Krishna B. Clough

Summary: The majority of patients undergoing bilateral prophylactic mastectomy request immediate implant-based breast reconstruction. Some patients, especially those with prior radiotherapy, are at increased risk of early cutaneous complications and implant loss. The authors developed the technique of primary fat grafting before delayed prophylactic mastectomy to minimize early complications for selective high-risk patients. They have completed 21 cases in 14 patients, 10 of whom had previous lumpectomy and radiation treatment for breast cancer. A single session of fat grafting, with a median injection volume of 250 ml (interquartile range, 200 to 300 ml), was performed a median period of 19 weeks (interquartile range, 16 to 28 weeks) before prophylactic mastectomy. All cases were direct-to-implant reconstruction using textured silicone implants. The median implant volume was 410 ml (interquartile range, 318 to 450 ml). A minor early complication developed in 14 percent of cases (three of 21), with no early implant loss. At a median follow-up of 9 months (interquartile range, 5 to 27 months), the authors found no cases of implant loss and an excellent or good aesthetic outcome (score of 5 or 4) in 16 of 21 cases (76 percent). Fat grafting before prophylactic mastectomy is a novel strategy to minimize early complications and avoid implant loss in patients at high risk of postoperative complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Background Oncoplastic surgery (OPS) allows wider resections with immediate breast reshaping by mammoplasty. This study reviews our experience with level 2 mammoplasties in patients with...

Oncoplastic techniques applied to breast-conserving surgery (BCS) allow large-volume resections without compromising cosmetic results. Level II oncoplastic techniques are based on mammoplasties. When required, they allow resection of more than 20 % of the breast volume; however, a subgroup of these patients will still have positive margins. The clinical management of positive margins after level II oncoplastic surgery (OPS) is a challenge. All patients who had undergone level II oncoplastic techniques at The Paris Breast Center between 2004 and 2013 were reviewed. The choice of the optimal mammoplasty technique was based on the tumor location and the ‘quadrant per quadrant atlas’. A total of 277 level II oncoplastic techniques were performed on 272 patients. The mean tumor size was 26 mm (range 2–160 mm), with a mean resected weight of 175 g (range 50–1540 g). The rate of positive margins was 11.9 %. Risk factors for positive margins identified in univariate analysis were histologic subgroup, tumor size, T stage and grade. In multivariate analysis, only patients with invasive lobular carcinoma had a significantly higher risk of positive margins. A second operation was required in 33 cases, and a third operation was required in three cases because of positive margins. Final breast conservation rate was 91 %. Level II OPS results in a low positive margin rate despite large tumor size. Patients with involved margins can be offered a second BCS if the remaining volume allows this.

In recent decades, the surgical management of breast cancer has steadily and considerably improved. Mutilating procedures have given way to more individualized surgical approaches aiming to preserve the breast as much as possible. For large tumors, preoperative chemotherapy is a major tool, but emerging oncoplastic surgery techniques are also a new approach in the armamentarium of breast cancer surgery, as a third option between conventional breast-conserving surgery and mastectomy. As this new treatment modality allows wider margin excision, it reduces the need for re-excision procedures and possibly increases breast conservation rates by extending the indications of breast-conserving surgery. This review will provide an overview of current practices and clinical data available to date on oncoplastic surgery.

Background The current retrospective study was intended to obtain up-to-date and comprehensive data on surgical practice for breast cancer throughout France, including neoadjuvant chemotherapy (NAC)...

Background Oncoplastic surgical techniques offer an option of breast conserving surgery for larger tumors with the use of glandular reshaping to prevent postoperative deformity. A technique for the...