The optimal margin for both wide local excision/lumpectomy and skin-sparing mastectomy remains undefined. Nahabedian1 suggests that a lumpectomy generally requires a 2-mm margin around the tumor whereas a mastectomy requires a much larger margin, often exceeding 1 cm.
In patients undergoing oncoplastic breast surgery, if the tumor is deeply situated within the breast parenchyma or arises in the lower pole of the breast, wide local excision is achieved using the inverted-T breast reduction pattern. In this scenario, an oncologically adequate tumor margin is achieved.
However, what if the tumor is not in the lower pole of the breast and is situated more superficially (close to or adherent to skin)? In this situation, excision of the overlying skin is required to attain a satisfactory tumor clearance. If the tumor is situated in the lateral aspect of the breast and also close to the skin, the tumor can still be excised with an adequate margin, including the overlying skin, by modifying the keyhole pattern.2 The pedicle used depends on the size and site of the tumor and the size of the breast.2 In tumors situated superficially in the medial pole of the breast, the pattern can also be modified using the same principles.
A 39-year-old woman was referred for oncoplastic breast surgery with a T1N0 carcinoma of the breast. The lump was situated close to the skin (a skin dimple was present), and the oncologic surgeon required that the overlying skin be excised to attain adequate tumor clearance. The notch-to-nipple distance was 26.5 cm bilaterally, and the distance from the nipple to the inframammary fold was 10 cm on the right and 8.5 cm on the left.
The modified pattern was applied (Fig. 1) and a breast reduction–type resection was undertaken; 350 g of tissue was removed from the right (nontumor) side. A superomedial medial was used. On the left (tumor side), 300 g of tissue was removed and a superior pedicle was used. The patient's postoperative course was uneventful (Fig. 2).
This modified pattern was also used in a patient who underwent skin-sparing mastectomy using the inverted-T breast reduction pattern. The end result was an S-shaped scar, not an inverted T.
This technique has the advantage of achieving oncologic clearance (including skin) in patients with superficially situated tumors undergoing either wide local excision (lumpectomy) or skin-sparing mastectomy. The disadvantage of the modified skin pattern incision is that the scars on the breast are not symmetrical and the pedicle used may also need to be altered to achieve a satisfactory tumor clearance margin.
Don A. Hudson, F.R.C.S., M.Med.
Department of Plastic and Reconstructive Surgery
Groote Schuur Hospital and University of Cape Town
Groote Schuur Hospital
Observatory, 7925 Cape Town, South Africa
1. Nahabedian MY. Critical analysis of reduction mammaplasty techniques in combination with conservative breast surgery for early cancer treatment (Discussion). Plast Reconstr Surg.
2. Hudson DA. A modified excision for combined reduction mammaplasty and breast conservation therapy in the treatment of breast cancer. Aesthetic Plast Surg.
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