Breast reshaping can be difficult to do when breast cancer is treated with conservative surgery. When less than 20-30% of the breast is removed with minimal ptosis, Level 1 oncoplastic surgery (OPS) techniques, such as advancement or rotation of glandular flaps, are recommended.
The extensive undermining of the epidermis and nipple-areolar complex results in a large, symmetrical, centro-lateral glandular flap that is turned into a hollow. This rotation glandular flap is a new technique that can be used after a wide excision in glandular breasts, not fatty breasts, and when the standard way of closing the hole would not look good.
When less than 20% of the breast volume will be removed, Level I OBS is carried out. In this surgery, the defect is repaired using tissue displacement procedures, and the nipple-areola complex (NAC) may need to be realigned if necessary. Level II methods are needed for the 20%–50% of breast volume that needs to be removed.
Therefore, smaller flaws are filled by local tissue displacement and glandular reshaping (such as round-block, omega, vertical, radial, V-, J-, and L-type incisions). 4, 13 The proper oncoplastic method will also be determined by the size and location of the tumour, as well as the ptosis and breast size. For instance, an oncoplastic tumorectomy is advised for medium to large tumours in a peripheral region of a small or medium breast.
But the current range of OBS techniques leaves surgeons with two big problems. The first one has to do with tumours in certain parts of the breast, like the upper inner quadrant (UIQ). When the resection zone is farther from the NAC, this problem will get worse.
This means that removing tumours close to where the sternum meets the clavicle, where there is less breast tissue and where the surgeon should try to avoid making incisions, is one of the hardest parts of Breast-Conserving Surgery. The size of the breasts is the other problem. Smaller breasts are harder to work with. When these things happen, you can’t use techniques where the NAC is moved or the skin is cut away.
The technique described here was first made for tumours in the upper inner quadrant, but it can be used for tumours in any quadrant. It is done when it is not possible to close the hole by bringing the edges of the resection together or when doing so would leave a deformity.
This technique involves a lot of undermining of the gland, so it should only be used on people with glandular breasts to reduce the risk of necrosis of the fat after surgery. Both clinically and with x-rays, this should be checked before surgery. Mammography done before surgery can tell how dense the breast is. A BIRADS 3 or 4 (heterogeneously dense or very dense) is necessary. This method is not good for people who are likely to get glandular necrosis, like those with fatty breasts, diabetes, who smoke, or who have had radiation therapy.
A breast tissue resection was performed using an elliptical breast tissue incision. The ellipse of tissue resection must cross the skin incision at a straight angle, hence the term “Cross.” Then, a typical lumpectomy was performed from the subcutaneous region to the prepectoral fascia. To maintain clean margins, the excision of the tumour should be conducted precisely. The resection site (elliptical tissue defect) was repaired radially, followed by the implantation of clips for more precise tumour site localization prior to radiation therapy.
After repairing the breast tissue defect, it is preferable, but not required, to install a closed suction draining system. The treatment concluded with the subcutaneous tissue and skin being sutured together. Depending on the preoperative strategy, intraoperative findings, and the multidisciplinary team’s choice, axillary surgery (axillary lymph node dissection or sentinel lymph node biopsy) may be conducted via a different incision.
This rotating glandular flap makes it possible to safely transfer the central gland into the defect that was created by a large local excision in the upper inner quadrant. It broadens the application of Level I OPS and makes it possible to safely repair larger faults while maintaining their cosmetic integrity.
All breast surgeons should be able to conduct this procedure, as it is based on regular surgical techniques, and does not require any additional training in plastic surgery.
Dr. Mansi Chowhan is an outstanding surgical oncologist with over a decade of experience in the medical field. She was awarded a gold medal in appreciation of her outstanding performance while studying for post-graduate education. She is extensively trained from world-renowned institutions like MSKCC, New York and Paris Breast Centre. Dr. Mansi specialises in breast oncoplastic surgery, head and neck surgery, and reconstructive procedures.
About
Dr. Mansi Chowhan
Oncoplastic Breast Surgeon-Surgical Oncologist
MS (Gold Medalist), FIAGES, MCh Breast Oncoplasty (UK), Fellow Breast Surgery (Paris), Fellow Head & Neck Surgery, IFHNOS – MSKCC (New York)
Dr. Mansi Chowhan is an expert Oncoplastic Breast Surgeon with experience of more than 14 years and has been awarded with a gold medal during her surgical post-graduation. Dr. Mansi is well-trained from world renowned surgeons and cancer institutions like the Paris Breast Centre, Memorial Sloan Kettering Cancer Centre (New York), University of East Anglia (U.K.) and Tata Memorial Hospital, Mumbai. She is a skilled surgeon with over 14 years of experience in some of the best hospitals in the Delhi- NCR region including Fortis Hospital, Artemis Hospital, Paras Hospital and Asian Institute of Medical Sciences, CK Birla Hospital. She works with utmost dedication and compassion to deliver international standard and personalized cancer care to the patients.
Copyright © 2023, The Onco Clinic (A Unit of Avid Oncology Pvt. Ltd.) All Rights Reserved.