Comments on: Improving Breast Cancer Surgery: A Classification and Quadrant per Quadrant Atlas for Oncoplastic Surgery (Clough KB, Kaufman GJ, et al. ASO DOI 10.1245/s10434-009-0792-y)

Excerpt

Breast-conserving procedures represent a challenging approach for early breast cancer treatment that can offer better results to women through close cooperation between general and plastic surgeons. As breast conservative approaches have spread during the past decades, many authors have attempted to perform classification of defect types and respective techniques for each quadrant. This requires great experience in breast reconstruction, wide knowledge of all breast reduction procedures, and constant upgrading of the new techniques reported in the literature with particular attention to original procedures published on the more accredited scientific journal, such as Annals of Surgical Oncology. In their article, Clough et al. proposed a new classification of oncoplastic techniques into two levels, based on the amount of tissue excised and the relative level of surgical difficulty: (1) level I approach in which <20% of breast volume is excised and no skin resection is required, and (2) level II approach in which up to 50% of breast volume is excised and therapeutic mammaplasties with skin excision are performed. In this classification, the reconstruction following wide resections of the upper inner quadrant (level II) is not exhaustively discussed, suggesting the Silverstein’s batwing procedure for excision of no more than 20%. The authors conclude in their Discussion about this troublesome location, stating that to date no further innovative techniques are available and more research is needed when performing wider excision of this quadrant. Furthermore, to reconstruct level II upper outer quadrant resections, the authors suggest a racquet mammaplasty with NAC undermining, which allows for its optimal reposition and central gland advancement. The authors have not provided patient photos from their experience with the Silverstein procedure, and only intraoperative images of the racquet technique are shown. However, we underscore that the Silverstein batwing procedure is useful for cancers located deep within or adjacent to the nipple-areolar complex but not directly connected with this area.1 It is not indicated for upper inner quadrant resections, and the racquet technique is an old procedure, which the same article references indicate, with a high risk for a type II/III breast deformity.2,3 We suggest to the authors an original procedure that we published in this journal in which we describe the use of a modified breast reduction Wise-pattern technique, in women with moderate-to-severe breast hypertrophy and tumor located in upper quadrants.4 All of our patients have healed uneventfully with no local or distant recurrence until now. Compared with the two above-mentioned procedures, it allows for wider and symmetrical excision of fatty to extremely dense breast glands, without NAC undermining, while preserving nerve and vascular supply of the NAC and breastfeeding capability. We have applied a similar modification of the Wise-pattern for skin-sparing mastectomy.5 Our procedure is original and reproducible, allowing these demanding breast resection locations. …