25 Rearrangement Surgery

10.1055/b-0037-144870

25 Rearrangement Surgery

Dennis C. Hammond, Kuylhee Kim

Many variables are used to describe the appearance of the breast. Anatomic features include volume, fat content, parenchymal content, breast position, skin envelope surface area, skin elasticity, volume-to-skin envelope ratio, nipple position, asymmetry, height, and weight. These characteristics are combined in numerous ways to describe different breast sizes and shapes. Even without the confounding effect of onesided surgery such as lumpectomy with or without radiation, the challenge of surgically altering the breast to create symmetry requires a well-thought-out and expertly executed surgical plan. It is easy to understand why reconstruction of the lumpectomy defect can be such a difficult undertaking.

Approximately 10% to 30% of patients are dissatisfied with the aesthetic result after a partial mastectomy with radiotherapy. ¹ – ⁷ There are many possible causes of aesthetic failure. Tumor resection can produce distortion, retraction, and noticeable volume change in the breast. Changes to the position of the NAC can accentuate asymmetry. Radiation also can have a profound effect on the native breast.

The nature of each deformity depends on the magnitude and location of the lumpectomy. In addition, radiotherapy has a significant deleterious effect on the remaining breast tissue, which limits the extent to which the breast can be safely reconstructed. All of these factors make reconstruction using simple rearrangement surgery one of the most challenging surgical problems in plastic surgery of the breast.

The Decision-Making Process

When choosing the most suitable technique to reconstruct a partial mastectomy defect, several factors should be considered; the longevity of the follow-up, the oncologic status, the severity of the deformity, and the patient’s wishes.

Edema, which occurs most commonly during the first year after surgery, and the effects of the radiotherapy may mask some volume loss. Therefore major correction procedures should be delayed until at least 1 year after radiotherapy. Radiation injuries typically resolve in 6 to 12 months after the last treatment.

A clean oncologic evaluation is required before planning any surgical procedure in one or both breasts. A careful analysis of the problem is the key to a successful outcome. When evaluating a patient for possible rearrangement surgery for reconstruction after a lumpectomy, certain conditions must be present for this approach to be effective. Before any technique is performed, the effects of radiotherapy on the breast to be reconstructed must have stabilized. Typically, the radiation injury initially manifests as an intense, dull red color of the skin in the irradiated field. The skin texture is edematous and firm. With a severe radiation injury, superficial epidermolysis also may be present, particularly in areas of skin folding. These postradiation changes must be allowed to settle before the breast can be operated on effectively. By allowing the swelling in the breast to resolve, the extent of the deformity can be better understood and surgical decision-making can proceed with greater accuracy. Rearranging the tissues is easier if they are as soft and pliable as possible. Once the skin has softened and the erythema has resolved, surgical rearrangement can be considered.

Several classification schemes have been developed to characterize delayed breast deformities and suggest reconstructive options ² , ⁸ – ¹⁰ (see Chapter 23). The tumor’s original location is important. For example, tumors located within the superolateral quadrant cause a lateral distortion of the breast gland and/or the NAC, and tumors located centrally or superiorly lead to retraction and an upward dislocation of the whole breast.

As with any reconstructive method, reoperative breast surgery has to be very carefully planned and executed for each patient. Before surgery, the surgeon should review records of previous procedures and treatments. The clinical evaluation should include all components of the defect. Skin deficiency may not always be obvious, but some kind of skin correction is needed, because skin retraction and scar tissue occur in almost every case. Any postradiation skin alterations should be noted, because they reflect the degree of parenchymal damage. It is difficult, however, to estimate the required amount of skin tissue needed to repair the defect. Nevertheless, severe NAC distortion is an indication that a large skin component is needed.

Patients presenting for rearrangement surgery must have enough tissue left in the treated breast to mold onto an acceptable breast mound. If this is not the case, volume replacement techniques must be employed to obtain an acceptable result. These include a breast implant, but an autologous latissimus dorsi myocutaneous flap or a transverse rectus abdominis myocutaneous (TRAM) flap is preferred. In cases of significant breast asymmetry in which the unaffected breast is larger than the treated breast, reducing the opposite breast may restore enough symmetry to allow rearrangement surgery to be considered as a viable technique. Alternatively, if a persistent size asymmetry is acceptable to the patient, simple reshaping of the affected breast with correction of scar contracture may provide a reasonable result. Whatever the circumstance, the patient must understand that simple rearrangement surgery is a difficult undertaking and the chance for developing a complication is significant.

Operative Strategy

Contralateral Reduction

Many patients who have undergone a lumpectomy with radiation can actually present with an aesthetic breast mound with the NAC properly positioned and thus do not require surgical alteration of the treated breast. Typically, such patients will have some degree of preexisting macromastia that minimizes the magnitude of the distortion created by the lumpectomy. However, it is very common for such patients to have a significant size asymmetry, with the opposite untreated breast being much bigger than the cancer-affected breast. This size discrepancy is a result of both the volume loss created by the lumpectomy as well as the soft tissue atrophy that is often associated with radiation. The magnitude of volume difference and any discrepancy in the level of the inframammary fold can cause the patient to feel self-conscious about her appearance, and it can be difficult to find clothing that does not emphasize this discrepancy. In these patients, a simple unilateral reduction can restore breast symmetry and make it easier for the patient to function socially.

If opposite breast reduction is indicated as a part of the overall reconstructive strategy, it is highly recommended that it be performed after the full effect of the lumpectomy and radiation has become evident.

Often it is not possible to predict how small or how misshapen the treated breast will become in the postoperative period after a lumpectomy. When these changes are allowed to stabilize, a more accurate opposite breast reduction can be performed to maximize the symmetry.

Technique

Essentially, any technique for breast reduction can be used to reduce the volume of the larger breast. However, several modifications in the surgical approach may be required to optimize symmetry.

Nipple-Areola Complex

In general, patients who present for unilateral breast reduction after lumpectomy and radiation had larger breasts preoperatively and therefore a larger areolar diameter. When applying a breast-reduction technique to such patients, it must be recognized that most skin envelope management strategies have a significant areolar reduction component built into the operative plan. However, areolar reduction rarely results from simple lumpectomy alone, and blind application of a normal reduction pattern can create an areolar diameter on the reduced side that is too small when compared to the diameter of the areola on the lumpectomy side. Therefore, when marking the pattern for the opposite sided breast reduction, an alteration in the pattern is often required to create an areolar diameter that is symmetrical with the previously treated breast.

Although the affected breast may have a reasonable aesthetic result after lumpectomy and radiotherapy, it is often positioned slightly lower on the chest wall than it would be after a standard reduction. The location of the NAC can also be lower than is typically seen after breast reduction. Because the affected breast is not being changed, it becomes necessary to alter the marking strategy used for the breast reduction to ensure symmetry.

Therefore, when planning the reduction of the unaffected breast, it is often necessary to mark the NAC position lower than it would be under normal circumstances. In addition, a more conservative volume and skin resection is commonly performed to match the affected breast. By altering the standard reduction approach in this fashion, better symmetry can be obtained.

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