Dermoglandular rotation flap with subaxillary advancement flap as an oncoplastic technique for breast cancer.

We propose a novel oncoplastic surgical technique, dermoglandular rotation flap with subaxillary advancement flap, as a feasible one-stage operation. Breast conserving surgery, incorporating the dermoglandular rotation flap with subaxillary advancement flap, was performed in 49 female patients with breast cancer, between January and December 2015. After a full-thickness fibroglandular resection including the tumor, an inferior- or a superior-based rotation flap was performed according to the location of the defect. The subaxillary flap consisted of skin, dermis, and subcutaneous fat tissue and was mobilized from the chest wall musculature. Since subaxillary skin has greater redundancy, it can be easily moved to reach the lateral aspect of the breast. Approximation of the subaxillary flap to the lateral side of rotated dermoglandular flap served to relieve skin tension and avoid displacement of the nipple-areola complex (NAC). Consequently, there was wider dermoglandular tissue rotation and efficient filling of defect without any significant postoperative deformity. The mean follow-up period was 46.5 ± 3.1 months (range, 42.4-52.1 months). Mean tumor size, on pathology, was 2.1 cm (range, 0.4-6.0). Mean excised breast tissue weight was 78.4 g (range, 28.6-195.0). More than half of the patients (51%) studied had excised breast tissue weighing more than 80 g. None of the included patients had positive surgical margins in final pathologic reports. Most patients answered excellent or good for self-estimated cosmetic outcomes including symmetry of the breast and NAC, breast shape, scarring, and overall satisfaction. A modified dermoglandular rotation flap technique along with subaxillary advancement flap is a feasible and effective oncoplastic technique for breast cancers.

Immediate chest wall reconstruction using an external oblique myocutaneous flap for large skin defects after mastectomy in advanced or recurrent breast cancer patients: A single center experience.

BACKGROUND AND OBJECTIVES: We report 75 single-stage chest-wall reconstructions using ipsilateral external oblique myocutaneous flap (EOMCF) to cover the extensive skin defects following resection of advanced or recurrent breast tumours at the Pusan National University Hospital. METHODS: Between January 2007 and October 2015, 75 women with advanced or recurred breast cancer who underwent extensive mastectomy with immediate chest wall reconstruction using EOMCF were reviewed retrospectively. RESULTS: Mean age was 50.5 ± 9.8 years and mean follow-up period was 36.7 ± 25.1 months. A total of 59 patients (78.7%) had stage III disease and the remaining 16 patients (21.3%) had stage IV. Mean excised breast tissue weight was 687.6 ± 416.5 g (range, 120.3-2797.1 g). The mean chest wall skin defect covered with an EOMCF was 228.3 ± 168.1 cm2 and corresponded to an approximately 15 × 15 cm defect. Average operative time for reconstruction was <2 h. There were no major complications such as flap loss, full thickness skin necrosis, or surgical site infections. With respect to loco-regional recurrence, nine patients (12%) experienced recurrence. Among the 59 non-stage IV patients, loco-regional relapse occurred in five patients (8.5%). CONCLUSIONS: EOMCF can effectively cover large chest wall defects with a few minor complications and reliable local disease control.

Immediate Nipple Reconstruction as Oncoplastic Breast Surgery: the Cigar Roll Flap with Inner Dermal Core Technique.

BACKGROUND: Postoperative loss of projection is the most common problem following nipple reconstruction. Despite the various available nipple reconstruction techniques, a simple and reliable method that maintains nipple projection has not yet been developed. Here, we introduce a simple and feasible method for immediate nipple reconstruction-the cigar roll flap with inner dermal core technique-which is expected to maintain long-term nipple projection. METHODS: Between January 2013 and August 2014, 23 breast cancer patients underwent unilateral nipple reconstruction using the cigar roll flap with inner dermal core technique during immediate breast reconstruction. The projection of the reconstructed nipple was measured at the time of surgery and after radiation therapy (average postoperative duration, 8 months). RESULTS: The mean nipple projection at the time of surgery was 1.1 ± 0.2 cm. After radiation therapy, the mean projection was 1.0 ± 0.2 cm. The mean maintenance of nipple projection was 84.5 ± 5.3 %. No immediate or delayed major postoperative complications were noted in our series. Most of the patients were satisfied with the three-dimensional projection of the nipple. CONCLUSIONS: The cigar roll flap with inner dermal core technique is a simple and reliable method for oncoplastic breast surgery during immediate nipple reconstruction and maintains constant projection without any major complications or donor-site morbidity. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

An Assessment of the Relationship Between Abdominal Obesity and the Severity of Upper Extremity Lymphedema.

BACKGROUND: Obesity is one of the well-known initiating and aggravating factors of lymphedema. Body mass index (BMI) is typically used to define obesity, but in Asian populations, health risks are elevated at lower BMI levels, and abdominal fat may be a better obesity metric. Thus, we assessed the potential association between abdominal obesity and lymphedema severity in postoperative breast cancer patients. METHODS AND RESULTS: Thirty-three women with breast cancer-related lymphedema participated in this study. Arm circumference was measured at four locations per arm to identify the maximal circumference difference (MCD) between the affected and unaffected sides. All patients underwent lymphoscintigraphy, and we calculated the quantitative asymmetry index (QAI) of both arms. A computed tomography was also performed to assess abdominal obesity after lymphedema. Abdominal obesity was classified as a visceral fat cross-sectional area larger than 70 cm2. Fourteen women (42%) were obese (BMI ≥25 kg/m2), and 18 women (54%) had increased abdominal fat. BMI obesity and abdominal obesity were significantly correlated, but five patients were classified with abdominal obesity, despite a BMI below 25 kg/m2. The mean arm circumference difference was 2.8 ± 2.4 cm. Decreased axillary QAI was significantly correlated with obesity, and increased arm edema (MCD ≥2 cm) was significantly correlated with abdominal obesity. CONCLUSION: Abdominal obesity was significantly correlated with increased MCD and should be considered along with obesity as an aggravating factor for lymphedema severity.

Oncoplastic surgery for inner quadrant breast cancer: fish-hook incision rotation flap.

BACKGROUND: In oncoplastic breast surgery, the size and location of the defect are two of the major factors affecting the post-operative cosmetic outcome after partial mastectomy. We introduce a modified superior-based dermoglandular rotation flap technique, which can be applied for relatively large tumours and in cases of inner quadrant defects of the breast without surgery of the contralateral breast. METHODS: Between January 2007 and December 2012, a total of 34 female patients with breast cancer underwent breast-conserving surgery using the 'fish-hook incision rotational flap'. A fish-hook-shaped skin incision line was designed from an axillary site to the tumour, about 2-3 cm below the skin crease of the inframammary fold. After partial mastectomy, a superior-based dermoglandular tissue flap was mobilized off the pectoralis major muscle and the lower abdominal flap was dissected downward. The dermoglandular flap was then rotated and the lower dissected lower abdominal flap was advanced in the upward direction to fill the defect and restore the breast shape. The cosmetic results were self-estimated 12 months after surgery. RESULTS: Mean excised volume of the breast was 23.2 ± 6.1%. The location of the tumours was as follows: upper inner (n = 13, 38.2%) and lower inner quadrant (n = 21, 61.8%). The overall cosmetic satisfaction was self-estimated as follows: excellent (n = 19, 55.9%); good (n = 10, 29.4%); fair (n = 4, 11.8%); poor (n = 1, 2.9%). CONCLUSIONS: The 'fish-hook incision rotation flap' is a feasible, effective oncoplastic technique that can be applicable to a relatively large defect located in the inner quadrant of the breast.

Immediate nipple reconstruction with a C-V flap and areolar reconstruction with an autograft of the ipsilateral areola.

BACKGROUND: The authors report a new nipple-areolar complex (NAC) reconstruction technique using an autograft of the ipsilateral areola for breast cancer with nipple invasion. METHODS: A total of 43 patients with breast cancer involving nipple invasion underwent oncoplastic surgery with NAC reconstruction. The nipple was reconstructed with a C-V flap, and the areola was autografted onto the new areola bed after the ipsilateral areola was confirmed to be tumour-free. The cosmetic results were self-evaluated by the patients after chemotherapy or radiotherapy according to a 4-point scoring system. RESULTS: Overall satisfaction with the cosmetic result was assessed as follows: excellent (n = 14), good (n = 19), fair (n = 7) or poor (n = 3). Oncological evaluation revealed no cases of local recurrence and five cases of distant metastasis. CONCLUSION: The immediate NAC reconstruction technique involving a C-V flap and autografting of the ipsilateral areola is a feasible method for obtaining realistic areolar reconstruction.

Prevalence and risk factors of nonalcoholic fatty liver disease in breast cancer patients.

AIMS AND BACKGROUND: We aimed to evaluate the prevalence of nonalcoholic fatty liver disease (NAFLD) in breast cancer patients using liver magnetic resonance imaging (MRI), and to investigate factors associated with NAFLD. METHODS: We evaluated 104 patients surgically treated for breast cancer at our hospital between September and November 2013. None of the patients had any other causes of secondary hepatic fat accumulation (such as significant alcohol consumption, use of steatogenic medication or inborn disorders). Hepatic fat accumulation was measured using liver MRI perfomed in all patients before surgical treatment. RESULTS: Based on the fat signal percentage from liver MRIs, 19 of 104 breast cancer patients were diagnosed with NAFLD, so the prevalence of NAFLD was 18.3%. In univariate analysis, factors associated with NAFLD were older age, high body mass index, type 2 diabetes mellitus (DM), hypertension, elevated aspartate aminotransferase, elevated alanine aminotransferase and elevated triglycerides (TG). In multivariate analysis, factors associated with NAFLD were high body mass index (BMI) (odds ratio [OR] 1.403; 95% confidence interval [CI] 1.111-1.771; p = 0.005), type 2 DM (OR 11.872; 95% CI 1.065-132.373; p = 0.044), and an elevated TG level (OR 50.267; 95% CI 4.409-573.030; p = 0.002). CONCLUSIONS: The prevalence of NAFLD in breast cancer patients was not different from that of the general population. High BMI, type 2 DM and an elevated serum TG level were factors associated with NAFLD.

Clinical application of a color map pattern on shear-wave elastography for invasive breast cancer.

PURPOSE: The aim of this study was to classify the color map pattern on shear-wave elastography (SWE) and to determine its association with clinicopathological factors for clinical application in invasive breast cancer. METHODS: From June to December 2014, 103 invasive breast cancers were imaged by B-mode ultrasonography (US) and SWE just before surgery. The color map pattern identified on the SWE could be classified into three main categories: type 1 (diffuse pattern), increased stiffness in the surrounding stroma and the interior lesion itself; type 2 (lateral pattern), marked peri-tumoral stiffness at the anterior and lateral portions with no or minor stiffness at the posterior portion; and type 3 (rim-off pattern), marked peri-tumoral stiffness at the anterior and posterior portion with no or minor stiffness at both lateral portions. RESULTS: High-grade density on mammography (grade 3-4) was more frequent in the type 1 pattern than the other pattern types (80.5% in high-grade density vs. 19.5% in low-grade density). For type 1 tumors, the extent of synchronous non-invasive cancers (pT0), ductal carcinoma in situ (DCIS), was 1.8-2.0 times wider than that measured by US or magnetic resonance imaging (MRI). For type 2 tumors, the invasive tumor components (pT size) size was 1.3 times greater than measured by MRI (p = 0.049). On the other hand, the pT size and pT0 extent of type 3 tumors were almost equal to the preoperative US and MRI measurements. In terms of immunohistochemical (IHC) profiles, type 3 tumors showed a high histologic grade (p = 0.021), poor differentiation (p = 0.009), presence of necrosis (p = 0.018), and high Ki-67 (p = 0.002). The percentage of HER2-positive cancers was relatively high within the type 2 group, and the percentage of triple negative breast cancer was relatively high in the type 3 group (p = 0.011). CONCLUSIONS: We expect that assessments of the SWE color map pattern will prove useful for surgical or therapeutic plan decisions and to predict prognosis in invasive breast cancer patients.

Effects of Quilting Suture Interval on Donor Site Seromas After Breast Reconstruction With Latissimus Dorsi Muscle Flap: A Randomized Trial.

BACKGROUND: Although breast reconstruction using a deep inferior artery perforator flap has been increasing, using a latissimus dorsi (LD) muscle flap is still the favored method for Asian female patients with breast cancer. However, because the incidence of donor site seromas has been relatively high, a quilting method on the donor cavity or insertion of drainage tube has been used to reduce the incidence and/or severity of postoperative seroma. We evaluated the effects of different intervals of quilting sutures on the postoperative drainage volume and components of seroma fluid. PATIENTS AND METHODS: A total of 36 patients with breast cancer underwent partial or total mastectomy with LD flap reconstruction. They were randomized into 3 groups according to the interval of quilting sutures: nonquilting (n = 10), 6-cm quilting (n = 14), and 3-cm quilting (n = 12). The clinicopathologic factors and time to drain removal, drainage volume, frequency of aspiration, and serous fluid components were investigated. RESULTS: No statistically significant differences were found in the clinicopathologic factors among the 3 groups. The time to drain removal was significantly shorter in the 6-cm quilting and 3-cm quilting groups than in the nonquilting group (P = .039 and P = .041, respectively). The total volume of drainage from the donor site was also decreased in the quilting groups (6-cm group, P = .046; 3-cm group, P = .021). The seroma components were not different among the 3 groups. CONCLUSION: Performing quilting sutures on LD flap donor sites is an effective method to reduce the volume of postoperative seroma. The present findings showed that a 6-cm suture interval is appropriate.

Synchronous BI-RADS Category 3 Lesions on Preoperative Ultrasonography in Patients with Breast Cancer: Is Short-Term Follow-Up Appropriate?

PURPOSE: Breast ultrasonography (US) has been widely used in the preoperative examination of patients with breast cancer. Breast Imaging Reporting and Data System (BI-RADS) category 3 (C3) lesions (probably benign) are regarded as having a low probability of malignancy (≤2%). The purposes of this study were to verify the malignancy rates for synchronous BI-RADS C3 lesions in patients with breast cancer and consider appropriate management strategies for these lesions. METHODS: Between January 2010 and January 2013, a total of 161 patients underwent surgery in our institute for breast cancer and synchronous BI-RADS C3 lesions. In the US reports, we found records of 219 synchronous BI-RADS C3 nodules in 161 patients. They were excised during surgery for breast cancer management. Stepwise logistic regression analysis was used to identify predictors of malignancy for synchronous BI-RADS C3 lesions. RESULTS: The rate of malignancy among the 219 BI-RADS C3 lesions was 9.6%. In simple logistic regression analysis, the size of the primary tumor (p<0.001), pathologic T (pT) stage (p=0.002), and progesterone receptor (PR) status of the primary tumor (p=0.029) were significant predictive factors. In multiple logistic regression analysis, the pT stage and PR status of the primary tumor remained significant predictors (p=0.004 and p=0.003, respectively), and human epidermal growth factor receptor 2 (HER2) was identified as another significant factor (p=0.006). CONCLUSION: In patients with breast cancer who are scheduled for surgery, needle biopsy or excision should be considered for synchronous BI-RADS C3 lesions identified on preoperative US when the primary tumor has the following risk factors: large size, high PR expression, and HER2 positivity.

Use of an absorbable adhesion barrier for reconstruction of partial mastectomy defects in the upper quadrant of large ptotic breasts.

INTRODUCTION: An absorbable adhesion barrier (Interceed(®)) is generally used during gynecologic or pelvic surgery. We report a new oncoplastic technique using the absorbable Interceed(®) sheet for upper quadrant breast cancer in large ptotic breasts with no other flaps. MATERIALS AND METHODS: From January 2007 to June 2013, a total of 25 patients with breast cancer underwent conventional breast-conserving surgery with the Interceed(®) sheet insertion technique. Tumors were removed with oncologically safe margins, and adjacent breast tissue was repositioned to adjust the breast's shape. When shaping was completed, the breast skin turgor was strengthened using Burrow's triangle displacement technique. Interceed(®) was then placed between breast skin and pectoralis muscle fascia with four-quadrant anchoring sutures. RESULTS: The tumors were located in the upper central (n = 12), upper inner (n = 11), and upper outer (n = 2) quadrants. The mean weight of the removed breasts was 82.1 g, and the mean operative time was 161.3 min. There were two postoperative complications-a wound infection and fat necrosis-which were resolved with conservative management. Radiation-induced fibrosis and skin thickening were identified by magnetic resonance imaging 8-12 weeks after radiotherapy. Overall patient and surgeon satisfaction with the cosmetic results were evaluated as excellent (n = 12), good (n = 11), or fair (n = 2). CONCLUSION: Use of the absorbable Interceed(®) sheet during surgery for upper quadrant breast cancer is feasible in patients with large ptotic breasts.