As the incidence of breast cancer continues to rise in the Western world, more attention has been given to both prevention and treatment of this disease. Prevention is aimed at identifying those patients at a higher risk for developing breast cancer (i.e., those with familial and hereditary factors) and screening tools such as self-breast exams and mammography in an attempt to catch the tumor at an earlier stage in the general population. Acceptable surgical treatment for breast cancer has evolved from radical mastectomy to modified radical mastectomy and to breast conservation therapy. More recently with the discovery that lumpectomy with sentinel node biopsy along with postoperative radiation offers a similar long-term survival to that of modified mastectomy, many patients have become candidates for even more conservative treatment. Breast conservation therapy (BCT), which includes lumpectomy and postoperative breast irradiation, is now offered to many stage I and II breast cancer patients as an alternative to mastectomy. Magnetic resonance imaging (MRI) is now frequently used to accurately determine the extent of breast disease in certain patient populations, especially high-risk populations. MRI is more precise in determining the extent of breast disease compared to mammography, thus allowing for more accurate surgical planning if breast conservation is desired (1,2).

Most patients treated with BCT are reported to have acceptable cosmetic results with minimal distortion and asymmetry. Some contraindications for BCT have included large tumor/breast ratio, large breast size, tumor location beneath the nipple, and collagen vascular disease. The criteria for BCT, however, have continued to evolve to include lower quadrant tumors, large tumors, very large breasts, and central tumors. As the group of patients undergoing breast conservation surgery has expanded, so too has the potential for disfigurement. Aggressive excision and re-excisions with wider margins to reduce the risk of local recurrence may leave the patient with a less acceptable cosmetic result. Women with very large breasts have historically been considered poor candidates for breast conservation because the necessarily high doses of radiation required to penetrate their thicker breast tissue may lead to negative skin changes and an increased risk of fibrosis. The radiated breast may thus appear contracted, distorted, or disfigured. Several studies have already shown the deleterious effects of radiation on larger breasts. Brierley et al. demonstrated late radiation fibrosis occurring in 36% of patients with larger breasts, compared with 3.0% for smaller breasts (3). Clough et al. found an excellent result following breast conservation surgery and radiation in 100% of A cup patients but in only 50% of patients with a D cup (4). Ray and Fish found that 92% of A/B cup patients had an excellent cosmetic result versus 64% of C+ patients (5). Some forms of chemotherapy are believed to exacerbate the negative effects of radiation. Deformities caused by radiation in women with large breasts may be difficult to manage and may require additional surgery, including reconstructive procedures using autologous flaps, implants, or some form of mammaplasty.

Unfortunately, for whatever reason, creative forms of breast conservation, which can include reduction mammaplasty, have not gained the type of wide acceptance in the United States that they have in Europe. The safety of reduction mammaplasty as part of breast conservation surgery in the treatment of breast cancer has been supported in many studies, primarily outside North America. At Georgetown University Hospital, the senior author (S.L.S.) more recently published a study of 11 patients who underwent breast conservation surgery that included bilateral reduction mammaplasty with no local recurrences and 1 death from distant metastasis after a 24-month follow-up. There were no major complications, but there were eight minor complications, including one hematoma, one keloid, one radiation burn, two cases of nipple hypopigmentation, and three cases of fat necrosis. When the patients surveyed were asked to rate their degree of aesthetic satisfaction, the mean score was a 3.3 out of 4.0 (6). Kronowitz et al. described using breast reduction for breast conservation therapy in mostly large-breasted patients (i.e., greater than D cup) in contrast to using local breast tissue rearrangement and/or flaps (i.e., latissimus dorsi or transverse thoracoepigastric flaps) for filling large partial mastectomy defects. Subgroups were categorized as immediate if the reconstruction was done at the time of the partial mastectomy prior to radiation therapy or delayed if reconstruction occurred after the partial mastectomy and radiation therapy. They found twice as many complications in the breast reduction group (50% vs. 24%) if the reduction was done in the delayed setting (averaging 4 months after radiation therapy). Most of the complications were related to poor wound healing commonly seen after radiation therapy (7). The MD Anderson Cancer Center group also found that there was a 7% local breast recurrence at the 36-month interval (8). Newman et al. found no local recurrence in 28 patients with stage I or II breast cancer who underwent reduction mammaplasty combined with breast conservation surgery after a median follow-up of 23.8 months. Eighty-six percent of the patients surveyed reported being very happy with their cosmetic result. Major wound complications
occurred in 7% of the patients, including 1 patient with cellulitis responsive to intravenous antibiotics and 1 patient with incisional necrosis requiring debridement. There were no major complications following radiation therapy (9). Smith et al. reported no complications or local recurrences following the breast conservation surgery combined with reduction mammaplasty and obtained a good or excellent result in all their patients (10). Another added benefit to performing reduction at the time of the resection for cancer is improvement in the symptoms typically described by many women with macromastia. It is now well established in the medical literature that the vast majority of women suffering from the symptoms of breast enlargement obtain relief after reduction mammaplasty (11). How about the alternative of performing breast reduction after breast conservation surgery and radiation are completed? Surgery on an already radiated breast is more difficult because the skin is atrophied and less elastic, the parenchyma is fibrotic and often edematous, the blood supply to the skin flaps and breast tissue is often compromised, and the local tissues have a diminished ability to heal. The senior author (S.L.S.) found that although the results are generally acceptable, the breast reduced after radiation is typically less attractive than the simultaneously reduced nonradiated one (12). The irradiated breasts also took longer to heal and suffered from prolonged edema and erythema. The results of our study showed that the specific reduction technique was inconsequential; however, we recommend limiting flap undermining and maintaining a wide pedicle to avoid complications such as flap and nipple necrosis. When considering reduction mammaplasty after radiation, we recommend waiting 12 months or so until the acute postradiation response—skin redness and swelling—has settled.