Oncoplasty is state-of-the-art for repair of partial mastectomy defects and is optimally performed before the delivery of radiotherapy. Depending on the pathology, access to intraoperative tumor margin assessment, or surgeon preference, oncoplasty can be performed immediately at the time of partial mastectomy or delayed before radiation therapy, which allows for review of the final pathology before repair. However, delayed repair before radiation requires two separate surgical procedures, and the aesthetic outcome is not always as desirable as immediate oncoplasty. Immediate oncoplastic dermoglandular repair before radiotherapy can involve various creative designs to rearrange the remaining breast tissue after partial mastectomy. Patients with large-sized breasts, including those women with C-cup-sized breasts and those with D-cup-sized breasts or larger, benefit from the use of the remaining breast tissue to repair the breast.
In patients with C-cup breasts with upper quadrant tumors with some degree of breast ptosis, displacement concentric mastopexy can be an ideal option for repair ( Fig. 9.1 ). The advantage is that the repair elevates the position of the nipple–areolar complex (NAC) and displaces the lower pole breast tissue to fill upper pole defects. After radiotherapy, the region of the defect may be fat grafted and the contralateral breast may be made smaller with direct liposuction or surgical excision of skin and fat. However, because the defect is repaired before radiotherapy, there is not usually a localized deformity, only a diffuse volume loss to the breast from radiotherapy. Therefore, most often, the second stage of this repair involves fat grafting to the entire breast after radiotherapy to replace the diffuse volume loss and minor adjustment to the contralateral breast for symmetry.
Mammoplasty is the optimal approach to repair partial breast deformities before radiotherapy in patients with D-cup-sized breasts or larger. Standardization of technique has become an important initiative in the United States and abroad as a means to encourage reconstructive breast surgeons to routinely perform oncoplasty. Vertical oncoplasty is used in large, ptotic-shaped breasts with narrow-base widths. Kronowitz Vertical Oncoplasty is a systematic approach to using vertical oncoplasty to repair partial mastectomy defects in all locations within the breast ( Fig. 9.2 ). In patients with upper pole defects, a superomedial or superolateral dermoglandular pedicle is used for repair, whereby the lower central breast tissue is rotated into the upper pole defect either clockwise or counterclockwise, respectively ( Fig. 9.3 ). With lower pole defects, the use of dual-dermoglandular pedicles allows for both elevation of the NAC and filling of the defect. For defects located within the lower inner quadrant, both a superior and inferolateral dermoglandular pedicle is utilized for the repair ( Fig. 9.4 ). Similarly, defects in the lower outer quadrant are repaired with a superior pedicle and inferomedial pedicle. The superior dermoglandular pedicle elevates the NAC position and the inferiorly based dermoglandular pedicle advances either medially or laterally to fill the defect.