Immediate reconstruction using a modified inframammary adipofascial flap after partial mastectomy

BCT has become the standard treatment for breast cancer as it achieves local control with acceptable cosmetic results [4]. However, an insufficient resection margin may result in local recurrence if too much attention is paid to cosmesis. Immediate reconstruction after BCT has thus become popular for early stage breast cancer [5, 6]. We previously reported our early experience of an oncoplastic technique whereby an inframammary adipofascial flap is used to repair partial defects in the lower part of the breast in Japanese women [1]. This technique is considered more useful for breast surgeons than for plastic surgeons to repair breast defects immediately and prevent intra- or postoperative complications; however, it can be difficult to harvest sufficient flap material via an incision close to the cancer lesion without special devices because the posterior edge of the flap is so far from the incision line. Thus, we describe a modified technique for reconstructing defects in the lower part of the breast in patients with early breast cancer, using a modified inframammary adipofascial flap (an inframammary adipofascial flap with dermis).

Postquadrantectomy deformities include localized skin and glandular tissue defects, distortion and/or dislocation of the areola, and retraction of the breast tissue. Perhaps the most prominent and common failure in achieving a good esthetic outcome is a lack of breast symmetry [7]. Surgical techniques used to address the conflict between oncological and cosmetic results are classed under the general term of “oncoplastic surgery” [8]: a new surgical approach that allows wide excision but prevents breast deformities by reconstructing large resection defects immediately [9].

The lower pole of the breast was the first recognized high-risk location for deformity [10‐13]. Retraction of the skin and downward deviation of the NAC, resulting from tissue excision from the 6 o’clock position, is known as the “bird’s beak” deformity [10, 13]. Existing mammaplasty techniques were initially modified to become oncoplastic techniques for correcting defects caused by surgery for specific tumors such as lower-pole cancer [10, 11, 14]. Numerous oncoplastic techniques have been developed and are gaining attention in the surgical literature. Several authors have described the utilization of an inverted T-mammoplasty technique for filling defects in all quadrants by extensive mobilization of the lower gland [15‐17]. Munhoz et al. concluded that the indications for oncoplastic surgery, combining partial mastectomy with a reduction-type operation, include patients with medium- or large-volume breasts, who have small to moderate defects and enough remaining breast tissue to permit reconstruction. They also concluded that the success of the procedure depends on patient selection, coordinated planning, and careful intraoperative management [15]. According to reports from Western countries, for patients with relatively large and ptotic breasts, oncoplastic surgery combining a reduction-type operation and recentralization of the nipple–areola complex produced good results [18, 19]. However, for most Japanese women, who have smaller breasts than many Western women, it may be more appropriate to reshape the breasts by filling them with extra-breast tissue, rather than performing reduction-type oncoplastic techniques [1‐3, 20, 21]. Moreover, some patients do not want to undergo oncoplastic surgery involving a combination of partial mastectomy, reduction, and recentralization of the nipple–areola complex, with or without a contralateral operation to achieve better symmetry. We previously reported how immediate breast reconstruction using an adipofascial flap to fill partial defects in the lower breast is useful for such patients. However, the incision made along the inframammary line to remove the lesion is sometimes far from the edge of the flap, making it difficult to obtain sufficient flap material, without special devices such as longer electric knives, endoscopic instruments, or retractors with lighting systems.

We have since modified our technique for attaching de-epithelialized skin by adding an additional incision to make it easier to harvest the flap. A nutrient vessel of this adipofascial flap is the inframammary intercostal artery perforator [22]. The tiny but certain increase of volume in the adipofascial flap can be improved by attaching dermis. It is unclear if the attached dermis improves blood flow, re-vascularity, and the survival of the flap versus flaps harvested in the standard manner, but it does make the procedures easier. We have no firm results of randomized prospective studies on reconstruction in this area with an inframammary adipofascial flap with or without peripheral dermis. Further study is required to resolve this issue. We did not observe any necrosis or flap volume loss by using either the original or modified technique (Fig. 4). Pigmentation remained in the center of the area from which tissue was removed in this patient, which was attributed to the resection of the scar produced by the CNB. However, postoperative ultrasonography and mammography showed no cystic formation or abnormal calcification.

One of the drawbacks of this technique is the additional scar in the middle of the abdomen; however, this scar is inconspicuous from the patient’s view and there has been no report of sensory or motor abnormalities. Studies on a large number of patients are needed to establish who should receive postoperative radiotherapy after breast-conserving surgery with immediate volume replacement using this flap so that it is acceptable for BCT.

We are aware that longer follow-up is needed for more accurate physical and cosmetic assessment. Based on our limited observation of a small number of patients, we concluded that this procedure provides excellent cosmetic results when performed by a breast surgeon. Oncoplastic surgery, combining partial mastectomy and immediate volume replacement with a modified inframammary adipofascial flap at the time of BCT in the lower region of the breast, can be performed easily and safely with good cosmetic results in patients for whom reduction-type oncoplastic surgery is contraindicated.