Published in:
01-12-2017 | Breast Oncology
Refining Tumor Resection Techniques for Managing Inferior Pole Breast Malignancies
Published in: Annals of Surgical Oncology | Special Issue 3/2017
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I read with interest the article by Holmes and Silverstein entitled “Triangle Resection with Crescent Mastopexy: An Oncoplastic Breast Surgical Technique for Managing Inferior Pole Lesions.”1 They described a technique that would allow a mammoplasty-like repair of the resection defect in the lower pole of the breast. It would be interesting to have an idea of the eventual cosmetic outcome of this technique and the corrective effect it has on the “bird beak” deformity. My practice is among a predominantly Asian population where breast tissue is usually of a lower volume than seen in Western populations.2 Performing a triangular resection through an incision with an extended vertical limb often poses a challenge for incorporation into a mastectomy ellipse.3 To overcome this problem in situations with smaller breast-tissue volume, tumours in the lower pole are classified and approached differently. Those closer to the nipple-areolar complex are tackled by using a golf-tee incision with a diamond-shaped resection pattern, whereas those closer to the inframammary fold are surgically treated with an anchor incision and an elliptical resection pattern.4,5 Both of these incisions may be easily incorporated into a mastectomy should the need arise, which is a point of consideration when dealing with nonptotic breasts. The cosmetic results using these incisions are demonstrated in Figs. 1d, 2c, d. The anchor and golf-tee incisions allow adequate exposure for mobilisation and direct closure of the parenchymal pillars with sutures. This avoids the unsightly bird beak deformity that was described by Drs. Holmes and Silverstein.1
Fig. 1
a–d For this patient with a sentinel node-negative, 1.8-cm mucinous carcinoma in the lower pole of the right breast within a B-cup brassiere-size tissue volume, an anchor incision was used to achieve wide excision of the tumour. In her case, elliptical tissue resection pattern was sufficient to achieve negative margins. On occasion, there may be a need to perform a triangular resection pattern. Whichever approach is chosen, adequate parenchymal mobilisation is essential for tissue pillar advancement and closure. She is now disease-free 86 months posttreatment
Fig. 2
a–d In addition to the tumour sited at the 6 o’clock periareolar region, this patient had two other lesions in the vicinity detected on imaging for which she requested excision, hence the localising wires. The golf-tee incision was planned such that it would be incorporated into a mastectomy ellipse in its entirety, together with the vertical stem. This was important, because the breast was nonptotic with low tissue volume, limiting the width of the mastectomy ellipse. b The two biopsy cavities after resection of the lateral lesion and en bloc resection of the two lesions in close proximity at 6 o’clock. Histology of the 6 o’clock lesion was reported as 20-mm, Grade 3, invasive ductal carcinoma with a negative sentinel lymph node. The other lesion at 6 o’clock was indistinguishable from the tumour, and a presumptive diagnosis was made that it was part of the malignancy. The 9 o’clock lesion was benign. Negative margins of at least 2 mm were obtained. c and d Postoperative results at 4 and 12 months. The patient is currently disease-free 49 months after treatment
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