Part 2 book “Oncoplastic breast surgery - A guide to clinical practice” has contents: Retroareolar breast cancer treated with central quadrantectomy, nipple-sparing mastectomy and immediate implant reconstruction with a mesh, nipple-sparing mastectomy and immediate implant-based reconstruction with a tiloop bra mesh,… and other contents.
34 Breast Conservation Surgery: The B Plasty, Involved Margins, Skin-Sparing Mastectomy a b c d e Fig 34.5 (a–f) A 67-year-old patient underwent breast conservation surgery using a B plasty for a 30 mm lobular cancer (receptor positive, HER2 negative, Ki 67: 20 %, G2) in the upper outer quadrant of the left breast The sentinel node was positive, and an axillary dissection was performed (2 positive lymph nodes out of 15) Re-excision was necessary due to involved margins with intraductal carcinoma in situ The breast was of medium size with no ptosis and a good cosmetic result after quadrantectomy 139 f (a, b) A skin-sparing mastectomy with immediate reconstruction with a latissimus dorsi flap and an implant was performed The flap was de-epithelialized except a skin island as a substitute for the areola (c, d) The postoperative cosmetic result years after surgery was excellent with good size and ptosis of the reconstructed breast and symmetry to the contralateral breast (e, f) Reconstruction of the NAC was declined by the patient Part VII Breast Conserving Oncoplastic Techniques: Central Resection Central Quadrantectomy and Reconstruction of the Nipple-Areola Complex with a De-epithelialized InferiorBased Pedicle with a Skin Island 35 Peter Schrenk 35.1 The Patient A 62-year-old woman was diagnosed (open biopsy) with Paget carcinoma of the left nippleareola complex (NAC) Mammography and breast MRI revealed suspicious microcalcifications 30 mm in size solely behind the nipple Vacuum needle biopsy found intraductal carcinoma in situ of intermediate grade Breast conservation surgery was suggested and planned as a central quadrantectomy The patient had a large and ptotic breast (Fig 35.1a–c) 35.2 Surgery Central quadrantectomy was performed as part of an inferior-based pedicle reduction mammoplasty with a resection volume of 1,150 g The inferior pedicle was de-epithelialized except a small skin island, which was used for reconstruction of the NAC (Fig 35.2a, b) Sentinel node biopsy found one negative sentinel node P Schrenk, MD Second Department of Surgery, Breast Care Center, Akh – LFKK Linz, Linz, Austria e-mail: peter.schrenk@liwest.at 35.3 Clinical and Cosmetic Outcome The postoperative course was uneventful Permanent histology found a Paget carcinoma of the nipple and a 30 mm carcinoma in situ of high grade with wide clear margins of more than cm No postoperative radiation was suggested by the tumor board due to the wide resection margins Nine months after surgery, reconstruction of the NAC and a contralateral reduction with an inferior-based pedicle were done (Fig 35.3a, b) Routine follow-up mammography years after initial surgery revealed scattered suspicious microcalcifications in the upper inner quadrant of the left breast over a distance of cm Vacuum needle biopsy confirmed ductal carcinoma in situ high grade Breast conservation surgery was suggested and planned as a vertical central quadrantectomy with resection of the (reconstructed) NAC or – in case the intraoperative radiogram of the specimen reveals large free margins – as an inferiorbased pedicle reduction mammoplasty with the reconstructed NAC as a skin island on the deepithelialized inferior-based pedicle (Fig 35.4a–c) The extension of the microcalcifications was marked with two wires (Fig 35.4c) The NAC was circumcised and the inferior pedicle was deepithelialized (Fig 35.4d) Wide excision of the upper inner periareolar quadrant was done © Springer-Verlag Vienna 2015 F Fitzal, P Schrenk (eds.), Oncoplastic Breast Surgery: A Guide to Clinical Practice, DOI 10.1007/978-3-7091-1874-0_35 143 P Schrenk 144 a b c Fig 35.1 (a–c) Preoperative view The 62-year-old patient had a Paget carcinoma of the nipple and intraductal carcinoma in situ of the left breast Central quadran- a tectomy was planned using an inferior pedicle reduction mammoplasty with a skin island for reconstruction of the NAC b Fig 35.2 (a, b) Intraoperative view Following central quadrantectomy, the inferior pedicle was de-epithelialized leaving a skin island for reconstruction of the nipple 35 Central Quadrantectomy and Reconstruction of the Nipple Areola Complex with an Inferior Pedicle a Fig 35.3 (a, b) Postoperative view The nipple was reconstructed with a star flap technique; an inferior-based b pedicle reduction mammoplasty was performed for symmetrization (a) (b) Postoperative result after years a b c d Fig 35.4 (a–g) Follow-up mammography found recurrence of intraductal carcinoma in situ in the upper inner quadrant of the left breast and extending to the NAC A central quadrantectomy performed as an inferior pedicle reduction mammoplasty with or without preservation of the reconstructed NAC – depending on the intraoperative specimen mammography and frozen section – was 145 planned (a–c) The extension of the microcalcifications was marked with two wires (c) The NAC was preserved on the de-epithelialized inferior pedicle (d) and used for reconstruction (e) Early postoperative view showed a smaller volume of the left breast but an otherwise good cosmetic result (f, g) P Schrenk 146 e f g Fig 35.4 (continued) Intraoperative mammogram of the specimen (resection weight 350 g) found the microcalcifications completely removed with wide free margins and no involvement of the reconstructed NAC, which was used for reconstruction (Fig 35.4e) Reoperation sentinel lymph node biopsy found two negative sentinel lymph nodes Permanent histology found an intraductal carcinoma in situ of high grade of 35 mm with wide clear margins The postoperative course was complicated with delayed wound healing (small necrosis of the skin of the neo-areola) managed conservatively The final postoperative result is seen in Fig 35.4f, g 35.4 Comments of Author • From an oncological point of view, central quadrantectomy is safe and comparable to mastectomy when postoperative radiation is applied • After central quadrantectomy using an inferior-based pedicle, the NAC can be reconstructed immediately with a skin island on the de-epithelialized pedicle This technique requires adequate breast volume with a medium- or large-size breast with at least moderate ptosis • Due to the large resection volume with wide clear margins, no radiation was suggested by the tumor board For the patient who had no prior radiation and the tumor recurrence was restricted to the upper inner periareolar region, reoperation quadrantectomy was done • Figure 35.5a–f shows another patient with a central quadrantectomy using an inferiorbased pedicle and reconstruct the NAC with a skin island from the inferior pedicle • In order to obtain a more pronounced volume of the breast, the medial and lateral pillars of the inferior pedicle may be mobilized and sutured together behind the inferior pedicle (Fig 35.6a, b) 35 Central Quadrantectomy and Reconstruction of the Nipple Areola Complex with an Inferior Pedicle a b c d e f Fig 35.5 (a–f) A 54-year-old patient with bilateral breast cancer The cancer in the right breast was located retroareolarly and extended into the upper outer quadrant, whereas the tumor in the left breast was in the upper outer quadrant (a–c) A central quadrantectomy with an inferior-based pedicle and reconstruction of the NAC with 147 a skin island was planned on the right breast, whereas due to the location of the tumor, an inferior pedicle mammoplasty was done on the left breast without resection of the NAC The patient underwent radiation on both breasts The postoperative result years after surgery was rated as excellent (d–f) P Schrenk 148 a Fig 35.6 (a, b) Central quadrantectomy and autoaugmentation of the breast volume After resection of the NAC, the lateral and medial pillars of the inferior pedicle b are incised (a), mobilized, and closed behind the central inferior pillar (b) to augment the breast volume Retroareolar Breast Cancer Treated with Central Quadrantectomy 36 Peter Schrenk 36.1 The Patient A 36-year-old premenopausal woman was diagnosed with a small (11 mm) retroareolar cancer of the left breast Mammography and breast MRI revealed no further pathology in both breasts Breast conservation surgery with resection of the nipple-areola complex (NAC) and direct closure of the defect was planned The breast was of medium size with minimal ptosis (Fig 36.1) 36.2 Surgery Central quadrantectomy using a circumareolar incision was done The NAC was completely resected including the retroareolar tissue including the pectoralis muscle fascia Sentinel lymph node biopsy found two negative nodes The breast tissue was mobilized and closed with two purse string sutures 36.3 Clinical and Cosmetic Outcome The postoperative course was uneventful Final histology found an 11 mm invasive cancer of intermediate grade and positive hormonal receptor status Radiation therapy and endocrine treatment were suggested Although the left breast was slightly smaller than the right breast, both the patient and surgeon were satisfied with the cosmetic result (Fig 36.2a, b) Reconstruction of the NAC was declined by the patient Clinical follow-up, however, found an increasing retraction of the scar in the retroareolar region (Fig 36.3) Radiologic findings were unsuspicious Eight years following surgery, routine mammography revealed a small (4 mm) invasive cancer and intraductal carcinoma in situ (DCIS) behind the right nipple Breast conservation was suggested, but the patient decided to undergo a skin-sparing mastectomy in order to spare radiation Skin-sparing mastectomy was done using a circumareolar incision Sentinel node biopsy found one negative node Immediate reconstruction was done with a latissimus dorsi muscle P Schrenk, MD Second Department of Surgery, Breast Care Center, Akh – LFKK Linz, Linz, Austria e-mail: peter.schrenk@liwest.at © Springer-Verlag Vienna 2015 F Fitzal, P Schrenk (eds.), Oncoplastic Breast Surgery: A Guide to Clinical Practice, DOI 10.1007/978-3-7091-1874-0_36 149 P Schrenk 150 The postoperative histology revealed a mm invasive cancer with DCIS both completely removed The postoperative course was uneventful Postoperative cosmetic result years after surgery was rated as excellent for the right breast; the left breast revealed a retraction of the scar in the former areola region, but both breasts revealed good symmetry (Fig 36.4) No reconstruction of the NAC was wanted by the patient 36.4 Fig 36.1 Preoperative view of a 36-year-old patient with a retroareolar cancer of the left breast Drawings show two possible incisions for a central quadrantectomy: elliptical or circumareolar incision In this patient, the areola/tumor was resected using a circumareolar approach a Comments of Author • The purse string technique for central quadrantectomy may be performed in patients with a small- or medium-size breast and a moderate ptosis Ptosis of the breast facilitates proper mobilization of the breast tissue and closure without tension • Retroareolar breast cancer requires resection of the NAC The mastectomy was performed using a circumareolar approach Reconstruction with a latissimus dorsi muscle is indicated in patients with a small- or medium-size breast and a moderate ptosis Whenever more volume is required, this may be gained adding a silicone implant • (Another possible technique for central quadrantectomy is a horizontal elliptical excision, which may also be used in small breasts with no ptosis (Fig 36.5a–d) or in patients with larger breasts, a T-like resection (Fig 36.6a, b) The latter also allows correction of ptosis and reduction of breast size.) b Fig 36.2 (a, b) Postoperative view years following central quadrantectomy and closure with a purse string suture The left breast was slightly smaller less than the right breast but with a good cosmetic result 62 Correction of Postquadrantectomy Deformity with a DIEP Flap 283 Fig 62.5 Delayed healing of the irradiated skin envelope of the breast in the first postoperative period Filling of the defect with autologous tissue – pedicled or microsurgical free flaps A rearrangement of the breast tissue or correction with silicone implants alone is usually contraindicated due to the form of the defect and the uncertain healing conditions in the irradiated tissue leading to high rates of implant protrusion In the respective case, reduction mammoplasty was denied by the patient, and the lack of skin was too large to allow lipofilling Mostly pedicled latissimus dorsi flaps or thoracodorsal perforator flaps offer a safe option to fill these defects with well-vascularized autologous tissue, especially in the lateral and upper portion of the breast Nevertheless, the latissimus has the disadvantage of muscle atrophy Therefore, in selected cases and experienced institutions, free flaps from the lower abdomen can be the method of choice to overcome severe asymmetries after breast-conserving surgery Fig 62.6 Symmetric breast size and position of the NACs months postoperatively with improved contour of the abdominal wall References Berrino P, Campora E, Santi P (1987) Postquadrantectomy breast deformities: classification and techniques of surgical correction Plast Reconstr Surg 79(4):567–572 Blondeel PN (1999) One hundred free DIEP flap breast reconstructions: a personal experience Br J Plast Surg 2(2):104–111 Deutinger M, Tairych G, Resch A, Biber E (1999) Contour defects after breast preserving therapy of breast carcinoma Primary and secondary possibilities of correction Strahlenther Onkol 75(11):577–582 Garsa AA, Ferraro DJ, DeWees T, Margenthaler JA, Naughton M, Aft R, Gillanders WE, Eberlein T, Matesa MA, Zoberi I (2013) Cosmetic analysis following breast-conserving surgery and adjuvant highdose-rate interstitial brachytherapy for early-stage breast cancer: a prospective clinical study Int J Radiat Oncol Biol Phys 85(4):965–970 Khouri RK, Khouri RK Jr, Rigotti G, Marchi A, Cardoso E, Rotemberg SC, Biggs TM (2014) Aesthetic appli- 284 cations of Brava-assisted megavolume fat grafting to the breasts: a 9-year, 476-patient, multicenter experience Plast Reconstr Surg 133(4):796–807 Kronowitz SJ, Feledy JA, Hunt KK, Kuerer HM, Youssef A, Koutz CA, Robb GL (2006) Determining the optimal approach to breast reconstruction after partial mastectomy Plast Reconstr Surg 117(1):1–11 Losken A (2011) Reconstruction of partial mastectomy defects Classification and Methods In: Spear SL (ed) Surgery of the breast, principles and art Lipincott Williams and Wilkins, Philadelphia, pp 140–164 Losken A, Hamdi M (2009) Partial breast reconstruction: current perspectives Plast Reconstr Surg 124(3):722–736 R Koller and C Grill Matory WE Jr, Wertheimer M, Fitzgerald TJ, Walton RL, Love S, Matory WE (1990) Aesthetic results following partial mastectomy and radiation therapy Plast Reconstr Surg 85(5):739–746 Slavin SA (2011) Reconstruction of the breast conservation patient In: Spear SL (ed) Surgery of the breast, principles and art Lipincott Williams and Wilkins, Philadelphia, pp 198–212 Trombetta M, Julian TB, Werts DE, McWilliams W, Kim Y, Miften M, Parda D (2009) Long-term cosmesis after lumpectomy and brachytherapy in the management of carcinoma of the previously irradiated breast Am J Clin Oncol 32(3):314–318 Part XIII Revisional Surgery (Surgery After Surgery) The Inverted T Mammoplasty for Defect Correction After Previous Breast Conservation Surgery 63 Elias E Sanidas 63.1 The Patient The 46-year-old patient had a history of previous breast biopsy for a 35 mm G2 triple negative cancer in the lower quadrant (6 o’clock position) of the right breast Due to involved margins with intraductal carcinoma in situ, reoperation surgery was planned using an inverted T reduction mammoplasty The breast was of large size and ptotic There was quite a tissue deficit in the lower pole, and the nipple-areola complex was dislocated in the inferior direction (Fig 63.1a–c) The blueprint of the operation can be seen in Fig 63.1d 63.3 Final histology found remnants of intraductal carcinoma in situ with wide free margins One out of 25 removed lymph nodes was involved with tumor The postoperative course was uneventful; chemotherapy and radiation were suggested The early (Fig 63.3) and late (Fig 63.4a, b) postoperative cosmetic result was judged as excellent 63.4 63.2 Clinical and Cosmetic Outcome Comments of the Author Surgery The drawings for the inverted T mammoplasty are seen in Fig 63.2a The periareolar region was de-epithelialized (Fig 63.2b), and the previous scar was included in the reduction (Fig 63.2b, c) Following wide local resection, the medial and lateral breast flaps were mobilized (Fig 63.2d) and rotated into the breast median (Fig 63.2e) Axillary dissection was performed using the same incision • Local simple re-excision was not appropriate in this patient for it would have resulted in an even more pronounced defect in the lower quadrant and an even poorer cosmetic result • Breast cancer patients should be operated by specialized surgeons • Oncoplastic techniques can correct previously bad aesthetic results The surgeons should have in mind a “library of operations” to choose from E.E Sanidas, MD, FACS Department of Surgery, Herakleion Crete Medical School, Herakleion, Crete, Greece e-mail: eliassanidas@gmail.com; esanidasbreastsurgeon@gmail.com © Springer-Verlag Vienna 2015 F Fitzal, P Schrenk (eds.), Oncoplastic Breast Surgery: A Guide to Clinical Practice, DOI 10.1007/978-3-7091-1874-0_63 287 E.E Sanidas 288 a b c d Fig 63.1 (a–c) Preoperative view The patient had a history of previous breast biopsy for a 35 mm invasive cancer in the lower quadrant resulting in a marked distortion of the nipple-areola complex (a, b) A large scar from previous surgery is seen in the lower quadrant (c) (d) The blueprint of the operation 63 The Inverted T Mammoplasty for Defect Correction After Previous Breast Conservation Surgery a b c d 289 e Fig 63.2 (a–e) Intraoperative view The incisions for T mammoplasty included the scar from the previous surgery and were drawn on the breast as well as the area to be deepithelialized (a) The periareolar region was de- epithelialized (b) Following wide local resection, (c) the medial and lateral breast flaps were mobilized (d) and closed in the midline (e) E.E Sanidas 290 Fig 63.3 Early postoperative result a b Fig 63.4 (a, b) Late postoperative result years after revision surgery using an inverted T mammoplasty Breast Conservation Surgery Following Cosmetic Reduction Mammoplasty 64 Peter Schrenk 64.1 The Patient A 37-year-old patient was scheduled for bilateral reduction mammoplasty for body contouring following massive weight loss of 64 kg at the Department of Plastic Surgery Routine mammogram months prior to the operation was unsuspicious Family history was negative Inferior based pedicle reduction mammoplasty was performed with the lateral and medial pillars of the inferior pedicle being mobilized and transferred into the upper quadrants to provide tissue for more volume The postoperative course was delayed with wound healing in the inframammary fold of the right breast One month after surgery, the patient noticed a mass in the upper outer quadrant of the left breast which was assumed to be a postoperative hematoma or fatty tissue necrosis Four weeks later, the patient was seen in the outpatient breast clinic for further evaluation of the mass Breast ultrasound revealed a speculated mass of 18 mm in the upper outer quadrant which was suspicious for breast cancer and suspicious axillary lymph nodes Breast MRI did not reveal P Schrenk, MD Second Department of Surgery, Breast Care Center, Akh – LFKK Linz, Linz, Austria e-mail: peter.schrenk@akh.linz.at additional lesions in both breasts Diagnosis was confirmed with core needle biopsy and revealed a triple-negative breast cancer of high grade and positive axillary lymph nodes Due to the tumor size, the involved lymph nodes, and the biology of the cancer, the patient underwent neoadjuvant chemotherapy, which resulted in a clinically and radiologically complete remission Following cosmetic reduction mammoplasty, the breast was of medium size and has moderate ptosis with the left breast slightly larger than the right breast (Fig 64.1a, b) Breast conservation surgery was planned as re-reduction mammoplasty of the left breast 64.2 Surgery The incisions of the previous reduction mammoplasty were completely reopened, and mobilization was carried out subcutaneously in direction of the upper outer and upper inner quadrant Quadrantectomy comprised the extension of the tumor after neoadjuvant chemotherapy which was marked preoperatively with a guiding wire Sentinel lymph node biopsy revealed a macrometastatic sentinel node and an axillary dissection was done The quadrantectomy defect in the upper outer quadrant was closed with the lateral pillar of the inferior pedicle, which was mobilized from the fascia and rotated into the defect © Springer-Verlag Vienna 2015 F Fitzal, P Schrenk (eds.), Oncoplastic Breast Surgery: A Guide to Clinical Practice, DOI 10.1007/978-3-7091-1874-0_64 291 P Schrenk 292 a b Fig 64.1 (a, b) Preoperative view The breast was of medium size and has moderate ptosis The scars after reduction mammoplasty had healed completely The a localization and size of the tumor prior to neoadjuvant chemotherapy in the upper outer quadrant of the left breast are outlined on the breast b Fig 64.2 (a, b) Postoperative result 18 months after re-reduction oncoplastic surgery and radiation revealed good cosmetic outcome 64.3 Clinical and Cosmetic Outcome The postoperative course was uneventful Histology found a pathologically complete remission of the tumor (yT0) but positive lymph nodes out of 28 removed nodes Radiation was given to the breast and the supraclavicular nodes The postoperative cosmetic result was rated as good with both breasts of good volume and symmetry (Fig 64.2a, b) 64.4 Comments of the Author • The principles of breast cancer surgery in patients with a previous reduction mammoplasty are the same as in patients without prior surgery and are complete resection of the cancer with a good cosmetic result Surgery may either be a quadrantectomy (Fig 64.3a–d), a re-reduction (Fig 64.4a–d), or any other technique known from oncoplastic breast surgery 64 Breast Conservation Surgery Following Cosmetic Reduction Mammoplasty a b c d 293 Fig 64.3 (a–d) Preoperative view of a 67-year-old patient with a history of cosmetic reduction mammoplasty 27 years ago Routine mammogram found breast cancer in the upper outer quadrant of the left breast (a, b) The tumor was removed by simple quadrantectomy (c, d) When another reduction mammoplasty is performed, the same surgical technique should be used with respect to the blood supply of the nipple in order to avoid complications such as delayed wound healing or nipple necrosis • Following reduction mammoplasty, typical postoperative changes such as fibrosis or microcalcifications are found in the mammogram They are usually distinguished by an experienced radiologist from malignancy Whenever there remains doubt in the diagnosis, needle biopsy or open biopsy should differentiate fatty tissue necrosis from malignancy • Tumor quadrantectomy after neoadjuvant chemotherapy allows resection of the tumor within its current extension This results in equal oncological outcome as resection of the former tumor bed, when surgery is combined with postoperative radiation • Sentinel node biopsy after previous reduction mammoplasty is possible and safe, although it may be associated with a decreased identification rate and a higher false-negative rate especially in patients with positive nodes or previously positive nodes which show a remission under neoadjuvant chemotherapy Reoperation sentinel node biopsy should always be combined with scintigraphy, for the identification of a sentinel node largely depends on a positive scintigram P Schrenk 294 a b c d Fig 64.4 (a–d) A 54-year-old patient had a reduction mammoplasty with an inferior based pedicle 20 years ago A 15 mm breast cancer was found in the lower outer quad- rant of the right breast (a, b) Postoperative view after inferior pedicle re-mammoplasty revealed a good cosmetic result Part XIV Nipple Areola Complex Nipple-Areolar Complex (NAC) Reconstruction: Good Case 65 Florian Fitzal 65.1 The Patient A 52-year-old woman presented with a central mass with inclusion of the nipple-areolar complex (NAC) in her right breast in 2010 The mass was 4.5 × cm large and directly behind the nipple-areolar complex and lateral at o’clock Multicentricity has been seen in radiological workup (MR mammography) The central mass had four satellite lesions posteriorly The biopsy demonstrated an invasive ductal adenocarcinoma with middle differentiation (G2) and intraductal components with high differentiation (G1) Immunohistochemistry showed ER+++, PR+++, and her2neu - Although it was quiet obvious that this luminal A like tumor may almost not respond to systemic chemotherapy, we offered her cycles of taxane-based neoadjuvant therapy to increase her chance of a breast conservation (Fitzal et al 2011) At the time of diagnosis, she was perimenopausal After neoadjuvant chemotherapy, MR mammography demonstrated a partial remission F Fitzal, FEBS, MD Breast Health Center, and Cancer Comprehensive Center Medical University Vienna, Hospital of the Sisters of Charity, Linz, Austria e-mail: florian.fitzal@meduniwien.ac.at, florian.fitzal@bhs.at (RECIST criteria) The primary tumor diameter was reduced from 4.5 × to 2.5 × cm and the satellite lesions from 1.2 to 0.6 cm The NAC was still close to the lesion Due to her large breast size (Fig 65.1) and the partial remission (cPR), we performed breast conservation; however, intraoperative frozen section demonstrated involvement of the NAC Thus, the NAC had to be resected as well 65.2 Surgery Five months after the diagnosis and weeks after the last chemotherapy cycle, we performed an oncologic resection of the tumor including the NAC using an inverse-T reduction mammoplasty The preoperative drawings are seen in Fig 65.1; the postoperative picture is illustrated in Fig 65.2 Final histology demonstrated ympT2 ypN2a (5/16) G2 invasive ductal adenocarcinoma of the right breast resected with clear margins R0 In total we resected about 400 cm3 of breast tissue The patient received perioperative antibiotic prophylaxis, and a frozen section was done to demonstrate clear margins during surgery We had to one re-resection positive margins during surgery and resection of the NAC The patient received adjuvant endocrine treatment with tamoxifen and goserelin as well as local radiotherapy to the supraclavicular nodes and the breast including a boost © Springer-Verlag Vienna 2015 F Fitzal, P Schrenk (eds.), Oncoplastic Breast Surgery: A Guide to Clinical Practice, DOI 10.1007/978-3-7091-1874-0_65 297 F Fitzal 298 65.2.1 NAC Reconstruction Fig 65.1 The 52-year-old woman has a cup D-sized ptotic breast with a retromammillary multicentric (4.5 × cm diameter) endocrine responding and her2neunegative invasive breast cancer The green markings were done preoperatively with the primary aim to use an inverted T technique reduction mammoplasty During surgery (1 month after chemotherapy) frozen section revealed invasive cancer cells within the nipple-areolar complex (NAC); thus, resection of the NAC was necessary Final pathological workup demonstrated ypmT2 ypN2a G2 R0 status Ten months after oncoplastic surgery (9 months after radiotherapy), the patient underwent contralateral reduction mammoplasty and NAC reconstruction The patient had a big left mammilla and a large nipple Thus, we used the skin from the left mammilla after its deepithelialization as well as the left nipple (nipple sharing) for the reconstruction of the NAC of the right side Preoperative drawings are seen in Fig 65.2 We used a 40 mm nipple cone to form the new nipple on the left side The outer skin of the mammilla has been deepithelialized as a round circle The reduction mammoplasty has been done on the left and after positioning the nipple; the right breast has been deepithelialized using a 40 mm mammilla cone The mammilla skin from the left breast was transplanted to the right deepithelialized area as full-thickness skin graft The skin was also incised with a scalpel to increase blood vessel ingrowth The nipple from the left breast has been cut in half and transplanted as a skin graft to the right side The new NAC was covered with sterile Fettgaze (Jelonet©), and sponges were sutured down to the new NAC Sponges and Fettgaze have been withdrawn after days The left breast was drained with vacuum suction drainages size 12 (Redon) as long as drainage fluid was less than 50 cc/24 h 65.3 Fig 65.2 Preoperative drawings months after adjuvant radiotherapy including brachytherapy for contralateral reduction mammoplasty (inverse-T technique) and rightsided nipple-areolar complex (NAC) reconstruction NAC reconstruction will be done using the skin of the left mammilla and the left nipple (Clinical and Cosmetic) Outcome Results after surgery on days 10 and and months after NAC reconstruction are shown in Figs 65.3, 65.4, and 65.5 First the NAC was low perfused and had some necrosis; however, after almost months, the wound healed, and sensation was not bad as reported by the patient 65 Nipple-Areolar Complex (NAC) Reconstruction: Good Case 299 Figs 65.3, 65.4, and 65.5 These pictures illustrated the result 10 days (Fig 65.3), month (Fig 65.4), and months (Fig 65.5) after NAC reconstruction and contralateral reduction mammoplasty 65.4 Comment of the Author The use of the contralateral nipple and areola to reconstruct the resected NAC improves cosmesis and reduces donor site morbidity as it is not necessary to use an additional donor site However, this technique may only be possible in patients with a large NAC Reference Fitzal F, Riedl O et al (2011) Oncologic safety of breast conserving surgery after tumour downsizing by neoadjuvant therapy: a retrospective single centre cohort study Breast Cancer Res Treat 127(1):121–128 ... central quadrantectomy The patient had a large and ptotic breast (Fig 35. 1a c) 35 .2 Surgery Central quadrantectomy was performed as part of an inferior-based pedicle reduction mammoplasty with a. .. 6 2- year-old patient had a Paget carcinoma of the nipple and intraductal carcinoma in situ of the left breast Central quadran- a tectomy was planned using an inferior pedicle reduction mammoplasty... Patient A 36-year-old premenopausal woman was diagnosed with a small (11 mm) retroareolar cancer of the left breast Mammography and breast MRI revealed no further pathology in both breasts Breast