Inferior Lesions: Zone 5

Inferior lesions in zone 5 are perhaps the easiest defects to fill, because they can be managed like a vertical Lassus or Lejour type of reduction closure. The tumor lies in the center of the lower pole and is resected much as in the standard breast resection of the Lassus procedure. This leaves medial and lateral pillars that are easily approximated, resulting in good coning of the final breast shape (▶Fig. 62.4)

This 26-year-old woman presented with an aggressive phyllodes tumor of the right breast with high mitotic activity (▶Fig. 62.5). A lumpectomy resulted in a single positive margin laterally but several close margins; re-excision of the lower pole tumor was advised. The patient already had flattening of the lower pole of the breast as a consequence of her initial transverse resection (▶Fig. 62.5b,e,h). A wider resection of the initial operative site was planned using a Lassus-type vertical reduction pattern. This permitted resection of a large area of skin formerly close to the tumor and allowed easy closure with excellent restoration of contour, although at the expense of a smaller breast volume. The patient is delighted with the outcome. Shape and symmetry are good, and nipple sensation has been preserved.

Inferolateral Tumors: Zone 7

Inferolateral tumors of zone 7 are best closed with a superomedial pedicle incorporating an accessory flap of inferior central tissue to rotate into the lateral defect. The accessory pedicle should be broad based to maximize vascularity; it is rotated laterally for volume fill. Nipple–areolar displacement may be relatively minor with this procedure unless the patient wants a significant mastopexy or breast reduction (▶Fig. 62.6).

This 49-year-old woman had a grade 2 infiltrating ductal carcinoma in the inferolateral region of the left breast. She desired breast preservation; however, because of her large breasts and the tumor size and location, she was deemed a poor candidate for breast-conserving therapy (BCT) alone (▶Fig. 62.7).

The oncoplastic reduction approach was chosen to make her a better candidate for BCT and to minimize the risk of poor cosmetic results. She underwent a 400-g partial mastectomy; the margins were clear. After the cavity was clipped, her breast was reshaped using the reduction technique. A superomedial pedicle was chosen to preserve nipple viability, and an additional 200 g was removed. The remaining glandular tissue, along with the dermatoglandular pedicle, was used to fill the defect and reshape the breast mound. A similar contralateral reduction procedure was performed using the superomedial pedicle. A total of 650 g was resected from the right breast in anticipation of some breast fibrosis after radiation therapy (▶Fig. 62.8).

The patient’s early results are shown at 1 month postoperatively, just before radiation therapy was begun (▶Fig. 62.9).

This 60-year-old woman had an inferolateral carcinoma of the left breast and was a candidate for BCT. Her breasts were extremely large and pendulous, with nipple-to-notch measurements of 41 cm and inframammary fold-to-nipple distances of 26 cm. Lower breast amputations with immediate nipple reconstruction were performed, because nipple grafts were considered risky in this obese smoker. She is shown 9 months postoperatively, with nipple–areolar reconstruction and tattooing. Her breasts remain soft, and symmetry is good (▶Fig. 62.10).

Inferomedial Tumors: Zone 2

The smaller the patient’s initial breast volume, the more difficult inferomedial defects are to reconstruct. Women with generous breast volumes de novo, particularly those with cleavage, have more tissue to transpose into the medial breast from the inferior central area. Small-breasted women may be too volume deficient to make breast conservation worthwhile. A tumor resection localized to the area of resection included in the standard inferior pedicle Wise pattern reduction will allow a very simple closure using standard breast reduction procedures, as shown above.

In smaller-breasted women, a parenchymal flap has to be advanced into the defect. This can be achieved using a superiorly based pedicle with an accessory block of inferior parenchyma from the lower pole. This may result in flattening of the lower pole if the patient does not have much inferior glandular ptosis with which to work (▶Fig. 62.11).

This 52-year-old woman with mammary hypertrophy and grade 3 ptosis presented with a 3.2-cm inferomedial tumor (zone 2). A lumpectomy was performed and 1 week later, after negative margins were confirmed, she underwent an inferior pedicle Wise pattern reduction with inferior displacement of upper medial breast fullness. Between this maneuver and positioning of the inferior pedicle, a 12 by 10 cm defect was completely filled, producing good breast shape and symmetry; 975 g was resected on the right and 734 g on the left (▶Fig. 62.12).

Postoperatively, she underwent 6 weeks of radiation therapy and is shown 3 weeks after completion of treatment. Shrinkage of the left breast is already apparent, and the skin flaps are tight and edematous (▶Fig. 62.13).

This 46-year-old woman had an infiltrating ductal carcinoma in the medial aspect of her left breast. She had minimal ptosis with relatively small breasts. Her mastectomy specimen weighed 40 g, leaving a defect in the medial breast, which is a cosmetically sensitive location. Her defect was filled with an extended superolateral dermatoglandular pedicle that was rotated medially; no additional tissue was removed. The inferior donor defect was closed in the usual vertical mastopexy fashion by plicating the medial and lateral pillars. In a similar procedure on the opposite breast, a small lower pole skin-glandular resection of 70 g was done (▶Fig. 62.14).

Superior Quadrant Tumors: Zone 3

Tumor defects located between the 11 o’clock and 1 o’clock positions on the breast can be easily filled by advancing an inferior pedicle, particularly in larger-breasted women with ptosis. The correction is simple and involves little more than a conventional Wise pattern inferior pedicle approach. The higher the tumor on the chest wall and the thinner the patient, the more difficult this becomes. If there is a paucity of available tissue, glandular “wings” of parenchyma from the lateral and medial upper quadrants can be mobilized to help close the defect (▶Fig. 62.15).

This 54-year-old woman presented with a 2-cm breast carcinoma at the 12 o’clock position above the nipple of her left breast. The lesion was 1.2 cm in diameter, and she opted for BCT. An inferior pedicle technique incorporating a Wise skin pattern was used. The superior translocation of the pedicle easily filled the lumpectomy defect, restoring excellent balance to the upper pole of her breast. She is shown 6 months after radiation therapy (▶Fig. 62.16).

This 39-year-old woman had a right breast upper pole tumor. She had relatively small ptotic breasts, with a significant potential for breast deformity after resection. The tumor required a 163-g resection, leaving a full-thickness defect lying above the location of the proposed nipple position. Insufficient glandular tissue was present above the nipple to fill the dead space using an inferior or central mound alone. This would have left a volume void above the nipple. We rotated glandular flaps from the medial and lateral breast mound to fill the volume void above the nipple (▶Fig. 62.17).

The skin was then redraped over the breast mound using the standard Wise technique. A contralateral mastopexy was performed using a central mound; 183 g was resected. Early results showed preservation of shape and symmetry (▶Fig. 62.18).

At 2-year follow-up, the upper pole contour was good (▶Fig. 62.19).