Twenty-five consecutive patients with a mean age of 56 (range, 37–74 years; SD, 2.1 years) who under underwent combination Wise pattern mammaplasty and LICAP reconstruction with a minimum of 6 months follow-up after radiotherapy. The mean size of the malignancy resected, or extent of disease was 6.5 cm (range, 3.7–9.2 cm; SD, 1.3 cm) on final pathology. The mean partial mastectomy specimen weighed 220 g (range, 130–310 g; SD, 45 g) including the weight from additional margins that were immediately resected at the time of surgery if indicated after consultation with radiology and or pathology. We also recorded sternal notch to nipple distances (mean, 31 cm; range, 23–36 cm; SD, 3.4 cm), body mass index (mean, 28 kg/m2; range, 22–37 kg/m2; SD, 2.7 kg/m2), dimensions of the perforator flap average (mean length, 22 cm; range of lengths, 17–29 cm; SD, 2.1 cm), mean height (7 cm; range of heights, 5–10 cm; SD, 1.3 cm). Six patients had a formal diagnosis of diabetes mellitus, and all healed without complication. Three active smokers were included in our series who successfully abstained from smoking before surgery, all of whom healed without incident.
Three patients (12%) had close or positive margins that were successfully re-excised. Seven patients (28%) underwent preoperative chemotherapy, and 6 patients (24%) underwent adjuvant chemotherapy. All patients underwent adjuvant radiotherapy. There were no instances of nipple necrosis or LICAP flap failure requiring reoperation. There were no persistent areas of fat necrosis related to the LICAP flap on follow-up clinical examination. Six patients (24%) had some fat necrosis related to the pedicle (all inferior pedicles) that was not in the region of the LICAP flap reconstruction. These were noted on clinical examination and were not reported by the patient as bothersome. There were 4 instances (16%) of delayed wound healing secondary to skin necrosis that were conservatively treated related to the Wise pattern closure. All surgical sites were healed by 8 weeks (average, 5.6 weeks; SD, 1.8 weeks). There were no instances of delayed healing of the donor site nor persistent seromas after drain removal.
The average time from reconstruction to radiation was 6.5 weeks (range, 4–10 weeks; SD, 1.5 weeks). The 4 patients that had delayed wound healing of the Wise pattern flaps all started radiotherapy no later than 10 weeks after surgery.
All patients had follow-up mammagraphy performed 6 months after radiotherapy. Twenty patients (80%) had a Breast Imaging-Reporting and Data System score of 1 or 2, whereas 5 patients (20%) had a Breast Imaging-Reporting and Data System 3 score, recommended for 6 months follow-up. These patients had likely benign areas of surgical scarring related to the mammaplasty and or LICAP flap.
We present here a description of the synthesis between volume displacement (oncoplastic reduction/mastopexy techniques) and autologous volume replacement (LICAP flap) to reconstruct the extensive partial mastectomy defect. The only previous description of merging volume replacement and displacement strategies to facilitate breast conservation was by Bornea and Nahabedian who separately described simultaneous placement of a submuscular prosthetic and simple volume displacement maneuvers. These techniques were most applicable to the small breasted nonptotic patient who was not interested in mastectomy or a local flap. Here, we extend the synthesis of volume replacement and displacement strategies to the ptotic patient who is a marginal candidate for breast conservation because of initial breast size and or extent of disease. Additionally, some patients request maintenance or enhancement of breast size after an extensive resection and a supplemental LICAP flap is a safe, simple, and reliable way to accomplish this given the need for future radiotherapy.
Although the approach described here is not well described in the field of reconstruction after breast cancer surgery, it has been extensively studied and reported on in the massive weight loss patient. Wise pattern mastopexy with volume supplementation from LICAP flaps is a well-described approach in the massive weight loss patient to enhance volume and shape of the deflated breast11–13 making use of the excess lateral subcutaneous tissues. We have simply adopted this strategy in the breast cancer patient to allow us to both supplement volume, improve shape, and fill a partial mastectomy defect.
Silverstein et al.6 has described “Extreme Oncoplasty” where sophisticated internal reshaping strategies based on the Wise pattern are employed to facilitate breast conservation in multifocal or multicentric breast cancers that were classically recommended to undergo mastectomy. His results demonstrate aesthetic outcomes and oncological recurrence rates that are very similar to traditional oncoplasty or more standard breast conservation. This gives credence to our ambitious attempts at extreme breast conservation. His group further described the “split reduction” that allows for modification of the Wise pattern to ensure a negative anterior margin by excising skin directly over the tumor and saving inferior breast skin to make up for this deficit.7
Despite these triumphs, there are still a significant number of patients with ptosis but minimal breast volume in comparison to the extent of tissue that requires resection. Despite employing complex internal reshaping strategies, additional volume was required to reconstruct these breasts. In most cases, this was to avoid a deformity. In a few cases, this was to maintain or augment breast volume after resection and was motivated by patient demands. There are numerous advantages to the LICAP flap. It has a reliable blood supply, takes 30 minutes to raise and close the donor site, and does not require microsurgical expertise as the perforators are reliably located within 5 cm of the anterior border of the latissimus dorsi and can be identified easily before surgery with a unidirectional Doppler (although this is not strictly necessary). There is minimal postoperative donor-site pain that heals reliably well. Additional benefits to this approach are that we are not using potentially diseased breast tissue to reconstruct the partial mastectomy defect as is done in traditional oncoplasty. Furthermore, the sophisticated glandular flaps that are created during traditional oncoplasty require aggressive separation of the breast tissue from the skin envelope. In a fatty breast, this can lead to extensive fat necrosis. The LICAP flap is not compromised by the extent of fatty replacement in the breast. Additionally, the extended LICAP flap can reach most parts of the breast and does not compromise the position of the nipple or shape of the new breast mound as the pedicle supporting the NAC and new breast mound can be positioned completely independently of the LICAP flap. In addition, as opposed to traditional oncoplasty, the final breast size is not limited by the residual volume after oncological resection. The LICAP flap allows us to safely augment some patients who would be dissatisfied with their final breast size without the use of an implant in the face of impending radiotherapy. The LICAP flap does not compromise the ability to use the muscular portion of the latissimus flap in the future and allows for the elimination of those lateral chest side rolls of fat that many find bothersome. It is within the skillset of most reconstructive breast surgeons. The use of the LICAP flap in concert with traditional Wise-Pattern oncoplasty is a different approach to standard oncoplastic breast conservation and should be considered in patients with ptosis and a tumor to breast size ratio where deformity might be expected secondary to volume deficiency when employing standard Wise-pattern mammaplasty techniques.
We have refined our technique over the past several years performing this combined procedure. Over time, we realized that de-epithelialization of the flap in situ is more efficient than after raising it and closing the donor site as this is easier if the flap is immobile. We have found that including the muscular fascia of the latissimus and trapezius improves stability and sturdiness of the flap (much like the overlying dermis). We have observed that suturing the flap to the pectoralis can sometimes give an unnatural result with retraction of the tissues by the muscle upon contraction. We prefer to secure the flap to the residual breast tissue. We have discovered that this flap has excellent blood supply and can reach virtually any part of the breast. We have replaced skin that is involved with cancer in the far upper inner quadrant of the breast with skin from the distal tip of the flap without any ischemic compromise.
The oncological resection and the reconstruction here are both performed by the author so there is no difficulty coordinating the schedules of 2 surgeons. Any re-excision that is required occurs quickly after the pathology returns. We feel that delaying re-excision makes it difficult to identify the tissue planes accurately after things scar down. The partial mastectomy cavity, which has been clipped, and has the flap filling it, is easily identified and re-excised in the first 2 weeks after surgery.
We have also gained some insight into obtaining better symmetry between the breasts. We now perform the contralateral mastopexy first before proceeding with the reconstruction of the partial mastectomy defect as this gives us a better idea of what our final volume should be. When we first started, we would often get into the situation where the reconstructed breast was significantly larger than the contralateral skin-only mastopexy that required us to go back and debulk the flap a bit to achieve symmetry. Radiotherapy will result in contraction of the tissues and make the flap side less bulky laterally at the pivot point, so it is wise not to over-correct this. We do routinely debulk the flap to some extent at the pivot point more superficially toward the dermis as the perforators are deep and come through the muscle at the inframammary fold near the anterior border of the latissimus. As we gained more experience with this flap, we felt more comfortable thinning out the flap superficially near the pivot point to make this area less bulky and more similar to the contralateral healthy side. Finally, we always reserve the use of liposuction several months after radiotherapy to debulk the lateral reconstructed breast if we felt it was still too bulky. This could be performed without taking into consideration the location of the perforators as the flap has recruited enough collateral blood flow to survive. We have recently performed bilateral LICAP flaps (not included in the series) and this obviously gives the best symmetry.
This series of patients described were all done in the immediate setting with the use of intraoperative gross and frozen section evaluation to confirm clearance of the cancer before reconstruction. Many of these patients had extensive ductal carcinoma in situ where the likelihood of margin involvement was higher and therefore an aggressive en bloc resection was planned to attempt to clear the disease. Others had extensive cancers before chemotherapy and had complete imaging responses after completion but still required a large segment of tissue removed. Presently, in cases of extensive ductal carcinoma or any significant uncertainty about margin status, we now routinely delay the reconstruction until the final pathology report is available. This allows us to definitively determine the amount of flap volume required to reconstruct the breast deficit and to obtain the best symmetry with the contralateral breast in a second surgery.
Wise pattern oncoplastic techniques have allowed surgeons to remove extensive breast cancers and reconstruct ptotic patients with smaller breasts while avoiding a postoperative deformity. As we extend the oncological indications for these techniques and apply them to even smaller breasted women with larger cancers, we will reach a point where additional volume is required from outside the breast to avoid mastectomy. The LICAP flap can provide a reliable, safe, and simple way to supply this volume and to facilitate breast conservation in an even greater proportion of our patients. Although the simultaneous use of volume displacement and replacement strategies has not been widely described in the literature, we believe it should be strongly considered in any patient who is a marginal candidate for traditional Wise-pattern oncoplastic approaches.
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Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
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