medial quadrants
MS-TD 1
Thoracodorsal artery (vertical branch)
MS-TD 2
Thoracodorsal artery (vertical branch)
Lateral, central and supero-medial quadrants All breast quadrants
LICAP
Intercostal artery, costal segment, anterior to the LD
4 2 cm LD muscle posterior to split in LD muscle 5 cm width of LD muscle from its anterior border e
AICAP
Intercostal artery, rectus segment
e
SAAP
Serratus Anterior branch (vascular connection to intercostal artery in 21%) Superior Epigastric Artery
Inferior and infero-medial quadrants Lateral and central quadrants
SEAP
Mean distance of 3.5 cm from the anterior border of the LD muscle in the 4e8 ICS Rectus/sheath
Same as LICAP
e
Rectus muscle/sheath caudal to costal margin to the first tendinous intersection
e
Lateral quadrants
Notes
Preserves TDAP/MS-TD/LD for future use
Only in 21%
Inferior, central and medial quadrants
TDAP, thoracodorsal artery perforator; MSTD, muscle-sparing thoracodorsal; LICAP, lateral intercostal artery perforator;, AICAP anterior intercostal artery perforator; SAAP, serratus anterior artery perforator; SEAP, superior epigastric artery perforator.
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reconstruction modality. In immediate reconstruction, the goal is to perform co-instantaneously tumor resection with oncologically appropriate margins and partial breast reconstruction. Immediate breast reconstruction offers many advantages over delayed breast reconstruction, such as a better aesthetic outcome due to the preservation of the three-dimensional breast skin envelope. Immediate delayed partial breast reconstruction is actually a two stage immediate surgical approach with delayed reconstruction (within a few days) until the results of the pathology report are known and the margins of the tumor excision are determined as sufficient or must be re-excised to clear margins before reconstruction. The final aesthetic outcomes are similar to those with immediate reconstruction [8,9,29,30]. Outcome During the last decade, 119 patients underwent oncoplastic surgery. The breast tumor and axillary lymph node surgery were done by different oncological surgeons meanwhile the reconstruction was performed by the author. The average age of the patients was 48 year old (range 31e69 years). Bilateral breast remodeling (displacement techniques) and pedicled flaps (replacement techniques) were used in 26 and 93 patients respectively. In three cases (2.5%) margins were involved with the tumor: two cases after pedicled TDAP flap and 1 case after remodeling techniques. Wider excision was done in two cases and skin-sparing mastectomy was required in the third patient because of all margins were involved with the tumor. Postoperative complications were limited to wound healings (4%), infection (2%), and hematoma (2%). When pedicled flaps were used, seroma in the donor site was only found in six cases of MS TDAP II flaps (5.5%). None of the preforator flaps were complicated with seroma in the donor site. With an average follow-up of 4 years (range 6 months to 10 years), 7 flaps (6.3%) were complicated with palpable fat necrosis. Further surgeries were required in 3 patients. One patient had excision of the fat necrosis with primary closure. The other two patients required a wide excision and reconstruction with pedicled skin flaps, however, mastectomy was required in the second patient because of the extended fat necrosis, and a free DIEP flap was then used for the breast reconstruction. In the group of breast remodeling, one patient had fat necrosis excision (3.8%). Local recurrence was found in two patients (1.7%). Both of whom were treated with a mastectomy. Discussion The combination of a quadrantectomy with an immediate partial breast reconstruction has been considered a decisive stage in the evolution of breast cancer surgery. This combination, often called “oncoplastic surgery”, allows a wider resection of the tumor with safe margins [10]. Moreover, good aesthetic results can be achieved because of the advantage of immediate reconstruction with supple, malleable non-irradiated tissue [8,9]. In our previous study, we have shown that during oncoplastic procedures larger resections can be made. A mean weight of 127 g of breast tissue was excised during oncoplastic procedures, compared to 86 g of breast tissue during breast conservative treatment [31]. In our study, larger tumors were treated with oncoplastic surgery while more DCIS was noted in the oncoplastic group comparing to the BCT group. We have shown that using oncoplastic surgery techniques, larger glandular excisions can be made [31]. The presence of DCIS at the surgical margin is associated with the identification of residual DSIC in 40e82% of re-excised specimens and is correlated with margin widths of: 41% at 1 mm, 31% at 1e2 mm and 0% with 2 mm of clearance [32]. A recent meta-
analysis concluded that a margin width was significant superior to lesser margins [7]. Oncoplastic techniques allow extensive resections with actual partial mastectomy specimens of more than 230 g, compared with institutional norms of about 40e50 g with the nononcoplastic approach [6]. Kaur et al. have demonstrated an oncological benefit in a comparative study in which positive margins were identified in 16% of breast cancer patients who had the oncoplastic approach versus 43% in patients with quadrantectomy [33]. A recent meta-analysis was performed by Losken et al. [34] in PubMed using key words “oncoplastic,” “partial breast reconstruction,” and “breast conservation therapy.” The three comparative groups included BCT with oncoplastic reduction techniques (Group A), BCT with oncoplastic flap techniques (Group B), and BCT alone (Group C). Comparisons were made on 3165 patients in the BCT with oncoplastic group (Groups A and B, 41 papers) and 5494 patients in the BCT alone group (Group C, 20 papers). Demographics were similar, and tumor size was larger in the oncoplastic group (2.7 vs 1.2 cm). The weight of the lumpectomy specimen was 4 times larger in the oncoplastic group. The positive margin rate was significantly lower in the oncoplastic group (12% vs 21%). Reexcision was more common in the BCT alone group (14.6% vs 4%), however, completion mastectomy was more common in the oncoplastic group (6.5% vs 3.79%). The average follow-up was longer in the BCT alone group (64 vs 37 months). Local recurrence was 4% in the oncoplastic group and 7% in the BCT alone group. Satisfaction with the aesthetic outcome was significantly higher in the oncoplastic group (89.5% vs 82.9%). Incorporating a reduction mammoplasty with partial mastectomy can potentially be a complex procedure. Recent literature, however, suggests that early complications are similar to mere reduction mammaplasty .The aesthetic outcome was considered good or very good in 81% of patients [15]. In Spear et al. review, none of the complications significantly interfered with healing, radiation, chemotherapy or the quality of the result [13]. The ability to adequately screen for tumor recurrence following oncoplastic procedures is important. Given the additional parenchymal manipulation, scar tissue or fat necrosis is not uncommon and might be suspicious on mammogram, magnetic resonance imaging, or physical examination. Further tissue sampling is often necessary to rule out tumor recurrence (up to 25%) [35]. This is easily accomplished with fine needle aspiration, core biopsy, or excisional biopsy. The addition of breast remodeling procedures does not seem to affect mammographic sensitivity, and qualitative changes are similar to those found following breast conservation therapy alone [36,37]. Epidermal inclusion cysts or areas of fat necrosis are often seen clinically or mammographically following breast reduction that are diagnostically amenable to fine needle aspiration or core biopsy. Mammographic reading following repair of a partial mastectomy defect using the latissimusdorsi myocutaneous flap is not impaired [37]. However, the need for additional imaging modalities (i.e., ultrasound, magnetic resonance imaging) is common. Previous studies showed actuarial 5-year local recurrence rates after oncoplastic surgery range from 8.5 to 9.4 percent [6,33,38]. Most reviews in the literature are of intermediate follow-up (up to 4.5 years), with local recurrence rates varying from 0 to 1.8 percent per year [38]. Nevertheless, it is not clear whether a larger resection would result in a better patient survival than the standard tumorectomy in the standard breast conserving surgery. In another review of literature, a total of 88 articles were identified for potential inclusion and reviewed in detail by the lead authors [39]. No randomized controlled trials were identified. Only 11 prospective observational or comparative studies fulfilled inclusion criteria and were selected. In these studies, 80% to 93% of the tumors were
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invasive. Tumor-free resection margins were observed in 78e93%, resulting in a 3e16% mastectomy rate. Local recurrence was observed in 0e7% of the patients. Good cosmetic outcome was obtained in 84e89% of patients. However, most studies showed significant weaknesses including lack of robust design and important methodological shortcomings, negatively influencing generalizability. The authors emphasized the need to for robust comparative studies, including both randomized controlled trials and welldesigned, multicenter prospective longitudinal studies [39]. Conclusion Breast conservation therapy has a proven track record for treating breast cancer whilst preserving uninvolved breast tissue. Oncoplastic surgery is a new multidisciplinary approach to breast cancer. It is oncologically safe due to larger tumor resections. Larger and ill-defined tumors are also treated with safe oncologic resections. The true value on local recurrence remains to be determined. Patients are more satisfied with outcomes when the oncoplastic approach is used. Oncoplastic surgery offers a better cosmetic outcome as partial breast reconstruction, using various techniques, is performed during the same procedure. In partial breast reconstruction, therapeutic mammaplasty techniques offer creative option for large and pendulous breast. On the other hand, perforator flaps which spare latissimusdorsi muscle function, provide valuable method for small size breasts. Disclosure The author has nothing to disclose. Conflicts of interest statement None declared. References [1] Jakesz R, Samonigg H, Gnant M, et al. Significant increase in breast conservation in 16 years of trials conducted by the Austrian Breast and Colorectal Study Group. Ann Surg 2003;237:556e64. [2] Fisher B, Dignam J, Wolmark N, et al. Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project. J ClinOncol 1998;16:441e52. [3] Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med Oct 17, 2002;347(16):1227e32. [4] Schwartz GF, Birchansky CA, Komarnicky LT, et al. Induction chemotherapy followed by breast conservation for locally advanced carcinoma of the breast. Cancer 1994;73:362e9. [5] Doridot V, Nos C, Aucouturier JS, Sigal-Zafrani B, Fourquet A, Clough KB. Breast-conserving therapy of breast cancer. Cancer Radiother 2004;8:21e8. [6] Clough KB, Lewis JS, Couturand B, Fitoussi A, Nac S, Falcou MC. Oncoplastic techniques allow extensive resections for breast-conserving therapy of breast carcinomas. Ann Surg 2003;237:26e34. [7] Dillon MF, Hill AD, Quinn CM, et al. A pathologic assessment of adequate margin status in breast conserving therapy. Ann Surg Oncol 2006;13(3): 333e9. [8] Hamdi M, Wolfli J, Van Landuyt K. Partial mastectomy reconstruction. Clin Plast Surg 2007:51e62. [9] Losken A, Hamdi M. Partial breast reconstruction: current perspectives. Plast Reconstr Surg 2009;124(3):722e36. [10] Audretsh WP. Fundamentals of oncoplastic surgery. In: Losken, Hamdi, editors. Partial breast reconstruction: techniques in oncoplastic surgery. St. Luis, Missouri: Q.M.P. Inc.; 2009. p. 3e26.
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[11] Cance W, Garey L, Calvo B, et al. Long-term outcome of neoadjuvant therapy for locally advanced breast cancer. Ann Surg 2002;236:295e302. [12] Petit JY, Garusi C, Greuse M, et al. One hundred and eleven cases of breast conservation treatment with simultaneous reconstruction at the European Institute of Oncology (Milan). Tumori 2002 JaneFeb;88(1):41e7. [13] Spear LS, Pelletiere CV, et al. Experience with reduction mammaplasty combined with breast conservation therapy in the treatment of breast cancer. Plast Reconstr Surg 2003;111(3):1102e9. [14] Mcculley SJ, Macmillan RD. Therapeutic mammaplastydanalysis of 50 consecutive cases. Br J Plast Surg 2005;58(7):902e7. [15] Munhoz A, Montang E, et al. Critical analysis of reduction mammaplasty techniques in combination with conservation breast surgery for early breast cancer treatment. Plast Reconstr Surg 2006;117(4):1091e103. [16] Dixon JM, Venizelos B, Chan P. Latissimusdorsi mini-flap: a technique for extending breast conservation. Breast 2002 Feb;11(1):58e65. [17] Hamdi M, Van Landuyt K, Monstrey S, et al. Pedicled perforator flaps in breast reconstruction: a new concept. Br J Plast Surg 2004 Sep;57(6):531e9. [18] Hamdi M, Van Landuyt K, de Frene B, et al. The versatility of the inter-costal artery perforator (ICAP) flaps. J Plast Reconstr Aesthet Surg 2006;59(6):644e52. [19] Kronowitz SJ, Kuerer HM, Buchholz TA, Valero V, Hunt KK. A management algorithm and practical oncoplastic surgical techniques for repairing partial mastectomy defects. Plast Reconstr Surg 2008 Dec;122(6):1631e47. [20] Clough KB, Kroll SS, Audretsch W. An approach to the repair of partial mastectomy defects. Plast Reconstr Surg 1999;104:409. [21] Munhoz AM, Montag E, Arruda E, et al. The role of the lateral thoracodorsal fasciocutaneous flap in immediate conservative breast surgery reconstruction. Plast Reconstr Surg 2006;117:1699. [22] Rainsbury RM. Breast sparing reconstruction with latissimusdorsiminiflaps. Eur J Surg Oncol 2002;28:891e5. [23] Losken A, Schaefer T, et al. Immediate endoscopic latissimusdorsi flap: Risk or benefit in reconstructing partial mastectomy defects. Ann Plast Surg 2004;53: 1e5. [24] Hamdi M. Pedicled perforator flap reconstruction. In: Losken A, Hamdi M, editors. Partial breast reconstruction: techniques in oncoplastic surgery. St. Luis, Missouri: Q.M.P. Inc.; 2009. p. 387. [25] Hamdi M, Van Landuyt K, Hijjawi JB, et al. Surgical technique in pedicledthoracodorsal artery perforator flaps: a clinical experience with 99 patients. Plast Reconstr Surg May 2008;121(5):1632e41. [26] Hamdi M, Spano A, Van Landuyt K, et al. The lateral intercostal artery perforators: anatomical study and clinical application in breast surgery. Plast Reconstr Surg Feb 2008;121(2):389e96. [27] Hamdi M, Decorte T, Demuynck M, et al. Shoulder function after harvesting a thoracodorsal artery perforator flap. Plast Reconstr Surg Oct 2008;122(4): 1111e7. [28] Hamdi M, Van Landuyt K, Ulens S, et al. Clinical applications of the superior epigastric artery perforator (SEAP) flap: anatomical studies and preoperative perforator mapping with multidetector CT. J Plast Reconstr Aesthet Surg Sep 2009;62(9):1127e34. [29] Kronowitz SJ. Immediate versus delayed reconstruction. Clin Plast Surg Jan 2007;34(1):39e50. [30] Kronowitz SJ. Delayed-immediate breast reconstruction: technical and timing considerations. Plast Reconstr Surg 2010 Feb;125(2):463e74. [31] Hamdi M, Sinove Y, DePypere H, et al. The role of oncoplastic surgery in breast cancer. Acta Chir Belg 2008 NoveDec;108(6):666e72. [32] Patani N, Khaled Y, Al Reefy Mokbel K. Ductal carcinoma in-situ: an update for clinical practice. Surg Oncol 2011;20:e23e31. [33] Kaur N, Petit JY, Rietjens M, et al. Comparative study of surgical margins in oncoplastic surgery and quadrantectomy in breast cancer. Ann SurgOncol 2005;12:539e45. [34] Losken A, Dugal CS, Styblo TM, Carlson GW. Meta-analysis comparing breast conservation therapy alone to the oncoplastic technique. Ann Plast Surg 2013 Mar 13. [Epub ahead of print]. [35] Losken A, Schaefer TG, Newell M, Styblo TM. The impact of partial breast reconstruction using reduction techniques on postoperative cancer surveillance. Plast Reconstr Surg 2009;124(1):9e17. [36] Mendelson EB. Evaluation of the postoperative breast. Radiol Clin North Am 1992;30:107. [37] Monticciolo DL, Ross D, Bostwick III J, Eaves F, Styblo T. Autologous breast reconstruction with endoscopic latissimusdorsi musculosubcutaneous flaps in patients choosing breast conserving therapy: mammographic appearance. Am J Roentgenol 1997;167:385e9. [38] Asgeursson KS, Rasheed T, McCulley SJ, Macmillan RD. Oncological and cosmetic outcomes of oncoplastic breast conserving surgery. Eur J Surg Oncol 2005;31:817e23. [39] Haloua MH, Krekel NM, Winters HA, et al. A systematic review of oncoplastic breast-conserving surgery: current weaknesses and future prospects. Ann Surg 2013 Apr;257(4):609e20.