The document discusses the principles of oncoplastic breast surgery and mastectomy techniques. It provides a brief history of mastectomy and describes the physics of breast shape. It advocates for using the Wise pattern incision technique for mastectomies, as it better preserves the skin envelope and shape compared to transverse incisions. Clinical examples are presented showing reconstruction outcomes using implants, flaps and skin-sparing techniques based on these principles.
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Current Practice and Principles of Oncoplastic Breast Surgery
1. ONCOPLASTIC SURGERY… First Principles and Current Practice Joel A. Aronowitz, MD Clinical Chief, Division of Plastic Surgery Cedars Sinai Medical Center
15. Law of LaPlace predicts pattern of breast shape Breast diameter is > in lower pole therefore the skin below the nipple is under greater tension and stretches the most. Nipple decent with the breast.
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17. Severe Tubular Deformity Note medial tightness, large areola typical of tubular breast. 17 yo treated with 500 cc silicone gel prosthesis and keyhole pattern mastopexy
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23. Ptosis due to relative paucity of breast volume Volume restored with prosthesis, skin envelope unchanged Restoration of Skin:Volume Proportion with Prosthesis
24. Relationship of Breast Skin to Volume Post-partum atrophy, lack of breast volume relative to skin envelope Reduction of skin envelope and adition of volume; ie, augmentation mastopexy
25. Excess Skin Envelope and Volume; Breast Reduction Excess breast volume and skin envelope. Rx; breast reduction, ie, a reduction of skin and volume
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30. The Patchwork Effect of Flap Skin after Transverse Mastectomy Surgical textbook drawing of mastectomy skin excisions Lat dorsi skin paddle
70. Skin-sparing Mastectomy : A Survey Based Approach to Defining Standard of Care J Shen MD 1 , J Ellenhorn MD 1 , Dajun Qian PhD 1 , David Kulber MD 2 , J Aronowitz MD 2 1 City of Hope Medical Center, Duarte, CA 2 Cedars-Sinai Medical Center, Los Angeles, CA Southern California Chapter of the American College of Surgeons 19 th Annual Scientific Meeting January 18, 2008
71. Practice Patterns N = 370 Standard transverse elliptical N = 75 (20) Skin-sparing MOST of the time N = 224 (61) Mastectomy with immediate reconstruction N = 331 (89) No immediate reconstruction N = 39 (11) Skin-sparing SOME of the time N = 32 (9)
72. Safety No. (%) Greater flap necrosis Yes No 91 (25) 279 (75) Excision of biopsy incision is mandatory Yes No 31 (8) 339 (92) Higher rate of local recurrence Yes No 38 (10) 332 (90)
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74. Perceptions by Clinical Setting * P-value ≤ 0.05 vs. Academic, Mixed, and HMO ** P-value ≤ 0.05 vs. HMO *** P-value ≤ 0.05 vs. Academic and HMO Private N = 260 Academic N = 30 Mixed N = 26 HMO N = 54 Skin-sparing mastectomy 158* (61%) 25 (83%) 23 (88%) 50 (93%) Feasibility 174** (67%) 24 (80%) 16 (62%) 48 (89%) Higher recurrence 29 (11%) 3 (10%) 3 (12%) 3 (6%) Improved cosmesis 166*** (64%) 29 (97%) 20 (77%) 42 (78%)