REVIEW
ONCOPLASTIC INTERVENTIONS IN THE UPPER OUTER QUADRANT OF THE BREAST
Rajput-Anghel Oana Adriana1, Ș.A. Popescu1,2
1Plastic Surgery and Reconstructive Surgery Clinic Bucharest Clinical Emergency Hospital, Bucharest, Romania
2“Carol Davila” Medicine and Pharmacy University, Bucharest, Romania Corresponding author: Popescu Șerban Arghir
Phone no.: +0722454336
E-mail: serban _arghir_popescu@yahoo.com
Abstract
More than 55% of malignant tumor of the breast occur at the level of the upper outer quadrant (UOQ). In the last decade, the quest for fulfilling the two main objectives of oncoplastic breast surgery – ensuring oncological safety and obtaining long-term optimal esthetic results – lead to valuable progress in improving and extending the application of the classic volume displacement or volume replacement techniques and, as well, in validating new and innovative surgical treatment methods. Therefore, an evaluative review of oncoplastic interventions at the UOQ level, based on the literature of the last decade, by analyzing the effectiveness and the efficiency of various surgical approaches is of high interest for both surgeons and patients.
Keywords: breast cancer; oncoplastic breast surgery; upper outer quadrant; breast partial reconstruction
Introduction
The imperative of oncological safety – complete cancer removal with adequate surgical free margins – and achieving local control remain the main consideration for deciding the surgical approach of breast cancer. With the advancements in diagnostic tools and techniques that facilitated early detection of cancer and the use of preoperative chemotherapy, breast conservation surgery (BCS) with adjuvant radiotherapy became the gold standard in the locoregional early-stage breast cancer treatment.
In the last decades, esthetic demands of both patients and surgeons, the aim for reduced psychological morbidity and for a better quality of patients’ life lead to a new, interdisciplinary and holistic approach – oncoplastic breast
surgery (OBS) – a fusion of BCS and plastic surgery techniques [1-4].
By reviewing the literature of the last decade, the present study aims at evaluating progresses in surgical approaches and techniques for oncoplastic interventions in the upper outer quadrant – the most frequent location for malignant tumors of the breast.
Materials and method:
In order to identify clinical studies and case reports on upper-outer quadrant breast cancer patients treated with various oncoplastic surgery procedures, a literature search was carried out using Medline, PubMed, Research Gate and Google Scholar databases. We focused on works published in the last decade (January
2007- August 2017) in English, French, Italian, Spanish, Portuguese and German languages. For databases’ screening the following key-words were used: “oncoplastic breast surgery”
(“OBS”), “oncoplastic breast surgery technique”, “breast partial reconstructive surgery”, “oncoplasty”, “breast conserving surgery” (“BCS”), “therapeutic mammaplasty”,
“partial breast reconstruction”, partial mastectomy”, “breast upper outer/lateral quadrant” (“UOQ”/ ”ULQ”). Among identified articles we evaluated titles and abstracts and further narrowed our research looking for those focusing on oncoplastic interventions at UOQ level. Aiming to minimize the omission of potentially relevant publications, we reviewed the reference lists of included studies and relevant reviews for additional eligible works. A total of 364 potential articles were identified during the primary evaluation. After the appraisal of inclusion criteria, 112 articles were selected for detailed review; out of these, 48 studies form the basis of the review.
The review included only studies, articles and case reports presenting relevant information concerning: tumor/defect location in upper outer quadrant of the breast; patient demographics (age, sex, tumor size and histology, excised breast volume); relevand information concerning the oncoplastic strategy, treatment and technique used for the presented cases;
sugical outcome: complications, oncological outcome (positive/negative margins, rate of local recurrence), functional and cosmetic results, follow up period.
Difficulties and limitations of study
We identified a relatively small number of studies on clinical series exclusively discussing oncoplastic interventions at the level of upper outer quadrant of the breast. In most cases, patients having upper outer quadrant OBS are included in larger series presenting various tumor/defect location, and this makes difficult or practically impossible to distinguish the specifically relevant data for this particular group.
Considering clinical practice, Clough et colab. [5] state that “there is no clear-cut division between standard BCS and
oncoplasty”. This statement proved to be truth when reviewing literature since many authors present and discuss oncoplastic techniques without referring them as BCS armamentarium.
The small size of clinical series, heterogeneous and often incomplete reporting of patient and tumor/defect characteristics and of surgical outcomes [6,7] significantly limit the access to all aspects necessary for a thorough analysis and for drawing relevant and valid conclusions.
Since the authors do not explicitly announce the evaluation scale used for assessing the cosmetic results, we underline the inherent discrepancies when comparing the declared results – the possibility of differences in results when using alternative instruments for the same case was demonstrated in previous studies [8].
UOQ surgical anatomy and general characteristics
In the UOQ the skin is usually thicker comparing to the central portion of the breast.
Since for the rest of the breast the resting skin tension lines are, in general, parallel to the concentric circumareolar lines, in the UOQ their localization may not be completely obvious when planning incision orientation [9]. Some authors, considering practical experience, recommend the use of curvilinear incisions [10].
The UOQ presents the highest concentration of glandular tissue [11]. The geographic pattern of normal parenchyma enhancement in pregnant and lactating patients, directly related to vascularization, shows a preferable enhancement in the UOQ, symmetrically in both breasts [12].
Coming from the lateral thoracic artery or lateral mammary artery branches, the vascular supply might present considerable variations, changes during the menstrual cycle and is greatest close to the time of ovulation [13-15]
These vessels are used for microsurgical anastomoses in various volume replacement reconstruction procedures. Careful identification and selection of suitable recipient vessels is a prerequisite of successful oncoplastic surgery.
The deep venous system follows the course of the arteries while the subdermal (superficial) venous plexus might be quite variable [15]. The
lymphatic drainage, particularly important due to its role in dissemination of breast cancer, parallels the venous one and is directed towards the axillary lymph nodes and further towards subclavian and supraclavicular nodes. The main lymphatic collectors leading from UOQ pass through the ventrocaudal part of the axilla into the sentinel node located in most cases in the fatty tissue of the lower ventral part of the axilla, near the intersection of the thoracoepicastric vein and the third intercostals
nerve [16]. The nerve supply come from the third anterolateral intercostobrachial nerve and from the supraclavicular nerves from the cervical plexus [17].
The UOQ overlays parts of pectoralis major, perctoralis minor and seratus anterior muscle.
Most clinical studies on large cohorts of patients show the high incidence of tumors and cancers at the level of UOQ and even a tendency of increasing proportion [18] (Table 1).
Study UOQa UIQb LOQc LIQd Central Whole breast/Other
Total no. of cases
Sohn et al [19] 58% 14% 10% 9% 9% 0% 13,984
Jung [20] 45% 24% 15% 5% 10% 1% 711
Aljarrah & Miller [18] 41% 19% 7% 5% 13% 15% 1,158 Aljarrah & Miller [18] 53% 12% 10% 6% 5% 14% 1,477
Lee et al [21] 57% 9% 13% 9% 0% 3% 216
Wu et al [22] 50% 22% 12% 6% 10% 0% 1,044
Bao et al [23] 55% 17% 11% 9% 8% 0% 305,443
Rummel et al [24] 53% 16% 15% 8% 11% 0% 980
Table 1 - Summary of reported data on the incidence of tumors and cancers on breast quadrants a.UOQ – upper outer quadrant; b.UIQ – upper inner quadrant; c.LOQ – lower outer quadrant; d.LIQ – lower inner quadrant
Some authors relate this high incidence of tumors with the anatomical particularities of the region – the existence of a greater amount of tissue (especially epithelial tissue) in this quadrant [25,26]. The genetic alterations [27]
and the increased use of cosmetics (antiperspirants/deodorants containing parabens that have oestrogenic activity) and underarm shaving [28,29] are, as well, among the main hypothesis. Still, due to the lack of consistent evidence based on quantitative reviews, the issue is still under debate and further research needed [30,31].
Comparing to other areas, due to the existence of adjacent structures from which we can mobilize tissue, UOQ is a favorable location for large-volume excisions and carry a lower risk deformity unless more than 20% of the breast volume is resected [5,10]
Deciding the surgical approach
It is accepted that, technically, all patients presenting large lesions, of more than 20% of breast volume (for which standard excision with safe margins is unsuitable) are eligible for OBS and the decision making on surgical technique is a complex, step-by-step process driven by patient and tumor location specific factors [5]
[32]. Most authors consider two main criteria as ground for decision on surgical approach:
excision volume and tumor/defect location [33].
Clough et al [5] include a third one: breast (glandular) density. Breast size, volume of the remaining breast tissue[34,35], breast’s shape distortion and ptosis degree [7], the condition of the recipient/donor sites (in the case of flaps) [36], psychological condition of patient [37] are, as well, important. If all these are objective, measurable and quantifiable, others are rather subjective: patient motivation and informed
decisions, and surgeon’s experience, skills, and technical preferences. The costs (in terms of time and resources) should be, as well, taken into consideration.
There are numerous studies proving that OBS best cosmetic outcomes and better
oncological results are obtained when performed immediately [7,38-40] In over 95%
of the cases presented in the studies included in this review one-time interventions were performed.
Figure 1 - Algorithm for deciding oncoplastic breast surgery technique in upper outer quadrant Assess breast size
Small-moderate Large
Assess the existence of sufficient breast tissue for reconstruction
Yes
Volume displacement techniques
No
Yes
Volume displacement techniques
No Tennis racquet mammaplasty
Modified round block Modified wise pattern Extended glandular flap
Extended glandular flap + adipofascial flap
Rhomboid flap
Larissimus dorsi miocutaneous (mini)flap Endoscopic latissimus dorsi muscular flap
Latissimus dorsi myocutaneous flap+thoraco- epigastric flap+ inferior pedicle rotational local flap
Lateral thoracodorsal flap
Volume replacement techniques Volume replacement techniques
Figure 2 - A B C
A. Periareolar incision and elliptical skin excision above the tumor; B. The nipple areola complex (NAC) is pushed downward and the wound is placed on the projection of the tumor. Partial mastectomy is performed on direct wiev; C. Suture of the periareolar incision and of rescted tumor skin projection.
Figure 3 - A B C
A. The new limits of the areola are outlined (inner interrupted circle). A circumferential incision is made at 15 mm distance. The nipple and tumor to be resected are outlined on the skin; B. The tumor is resected together with the nipple and the skin of the areola is mobilized from the sub cutaneous tissue; C. The skin of the areola and the breast tissue is closed.
Taking into account all these criteria and considerations, numerous OBS and partial breast reconstruction management algorithms were suggested [5,7,41,42]. UOQ specific characteristics allow wide-sized excisions and the use of a rich armamentarium of surgical techniques, from very simple and functional to complex and cosmetic [43]. Generally, these techniques are classified in two categories:
volume displacement (involving glandular reshaping) and volume replacement (involving the use of autologous local or distant tissue flap). Considering the amount of excised tissue and the relative level of surgical difficulty, Clough et al [5] introduces another classification of OPS procedures: level I OPS (resection of ≤20% of breast volume, dual-plane undermining, including the NAC, and NAC recentralization if nipple deviation is anticipated) and level II OPS (excision of 20–
50% of breast volume, mammoplasty and extensive skin excision).
Since the risk of necrosis after extensive undermining is higher in low-density glandular tissue with major fatty composition, level II OPS is recommended that requires only posterior undermining, leaving the skin attached, while Level I OPS is more suitable for dense glandular breast.
Generally, for small size breasts volume replacement techniques are recommended while for medium and large size breasts volume displacement techniques lead to good/excellent esthetic results. Yet, in both cases, decision depends on the existence of sufficient viable breast tissue for reconstruction after tumor resection.
Considering the proved clinical value of the above-mentioned indications, we present here an algorithm for deciding OBS technique for UOQ of the breast (Figure 1) and a set of considerations on some of the new innovative approaches clinically validated and reported in the reviewed articles and works.
A.Volume displacement techniques
Modified round block (Doughnut) technique (MRBT)
Often utilized in OBS, the round block (doughnut) technique has the disadvantages of late-onset scar widening and areola’s shape and/or position, and, as most volume displacement procedures, has a primarily indication for medium and large size breasts and tumor located near to the nipple. The modified round block technique (MRBT) validated by Zaha et al. [44] consists in a single circular incision without the excision of the periareolar skin and subcutaneous dissection extended to the entire breast. By application of a wound retractor the wound is widened and moved onto the tumor and partial mastectomy performed under direct vision. The wound is then closed without tension (Figure 2). As a result, the scar formation was minimal, no subsequent changes in the shape or the position of areola, and defects following excision of tumor distant from NAC (5,2 cm median distance) were successfully repaired. The technique is useful for performing interventions in small-medium without major ptosis and areolae smaller than 3 cm in diameter, and defects located peripherally after excision of >20% of breast volume [45]. If the tumor is closer than 20 mm to the nipple, nipple resection is necessary [46] (Figure 3).
Poor cosmetic outcomes might appear due to radiation therapy and inadequate dissection from the skin and the pectoralis fascia of the breast tissue medial and lateral from the defect [47,48].
Modified Wise pattern
Wise pattern for skin resection is one of the most used in reduction mammaplasty. Since the tumor and defects situated in the UOQ of the breast usually do not fall within the area this technique is indicated for, various modification to Wise pattern [49-50] were reported.
Essentially, the “skin trading” principle is applied: skin normally preserved as part of the pattern is “traded” for the same amount of skin from the inframammary fold on the side of the tumor which is preserved (Figure 4). A major advantage of this procedure is exchanging potentially vascular compromised skin for reliably well vascularized tissue enabling skin overlying the tumor resection area to be exchanged for not undermined skin. The
technique facilitates oncological mammoplasty in UOQ without the need for secondary or extended pedicles and the resection of skin overlying the tumor or scars from previous surgery is also usually possible. Higher medial scars that may occur with this technique tend to be less conspicuous and similar to a reduction mammaplasty [50]. No local recurrences are reported after 1-2 years follow up and cosmetic results were excellent, natural breast shape being achieved.
Extended glandular flap
The glandular flap is generally recommended as a volume displacement technique for closing defects smaller than 20%
of breast volume, in medium to large size breasts, as a level I OBS according to Clough et al [5]. The extended glandular flap reported by Ogawa et al. [55], comprising the mammary gland and the fat in the subclavicular area proved to be efficient for defect reconstruction in the UOQ of dense small breasts. Ogawa’s clinical series included 17 patients. The incision sized varied from 7x5 cm to 15x9 cm, representing 30% and, respectively, 40% of breast volume in small size breasts, from 6,5x6,5 cm to 14x11,5 cm, representing 20%
and, respectively, 40% of breast volume in medium size breasts, and 10x10 cm, representing 20% of large size breast. Breast density is favorable for mobilization of glandular tissue by advancing it into the excision cavity without a high risk of fat necrosis [55]. Comparing immediate and 19-35 months follow up results, no local recurrence was identified but excellent results showed in small size breasts patients. The procedure is easy to perform. Preoperatively, the upper edge of the breast at the subclavicular area and the nipple position are marked and the location of perforators from the internal mammary artery identified by Doppler examination. After partial resection, the extended glandular flap is made by freeing the breast from the skin and the pectoral fascia tup to the marked subclavicular area (Figure 6). Special attention should be paid to keeping the perforators of the internal mammary artery and/or the branches of the lateral thoracic artery intact while making the flap. Flap insertion is followed by checking the breast’s shape while applying pressure from the upper side until the nipple is positioned as
marked before surgery (Figure 5). The flap is secured with absorbable sutures to the surrounding tissue, the skin is sutured, and a
suction drain placed where the skin was freed from the underlying tissue. Al patients were given radiation therapy postoperatively [55].
Figure 4 - A. The Wise pattern; B.The vertical scar reduction mammaplasty involves the lower central quadrant (zone 5); C. In the upper outer quadrant (zone 6) an inferomediolateral pedicle is used, the preserved lateral tissues are used to fill the defect on closure of the Wise skin pattern, while the preserved medial tissues bring a cosmetic effect.
If extended glandular flap provides not enough tissue for filling the defect (as the case of very small breasts), Ogawa et al. [56] suggest the use of an inframammary adipofascial flap for volume completion. This flap is reflected back to the breast area after modeling the breast mound with extended glandular flap.
Inframmamary line is to be reshaped after reshaping the breast. This way 9x8-10x12 cm excision, representing about 40% of the breast volume could be filled up without additional scars (both flaps are created through the same skin incison). No or minor deformation of inframmamary area occurs since not much tissue from this area is necessary. The procedure is simple and with limited indications to outer area of small dense breasts (Figure 7) [56].
Figure 5- The new nipple position is the one marked with the patient in standing position while applying pressure from the upper pole.
(Original reference: [53]) A
C
B
Figure 6 - Extended glandular flap: the flap is made by freeing the breast from the skin and pectoral fascia. The flap is moved into the defect and the breast is remodeled. (Original reference:
[53])
Figure 7 - The inframammary adipofascial flap:
the flap is reflected back to the breast area that is remodeled using an extended glandular flap.
B. Volume replacements techniques Rhomboid flap (Limberg flap)
The rhomboid flap, a type of transposition flap, can be elevated as a cutaneous or fasciocutaneous flap. The flexibility of the skin and the amount of subcutaneous fat tissue determine the area of the defect that a rhomboid flap can cover.
The main steps of surgical procedure consist in: drawing a diamond shape around the identified projection of the tumor on the skin (considering the necessary safe margins according to the tumor size) and completing tumor excision with or without axillary lymph node dissection, marking the rhomboid flap to be used laterally to the defect, at least 2 cm away from the tumor borders, flap incision to the muscular plan and detachment to allow complete rotation, synthesis by fixing the flap base to the subcutaneous tissue of the upper margin of the area to be repaired in order to better support the flap and skin suture (Figure 8). If suitable perforator vessels from intercostal artery are identified during the flap elevation, they can be included to improve blood circulation to the flap. The existence of ample loose donor tissue in the UOQ area allow closure without tension [35,57,58].
Figure 8. A. Rhomboid flap in breast conserving surgery preoperative marking; B. resection of the tumor and the rhomboid flap raised; C. placement of the rhomboid flap after tumor resection (axillary dissection is made using another incision).
There are some critical aspects to be considered when planning and performing surgery. The flap size is to be estimated after tumor resection because the skin contracture caused by tumor invasion is released after tumor resection and the defect become slightly larger
compared to the prior marking [36]. Since the flaps for covering UOQ defects are to be projected proximal to the axilla, sentinel samplings and axillary dissections can be performed from the same incision used for flap elevation by dissecting them from the base of
the donor area after flap removal [57]. When the flap is designed on superior pedicle within the axilla, a dog-ear deformity, difficult to revise during surgery, appears in this area [36]. The standing cones appears especially in young patients with thicker skin when the flap’s rotation point approaches 60 degrees [59].
The main advantages of this technique consist in: possibility of en bloc resection of skin and glandular tissue even in large tumors, obtaining regular and adequate safe margin of resection, provides sufficient dermal tissue for reconstruction, permit muscle sparing, avoiding distortion of mammary groove. In terms of efficiency, the rhomboid flap technique is simple and easy to perform, flap elevation does not necessitate a special device, necessitates a relatively short time for surgery and hospital stays and does not delay adjuvant therapy administration.
Latissimus dorsi (LD) flap
Among various volume replacement techniques presented in the studies included in the present review, latissimus dorsi flap remains the preferred technique for OBS interventions in UOQ of the breast, being used in 42,69% of the described cases. The LD flap is based on the thoracodorsal artery and provides skin, muscle and subcutaneous tissue for repair cutaneous and glandular defects. Used as myocutaneous (LDMCF) or muscle flap (LDMF), as single- source of tissue or in combination with other flaps, harvested by open surgery or by
endoscopy, this flap proved to be safe and reliable. In the last decade, the LD myocutaneous mini-flap [60] for UOQ defects increased in popularity due to its advantages:
avoiding a frontal scar performing a single lateral retromammary incision for quadranectomy, axillary dissection, flap harvest, and reconstruction of the defect all together (Figure 9). The general indication for LDMC flap and myocutaneous LD mini-flap is for small to moderate size breasts. Yet, good functional and esthetic results were reported in patients with large ptotic breasts [61].
LDMCF represents an optimal OBS technique for large defects (>150 g excised volume) affecting up to 40% of breast’s volume [21] [62]. When larger volume is required, a combination of LDMCF with thoraco-epigastric flap and an inferior pedicled rotational local flap would allow reconstruction of large defects (up to 972 g excised volume) in breast cancer patients with macromastia or ptosis [63] (Figure 10).
Among disadvantages of using LD myocutaneous flap the following are mentioned:
wide scar at the donor site, limited range of shoulder motion, incidence of seroma, difficulty of surgical procedure that implies a longer surgical time. Donor site scarring is the main reason for over 65% of patients appreciate overall cosmetic and functional result as good or fair.
Figure 9 - Latssimus dorsi myocutaneous miniflap: preoperatively marking including the tumor, the segment of breast to be removed (B) and the latssimus dorsi myocutaneous miniflap to be used in reconstructing the defect (A).
Figure 10 - Combined pedicle flap surgical technique: latissimus dorsi myocutaneous flap (LDMCF) + thoracoepigastric flap (TEF) + inferior pedicled rotational local flap (IPRLF) A. through an incision (1), the partial mastectomy is made (2); the width of TEF (3) should be more than 8 cm; B.the obtained TEF is placed at the lower border of LDMCF; C. defect from partial mastectomies would be filled with LD flap (4) and TEF; D. the counter traction (5) of the inferior pedicled rotational local flap is done and the “dog ear”(6) is trimmed off both sides of the incision.; d. completion of the combined pedicle flap. (Original reference: [60])
Endoscopic latissimus dorsi flap
The main aim of endoscopic LD muscular flap harvesting is to reduce scarring and donor site morbidity. Since literature offers multiple detailed descriptions of flap harvesting technique [64,65], we will focus on aspects related to UOQ interventions.
Identified information recommends this approach for replacement of 20% to 40% (50- 100 g excised volume) [66]. When placed in UOQ of the breast, defect site is nearer to the donor site and the mastectomy incision can be used as the main incision. One incision is added on the flank for trocar insertion and a sentinel lymph node biopsy incision is used for dissection of the muscle origin and thoracodorsal pedicle. This way, only the scar in the mastectomy site is more visible while the axillary and trocar insertion site scars are almost invisible. On the other hand, the need to change patient’s position from the supine position
(during partial mastectomy) to lateral decubitus (for flap harvesting) elongates the operation time and increases the chances of infection [66].
Since the muscle is denervated (to prevent postoperative animation), breast shrinkage is to be expected and further volume reduction would result after radiation therapy. Therefore, the reconstructed breast should be larger than the desired size and should make sure there is sufficient tissue volume to be transferred for reconstruction [66]. Still, there are no data on the appropriate volume of overcorrection.
Keeping subscarpal fat on top of the muscle would both add volume and reduce the risk of atrophy [65].
This technique is a difficult one so familiarity with both instrumentation and endoscopic approach is necessary. One of the main challenges is to obtain an optimal visual field. Yang et all [66] and Losken [65]
recommend the use of a retractor or an endoscopic retractor placed via the main
incision since other attempted methods request both sophisticated and expensive devices, additional cost, and experienced skills.
Lateral thoracodorsal flap
The lateral thoracodorsal flap is a wedge- shaped fasciocutaneous transposition flap with an axis along the lateral and dorsal extensions of the inframammary fold, with the superior border starting at the medial to anterior axillary fold and extending laterally, and with a curved inferior border extending to the anterior axillary line (Figure 11). For determining the flap dimensions the pinch test is useful and the base of the flap might be set at 5-10 cm while the length to 7-12 cm [59,67]. As a principle, the flap width should be designed considering the possibility of direct closing of the donor site [68]. When large flaps are necessary, a convex flap design allows a larger amount of skin and narrows the base for avoiding wound tension closure [59] and an aesthetically satisfactory result is achieved by creating a pear shape [67].
A B
Figure 11 - Lateral thoracodorsal flap: A:
intraoperative design after tumor resection; B.
mobilization of the flap and sutures in the final position.
Figure 12 - L-positioned propeller flap: the long part of the flap is used for the partial breast defect reconstruction while the short part of the flap will fill the axillary dead space.
When additional volume is necessary for defect reconstruction, the superior (scapular) and inferior (lumbar) fat compartments irrigated by the proximal perforator of the descending branch of the thoracodorsal artery can be partially included in the flap [68]. The application of perforator concept (thoracodorsal
artery perforator – TDAP flap) considerably extended the range of alternative for raising thoracodorsal flap: propeller flap [69] (Figure 12), flip-over flap, muscle-sparing flap [68].
The indication is for small to moderate size breasts for defects after excising 38-150 g tissue volume. [21,34,66]. Between 79-82% of
reported patients declared overall general satisfaction with the procedure and 69-81.7%
were satisfied with the esthetic results. There are some important aspects to be considered for flap design and surgery planning. The lateral thoracodorsal flap is contraindicated if there is a history of surgery to the lateral chest wall [21].
For providing flap viability it is necessary to include the fascia of the LD and anterior serratus muscles while elevating the flap (the flap’s vascular supply derives from the lateral intercostals perforators and muscular fascia).
Particular attention should be given to donor site management – complications are usually higher than flap complications and hypertrophic and depressed scars might appear [59]. The most common complications (steatonecrosis, distal tissue necrosis, and distal tissue suffering) can be avoided by adequate resection of the distal part of the flap until healthy red bleeding is observed [68].
The main advantages of using lateral thoracodorsal flap in OBS are: excellent skin and tissue matching with the native breast, an inconspicuous scar positioned under the arm and brassiere [21]; muscle and nerves sparing and less invasiveness at the donor site, morbidity of the donor site is minimized without sacrificing muscles or nerves, implying less invasiveness [67]. All these result in good functional and esthetic outcomes. The technique is relatively simple and consistent. Since most complications are predictable and manageable, they do not impact on hospital stay or on adjuvant treatment.
Conclusions
In spite of the disproportionate number of breast cancers occurring in the UOQ of the breast, discussions regarding OBS interventions at this level are not specifically conducted. The majority of the identified reports in the last decade literature give scattered and incomplete information. Yet, there is a noticeable permanent preoccupation for improving the application and extending indications of already
“classic” techniques and, as well, for clinically validating new surgical approaches with the aim of obtaining best oncologic, functional and cosmetic results.
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