Aesth. Plast. Surg.

31:71 75, 2007

DOI: 10.1007/s00266-005-0063-7

Original Articles

A Modied Excision for Combined Reduction Mammoplasty and Breast

Conservation Therapy in the Treatment of Breast Cancer

Donald A. Hudson, F.R.C.S., M. Med.

Department of Plastic and Reconstructive Surgery, University of Cape Town, Cape Town, South Africa

Abstract. Wide local excision combined with postoperative
radiotherapy is a useful technique for patients with breast
cancer. For patients with macromastia whose tumor is sit-
uated in the lower pole of the breast, a breast reduction
(keyhole\inverted T pattern ) can be used to achieve wide
local excision. However, for patients whose tumor is not in
the inferior portion of the breast, and in whom this cancer
also is situated close to the skin (requiring excision of skin
with a 1-cm margin for oncologic safety), the traditional
keyhole pattern cannot be used. A modication of the
keyhole pattern\inverted T is described. The pedicle used
depends on the site of the tumor. Although the breast scars
are in dierent positions, a similar breast shape as well as
symmetry still can be achieved. This is a useful technique
for a select subgroup of patients. The outcomes for three
patients are presented.
Key words: Breast cancerConservation surgery
Breast conservation therapy consisting of wide local
excision and postoperative radiotherapy is a well-
established form of treatment for breast cancer [2 4].
The technique has the advantage of preserving the
original breast skin and retaining the nipple areola
complex [2 4]. The disadvantages include the eects
of radiotherapy on the breast and the fact that if
tissue is excised from only one breast, asymmetry
may result.
For patients with large breasts whose tumor is
situated in the inferior pole of the breast, a bilateral
breast reduction can be performed [2 4]. This en-
ables a wide local excision of the tumor, and by
Correspondence to D. A. Hudson, F.R.C.S., M. Med.; email:
hudsond@ uctgsh1.uct.ac.za
removal of tissue from both breasts, also creates
breast symmetry. In addition, it enables some path-
ologic assessment of the opposite breast [2].
This article reports on three patients whose tumor
was situated close to the skin in the upper and lateral
aspect of the breast. A bilateral breast reduction was
performed, but the skin markings were modied to
enable an oncologically safe procedure including
excision of the overlying skin.
Technique
The technique involves the keyhole\inverted T pat-
tern consisting of three triangles (Fig. 1). There is a
vertical triangle, a medial triangle, and a lateral
triangle. The inferior margins of the medial, lateral,
and vertical triangles usually are placed along the
inframammary fold. With this technique, the lateral
triangle is not positioned at the lateral base of the
breast, but is advanced up onto the breast to overlie
the tumor (Fig. 2).
Markings
The patient is marked routinely in a standing position
before breast reduction. The tumor is identied and
the skin overlying the tumor is marked such that a
1-cm tumor clearance of the tumor is achieved
(including skin). In the reported cases, the tumor was
situated in the upper and lateral aspect of the breast,
and would not be included inside the markings of a
traditional keyhole pattern.
The new nipple position is marked at the level of
the inframammary fold, according to standard pro-
cedure. The markings are completed as if only a
vertical and medial reduction is to be performed
72
Fig. 1. The keyhole\inverted T breast reduction pattern can
be considered to consist of three triangles: a medial triangle,
a lateral triangle, and a vertical or middle triangle. In this
article, the lateral triangle is transposed up onto the breast
to overlie the tumor (see Fig. 2).
Fig. 2. The lateral triangle (GFH) is situated over the
tumor (X). X=tumor.
(Fig. 2). The inferior margin of the medial and ver-
tical triangles are placed, as usual, in the inframam-
mary fold.
The two vertical lines are traditionally marked
approximately 5 cm in length. However, in these
patients, the lateral vertical line (line AE in Fig. 2)
extends from the (vertical ) apex of the T, not for
5 cm, but to the midline of the breast at the infra-
mammary fold (point E in Fig. 2). This means that
the lateral vertical line (AE) is longer than the medial
vertical line (AB). In Fig. 2, the medial line AB is still
marked 5 cm in length, but the lateral vertical line,
AE, is obviously longer.
The lateral triangle is marked over the site of the
tumor such that it also allows a margin of skin
excision 1 cm beyond the tumor. This triangle forms
the lateral extension of the markings on the breast.
To ensure that line AE becomes the same length as
AB, the lateral triangle is designed such that the
length of the triangle base (GF) equals AB. Described
another way, the base of the medial triangle (BD) is
the same as that of the lateral triangle (GF).
It should be noted that the lateral triangle is
marked to enable excision of skin 1 cm beyond
Breast Conservation Therapy
Fig. 3. Preoperative view of patient 1 with a T1NO tumor
of the left breast. The tumor was inferior and lateral to the
nipple areola complex (NAC). Operative markings are seen.
Note that the lateral triangle was placed superior to the
inframammary fold.
the borders of the breast tumor. The lateral extent
(the apex of the triangle) passes to the lateral border
of the breast (Figs. 3, 4, 7, and 8).
Any pedicle (viz, superior, superior-medial, infe-
rior, or lateral) can be used. The choice is made
according to the site of the tumor, the safety of the
pedicle, and its ease of rotation. Similarly, if the
tumor is situated in the medial quadrant, the medial
triangle of the keyhole pattern can be moved supe-
riorly to overlie the tumor.
Clinical Cases
Case 1
A 44-year-old woman presented with a T2N0 carci-
noma of the left breast situated laterally just inferior
to the nipple and close to skin. Her right breast was
slightly bigger than her left breast (Figs. 3 and 4). The
nipple-to-notch distance was 23 cm on the left and 25
cm on the right, and the distance from the infra-
mammary fold to the nipple was 8 cm on the right
and 9 cm on the left. A bilateral reduction was
performed using a superior pedicle, with 150 g excised
from each side. At this writing, the patient has
completed her course of chemotherapy and radio-
therapy, and it has been 10 months since her surgery
(Figs. 5 and 6).
Case 2
A 44-year-old woman presented with a T2N0 carci-
noma of the right breast (Figs. 7 and 8). The carci-
D.A. Hudson
Fig. 4. Oblique view showing the site of the tumor and the
markings of the lateral triangle.
Fig. 5. Postoperative result, anterior view. This patient had
150 g excised from each side. Reasonable symmetry is dis-
cernable.
noma was situated in the superior and lateral aspect
of the breast (above the position of the nipple) The
patient also was markedly obese. The nipple-to-notch
distance was 35 cm on the left and 34 cm on the right.
The distance from the inframammary fold to the
73
Fig. 6. Postoperative result. Lateral view showing lateral
scar above the inframammary fold.
Fig. 7. Preoperative markings in an obese patient (patient
2) with large pendulous breasts and a T2N0 tumor of the
right breast. The tumor is situated both above and lateral to
the nipple.
nipple was 13 cm on the left and 15 cm on the right.
The patient had grade III ptosis (Figs. 7 and 8). A
bilateral breast reduction was performed, with
1,100 g excised from the left side and 1,050 g excised
from the right side. A superior-medial pedicle was
used (Figs. 9 and 10). The patient has subsequently
74
Fig. 8. Preoperative oblique view showing the lateral tri-
angle in a more superior position. The superior line of the
lateral triangle is at the height of the superior aspect of the
areola.
Fig. 9. Postoperative result after excision of 1,100 g from
right side and 1,050 g from the left side. Reasonable sym-
metry and shape were obtained.
also had a course of chemotherapy and radiotherapy.
At this writing, it has been 9 months since the
reduction using the modied pattern.
Case 3
A 44-year-old woman presented with a T2N0 carci-
noma of the left breast (tumor in the upper lateral
quadrant similar in position to that in case 2). The
nipple-to-notch distance was 29 cm on the left and 30
cm on the right. The distance from the inframam-
mary fold to the nipple was 11 cm bilaterally. She had
a grade III ptosis. A modied pattern breast reduc-
tion (similar to that in case 2) was marked, and the
superiomedial pedicle was used, with 520 g resected
from the left breast and 500 g resected from the right
breast. Her postoperative course was complicated by
an axillary seroma, which responded to drainage. At
this writing, she is 2 months postoperative and about
to begin a course of radiotherapy.
In all three cases, an axillary dissection was per-
formed through the same skin incision.
Breast Conservation Therapy
Fig. 10. Postoperative result. Oblique view (close-up)
showing the site of the lateral scar.
Discussion
Wide local excision using a breast reduction pattern
to eect excision of the tumor is an appealing option
for patients with macromastia (in whom the cancer is
situated in the inferior pole of the breast). It allows
the patients both to undergo adequate oncologic
treatment of the tumor and to relieve the symptoms
of macromastia. The nipple areola complex is
retained, and the patients achieve symmetrical breasts
with symmetrical scars.
When the neoplasm is situated in the upper half
of the breast, wide local excision using a breast
reduction pattern is more dicult, particularly when
the tumor is situated close to skin. This problem is
not commonly addressed in the literature. However,
because the most common site of breast tumors is
the upper outer quadrant of the breast, this site
deserves more attention. Clough et al. [1] presented
a patient whose tumor was situated in the lateral
aspect of the lower quadrant of the breast and rec-
ommended canting the whole keyhole pattern lat-
erally. These authors, however, did not discuss the
results of this technique or its limitations. This is
another method that can be used, but it seems really
applicable only to tumors still situated in the infe-
rior pole of the breast.
An alternative method is to modify the key-
hole\inverted T pattern as described earlier. The
advantage of the technique is that it still allows wide
local excision to be performed (including excision of
the overlying skin with a 1-cm tumor clearance) even
though the tumor is not situated in the inferior pole
of the breast. As in any breast reduction, the pedicle
can be designated as inferior, lateral, superior-medial,
or the like. In the three reported patients, a superior
pedicle (one patient) and a superior-medial pedicle
(patients 2 and 3 ) were used. Certainly, in cases 2 and
3, for example, an inferior pedicle could also have
been used. The pedicle is chosen such that the onco-
logic requirements are still met. For example, if the
tumor is lateral to the nipple, a medial pedicle may be
used to ensure that an adequate tumor margin is
achieved.
D.A. Hudson
The disadvantages of the technique include asym-
metrical breast scars (Figs. 4 and 9), and the fact that
the technique is slightly more demanding for
achievement of a symmetrical shape. The surgeon
must also be conversant with the use of dierent
pedicles for breast reduction. Additionally, the upper
medial quadrant and the superior aspect of the breast
(infraclavicular) are areas in which the technique
cannot be applied.
The modied breast reduction pattern allows
excision of a tumor in a widespread area of the breast
(including the overlying skin). It can be considered an
alternate technique for patients with larger breasts
who have peripheral tumors close to skin to un-
dergo an oncologically safe wide local excision and to
relieve the symptoms of macromastia.
75
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