14 Central Quadrant Technique

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12Oncoplastic Surgery: Central QuadrantTechniquesKristine E. Calhoun and Benjamin O. Anderson

12.1 Introduction

Breast-conserving therapy was introduced as an alternative to

breast sacrifice for women affectedby breastcancer beginning

in the 1970s and clinical trials have since demonstrated

equivalency in terms of overall survival between lumpectomyplus radiation and mastectomy[1, 2]. Although there are clear

contraindications to lumpectomy, for the appropriately

selected individual, breast-conserving therapy offers both

effective treatment and the psychological benefit of retention

of the breast.

In a traditional lumpectomy, there is no specific effort to

obliterate the internal resection cavity. In fact, closing

fibroglandular tissue can result in unsightly defects if

alignment of the breast tissue is suboptimal. Fibroglandular

tissue that is sutured closed at middle depth in the breast

while the patient is supine on the operating table can result

in a dimpled, irregular appearance when the patient stands

up. Given this potential, most surgeons choose to close the

skin of a lumpectomy without approximation of the

underlying tissue. Although the simple scoop and run

approach to lumpectomy may work well for small tumors,

declivity of the skin and/or displacement of the nipple

areola complex (NAC) may occur if the lesion removed

from the breast is sizable and may create especially trou-

bling defects for central lesions.

For breast conservation to be effective, the primary

tumor must be resected with adequate surgical margins

while simultaneously maintaining the breasts shape and

appearance, goals which may prove challenging and in

some settings seem to be conflicting [3, 4]. In 1994,

Audretsch [5] was one of the first to advocate the use of

oncoplastic surgery for repair of partial mastectomy

defects by combining the techniques of volume reduction

with immediate flap reconstruction. Although initially used

to describe partial mastectomy combined with large myo-cutaneous flap reconstruction using the latissimus dorsi or

the rectus abdominis muscles, oncoplastic surgery now

more commonly describes numerous surgical techniques

that utilize partial mastectomy and breast-flap advancement

to address tissue defects following wide resection.

Compared with breast reconstruction using a myocutaneous

flap, breast-flap advancements are easily learned and

implemented by breast surgeons, even those lacking formal

plastic surgery training.

A comprehensive understanding of normal ductal anat-

omy is critical to planning an oncoplastic partial mastec-

tomy [3, 6]. The modern anatomic analysis of ductalanatomy suggests that the number of major ductal systems

is probably fewer than ten [7]. The size of ductal segments

is variable and whereas some ducts pass radially from the

nipple to the periphery of the breast, others travel directly

back from the nipple toward the chest wall. In contrast,

well-defined breast vasculature allows the surgeon to

remove and remodel large amounts of fibroglandular tissue

without major risk of breast devascularization and/or tissue

necrosis. The commonest sources of arterial blood supply in

the human breast arise from the axillary and internal

mammary arteries. By maintaining communication with one

of these two arterial connections, one maintains an adequateblood supply for the breast parenchyma during tissue

advancement and mastopexy closure.

The use of oncoplastic surgical techniques for breast

conservation allows wider resections without subsequent

tissue deformity, and thereby allows surgeons to achieve

wide surgical margins while preserving the shape and

appearance of the breast [8]. Such techniques can be

especially useful for more centrally located lesions, which

when resected with standard surgical techniques may result

K. E. Calhoun B. O. Anderson (&)

Breast Health Clinic, Department of Surgery,

University of Washington, Seattle, USA

e-mail: [email protected]

K. E. Calhoun

e-mail: [email protected]

C. Urban and M. Rietjens (eds.), Oncoplastic and Reconstructive Breast Surgery,DOI: 10.1007/978-88-470-2652-0_12, Springer-Verlag Italia 2013

117


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in suboptimal cosmetic outcomes. Although specific onco-

plastic techniques differ from one another, all of the

approaches involve fashioning the tissue resection to the

anatomic shape of the cancer while ensuring that wide

margins, ideally more that 1 cm, are achieved in an optimal

number of patients [3, 6]. The indications and contraindi-

cations for oncoplastic surgery are the same as those for

traditional breast-conserving surgery, and such techniquesshould only be offered to those otherwise believed to be

breast-preservation candidates on the basis of size and

centricity.

The techniques described in this chapter include those

used for central segmental resections that utilize breast-flap

advancement (so-called tissue displacement techniques) and

include central lumpectomy, batwing mastopexy lumpec-

tomy, donut mastopexy lumpectomy, and variations on

reduction mastopexy lumpectomy which utilize a pedicle

flap to restore the NAC.

12.2 Preoperative Planning

Patients undergoing central quadrant resections should

undergo standard preoperative history taking and physical

examination, with the elements of gynecologic, family, and

social history, including smoking, emphasized. Special

attention should be given to any prior breast surgical his-

tory, including the placement of breast implants. Needle

sampling should be performed to provide tissue diagnosis of

malignancy. At our institution, internal review of all

external pathology slides is required to confirm that we

agree with the histopathologic diagnosis.

Those being considered for oncoplastic resections should

undergo a standard preoperative breast imaging workup,

which typically includes some combination of mammog-

raphy, ultrasonography, and in selected circumstances

breast MRI. Although mammography may underestimate

the extent of ductal carcinoma in situ by as much as

12 cm, it is still warranted and is often the initial

diagnostic study [9].

Although controversial, the use of MRI may contribute to

the surgeons ability to preoperatively determine the extent

of disease, especially for mammographically subtle and/or

occult cancers, and to conceptualize the location of the

tumor more three-dimensionally than allowed on mam-

mography. Compared with mammographic and ultrasono-

graphic images, the extent of disease seen on MRI may

correlate best with the extent of tumor found on pathologic

evaluation. In addition, MRI has the lowest false-negative

rate in detecting invasive lobular carcinoma [10]. Although

its sensitivity for detection of invasive breast cancer is high,

MRI unfortunately has a low specificity of 68 % in the

diagnosis of breast cancer before biopsy [11]. Up to one-

third of MRI studies will show some area of enhancement

that needs further assessment that ultimately proves to be

histologically benign breast tissue [3]. A consensus state-

ment from the American Society of Breast Surgeons [12]

updated in 2010 supports the use of MRI for determining the

extent of ipsilateral tumor or the presence of contralateral

disease in patients with a proven breast cancer (especially

those with invasive lobular carcinoma) when dense breasttissue precludes an accurate mammographic assessment. For

cancers containing both invasive and noninvasive compo-

nents, a combination of imaging methods may yield the best

estimate of overall tumor size [13].

12.3 Perioperative Planning

Once a central oncoplastic approach has been selected,

decisions regarding the use of preoperative wire localization

for nonpalpable malignancies must be made. In planning

oncoplastic resections, the surgeon needs to accurately

identify the area requiring removal. Silverstein et al. [14]

suggested the preoperative placement of two to four brac-

keting wires to delineate the boundaries of a single lesion.

In a study by Liberman et al. [15], wire bracketing of 42

lesions allowed complete removal of suspicious calcifica-

tions in 34 patients (81.0 %). It has been suggested that

single wire localization of large breast lesions is likelier to

result in positive margins, because the surgeon lacks land-

marks to determine where the true boundaries of nonpal-

pable disease are located. For such scenarios, multiple

bracketing wires may assist the surgeon in achieving

complete excision at the initial intervention. For more pal-

pable lesions, such wire localizations may be a moot point.

Skin landmarks should be marked with the patient sitting

up in the preoperative area, including the inframammary

crease, the anterior axillary fold at the pectoralis major mus-

cle, the posterior axillary fold of the latissimus dorsi muscle,

the sternal border of the breast, and the periareolar circle.

Identifying these entities with the patient in the upright

position is very important for the final cosmetic outcome,

because these anatomic sites may prove challenging to

accurately locate once the patient is anesthetized and lying

supine on the operating room table. Generally, for reduction-

type procedures, markings will be placed on both breasts.

For all oncoplastic techniques, the patient should be

supine on the operating room table and with both arms

abducted on arm boards and secured. It is preferable to have

both breasts prepared and draped into the field so that visual

comparison with the patient in a beach chair position is

possible as the wound is closed. Such an approach allows

the surgeon to identify any areas of unnecessary tugging or

dimpling which are inadvertently created so that they can be

corrected.

118 K. E. Calhoun and B. O. Anderson


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12.4 Central Quadrant Techniques

12.4.1 Central Lumpectomy

For those cancers involving the NAC, including Pagets

disease of the nipple, the cosmetic impact of nipple removal

with central lumpectomy typically accounts for the common

use of mastectomy in this situation. In recent years, withimproved NAC reconstructive capabilities, central lump-

ectomies have been utilized more. Although central lump-

ectomy removes the NAC and underlying central tissues, it

typically leaves behind a significant breast mound, espe-

cially for those with larger breasts at the baseline. The

cosmetic outcome with central lumpectomy can range from

good to outstanding, depending on the womans body

habitus, and is likely to be better tolerated than recon-

struction of an entire breast [3]. Central lumpectomy can be

particularly valuable in women with large breasts where

loss of the entire breast with mastectomy may create

prominent asymmetry. Surgical issues of NAC reconstruc-

tion in an irradiated field, including wound-healing issues

and NAC loss, must be considered, so early referral for

plastic surgery is warranted.

In central lumpectomy, the incision can be made in the

pattern of a large parallelogram that encompasses the entire

NAC, or can be more circular in nature (Fig. 12.1af). Afterexcision of the skin island/NAC, short-distance mastec-

tomy-type skin flaps are raised along both sides of the

wound. The dissection is carried down to the chest wall and

the breast gland is lifted off the pectoralis muscle. After

full-thickness excision of the tumor, four to six marking

clips are typically placed at the base of the defect within the

surrounding fibroglandular tissue for future imaging and

radiation oncology purposes. A small drain may also be

placed in the lumpectomy wound in cases where the

Fig. 12.1 Central lumpectomy.a Preoperative marking with the

patient in the upright position.

b Intraoperative marking with the

patient in the supine position

illustrating positional shift of the

breast landmarks. c Initial skin

incision revealing wide exposure

over the target lesion. d Central

resection. e Postexcision cavity.

f Final closure

12 Oncoplastic Surgery: Central Quadrant Techniques 119


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dissection is more extensive and fear of seroma is increased.

For adequate evaluation of margin status by the pathologist,

sharp rather than cautery dissection should be considered, as

sharp dissection will not alter the histological margins of the

resected tissues with the so-called cautery effect. Larger

intraparenchymal vessels can be ligated or coagulated dur-

ing the dissection, and cautery can then be used on the

exposed fibroglandular tissue faces to control bleeding.Once tissue specimens have been resected and hemos-

tasis has been obtained, the fibroglandular tissue at the level

of the pectoralis fascia is undermined so that breast-tissue

advancement can be performed over the muscle. Once the

fibroglandular tissues have been sufficiently mobilized and

hemostasis has been confirmed, the margins of the residual

cavity are shifted together by the advancement of breast

tissue over muscle and the defect is sutured at the deepest

edges using 3-0 absorbable sutures. The direction of tissue

advancement can be adjusted depending upon the location

of the fibroglandular defect and the excess tissue that can be

shifted to close it. The goal of the mastopexy is to perform

as complete a closure over the pectoralis muscle as possible

to discourage communication between the anterior skin and

the deeper tissues. Side to side comparisons with the patient

in an upright position are warranted to ensure that no

unusual retractions of the tissues or unsightly cosmetic

results have occurred.

The superficial tissue layer is next closed with an inter-

rupted subdermal 3-0 absorbable suture, and the skin is

closed with 4-0 absorbable subcuticular sutures in routine

fashion. Two variations on closure exist. The first, which is

more typical, involves closure in a manner which results in

a scar that is a horizontal, straight line, and the second

involves closing the wound utilizing a purse-string closure

to facilitate areolar tattooing.

12.4.2 Batwing Mastopexy Lumpectomy

For cancers adjacent to or deep to the NAC, but without

direct involvement of the nipple, lumpectomy can suc-

cessfully be performed without sacrifice of the nipple itself.

The batwing approach preserves the viability of the NAC

while preserving the breast mound by using mastopexy

closure to close the resulting fibroglandular defect of the

full-thickness resection. This procedure may result in lifting

of the nipple into the upper breast, and a contralateral lift

may need to be performed to achieve symmetry, especially

when the native breast is large and pendulous.

Two similar semicircle incisions are made with angled

wings on each side of the areola (Fig. 12.2ae). The two

half-circles are positioned so they can be reapproximated to

each other at wound closure. Removal of these skin wings

allows the two semicircles to be shifted together without

creating redundant skin folds at closure. Fibroglandular

tissue dissection is carried down deep to the known cancer,

with the depth in relation to the chest wall dictated by the

position of the lesion within the breast. In most situations,

the dissection is carried down to the chest wall and the

breast gland is lifted off the pectoralis muscle in a fashion

similar to that for central lumpectomy. The principles of

sharp dissection and the placement of marking clips are alsosimilar to those utilized in central lumpectomy.

Following full-thickness resection of the target, mobili-

zation of the fibroglandular tissue for mastopexy closure

will likely be required. The breast tissue is elevated off of

the chest wall at the plane between the pectoralis muscle

and breast gland, and the fibroglandular tissue is advanced

to close the resulting defect. The deepest parts are

approximated by interrupted sutures. We typically secure

the fibroglandular tissue to fibroglandular tissue and do not

place anchoring stitches into the chest wall, thereby

allowing the approximated breast tissues to move along the

chest wall. The superficial layer is closed in the same

fashion as in central lumpectomy. As this procedure can

cause some lifting of the nipple, it may create asymmetry

compared with the noncancerous breast. A contralateral lift

can be performed after adjuvant radiation therapy has been

completed and the treated breast has declared its new size

and shape to achieve symmetry, although some plastic

surgeons may choose to perform this symmetry procedure

concurrent with the oncologic surgery.

12.4.3 Donut Mastopexy Lumpectomy

For segmentally distributed cancers located in the upper or

lateral breast that approach the NAC, donut mastopexy

lumpectomy can be used to achieve effective resection of

long, narrow segments of breast tissue. Donut mastopexy

avoids a visible long radial scar which is against Kraissls

line or Langers line. In this procedure (Fig. 12.3af), two

concentric lines are placed around the areola and a peri-

areolar donut skin island is excised, with only a peri-

areolar scar visible after this operation. Deepithelialization

by separating this skin island from the underlying tissues is

done, taking care to avoid full devascularization of the

areolar skin. The width of the donut skin island should be

approximately 1 cm, but is somewhat dependent on the size

of the areola and the expected extent of excision. Removal

of this tissue ring is required, as it allows both adequate

access to and exposure of the breast tissue and closure of the

skin envelope around the remaining fibroglandular tissue

that will reduce tissue volume overall.

A skin envelope is created in all directions around the

NAC. The quadrant of breast tissue containing the target

lesion is fully exposed utilizing the same dissection used for



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a skin-sparing mastectomy. The full-thickness breast gland

is then separated from the underlying pectoralis muscle and

delivered through the circumareolar incision. The segment

of breast tissue with the tumor is resected in a wedge-

shaped fashion, with the width of tissue excision required to

achieve adequate surgical margins balanced against the

difficulty that will be created by virtue of an oversized

segmental defect.The remaining fibroglandular tissue is returned to the

skin envelope and the peripheral apical corners of the

fibroglandular tissue are secured to each other and then

anchored to the chest wall. This anchoring step maintains

proper orientation of the mobilized fibroglandular tissue

within the skin envelope during the initial phases of healing.

A purse string using a 3-0 absorbable suture is placed

around the areola opening, and is clamped at a size that

reapproximates the original NAC. Interrupted inverted 3-0

absorbable sutures are placed subdermally around the NAC,

at which time the purse-string suture is tied and then 4-0

subcuticular sutures are used to close the wound. Uplifting

of the NAC may create mild asymmetry in comparison with

the untreated breast. If desired, a contralateral lift can be

performed to achieve symmetry.

12.4.4 Reduction Mastopexy LumpectomyModifications

Initially used in women with macromastia and excessive

breast ptosis, this procedure is currently used for resection

of lesions in the lower hemisphere of the breast between the

4 oclock and 8 oclock positions, where scoop and run

lumpectomy using circumareolar incision would result in

unacceptable down-turning of the nipple owing to scar

Fig. 12.2 Batwing mastopexylumpectomy. a Preoperative

marking with the patient in the

upright position. b Intraoperative

marking with the patient in the

supine position. c Resection

cavity. d Final closure.

e Postoperative result with the

patient in the upright position



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contracture after radiotherapy. This unpleasant cosmetic

outcome can be prevented by using the technique of

reduction mastopexy lumpectomy (Fig. 12.4af). Recently,

the indications for using reduction techniques have been

expanded to include women with centrally located tumors

faced with NAC loss. In these situations, the reduction is

coupled with a deepithelialized pedicle flap with an over-

lying skin island to recreate the NAC, ultimately resulting

in a Wise-type scar and a neo-nipple [16].In traditional reduction mammoplasty, a keyhole pattern

incision is made and the skin above the areola is deepi-

thelialized in preparation for skin closure. A superior ped-

icle flap is created by inframammary incision and

undermining of the breast tissue off the pectoral fascia to

mobilize the NAC and underlying tissues. Mobilization of

the breast tissue allows palpation of both the deep and the

superficial surfaces of the tumor, which can aid the surgeon

in determining the lateral margins of excision around the

target lesion. When it is used for a central lesion, the pri-

mary tumor and overlaying NAC are resected down to the

chest wall. The principle of sharp dissection and the

placement of marking clips are the same as those for par-

allelogram mastopexy lumpectomy. A caudally located

inferior flap is then deepithelialized, except for an appro-

priately sized skin island that will function as the neo-nip-

ple. Following this, redundant medial, lateral, and superior

tissues are then resected while preserving the pedicle tissue.An incision at the inframammary crease facilitates mobili-

zation and assists in restoration of normal breast shape and

contour.

Once all tissues have been resected, the central, inferior

pedicle is mobilized, brought cephalad, and utilized to

occupy the defect created by removal of the prior NAC. The

neo-nipple is sutured to the margins of NAC resection. The

medial and lateral breast flaps are undermined and sutured

together to fill the excision defect, leaving a typical

Fig. 12.3 Donut mastopexylumpectomy. a Preoperative

marking including marking of the

region to be removed based on

preoperative bracketing wires

and concentric circles for skin

donut excision. b Initial skin

incision. c Delivery of tissue

segment through the periareolar

incision. d Remaining cavity

after resection. e Purse-string

closure. f Final operative result



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inverted-T scar. Variations of this technique have been

reported, including the Grisotti flap, which extends the

pedicle laterally and results in an inferior and laterally

sweeping incision [16], and free nipple graft from the skin

of the contralateral reduction tissue [17]. Finally, some

choose to utilize the reduction flap without creation of a

neo-nipple, leaving the patient with a Wise-type incision

and the choice of NAC in a delayed fashion [16].

12.5 Postoperative Management

Although drains are rarely required in standard partial

mastectomy cases, with more extensive dissections, such as

donut mastopexy lumpectomy, fluid accumulation can

become more pronounced and require postoperative aspi-

ration. In recent years, we have started to place small, 15F

drains overnight to avoid excessive fluid accumulation in

the dissected breast that might distort the oncoplastic clo-

sure. These drains are typically removed either prior to

discharge or on the first postoperative day in the clinic.

12.6 Complications

When using central oncoplastic approaches, surgeons with-

out formal plastic surgery training must determine whichprocedures they are comfortable performing without plastic

surgery consultation or intraoperative collaboration [3].

Although these techniques appear to be relatively safe in the

immediate postoperative period, issues such as wound

infection, fat necrosis, and delayed healing with the more

advanced techniques are all potential, reported complications

[1820]. Despite more extensive resections, hematomas

requiring reoperation appear to be infrequent, occurring

roughly 23 % of the time in two recent studies [19, 20]. The

Fig. 12.4 Reduction mastopexylumpectomy. a Preoperative skin

markings showing the keyhole

incision pattern. b Initial skin

incision. c Full-thickness

resection. d Excised specimen

and residual cavity. e Closure.

f Final result



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blood supply of the external nipple arises from underlying

fibroglandular tissue using major lactiferous sinuses rather

than the collateral circulation from surrounding areolar skin,

so nipple necrosis may occur if dissection extends high up

behind the nipple, but is also fortunately rare [3]. Finally, in a

review of 84 women who underwent partial mastectomy and

radiation therapy, Kronowitz et al. [21] showed that

immediate repair of partial mastectomy defects with localtissues results in fewer complications (23 vs. 67 %) and

better aesthetic outcomes (57 vs. 33 %) than that with a

latissimus dorsi flap, which some surgeons used for delayed

reconstructions [22].

12.7 Results

The main goal of oncoplastic lumpectomy remains negative

surgical margin resection. Complete excision of calcified

lesions and masses should be confirmed with specimen

radiography during surgery. Additional oriented margins

can be resected prior to mastopexy closure when the

radiograph suggests inadequate resection may have occur-

red, hopefully eliminating the need for a delayed re-exci-

sion. Although some centers use intraoperative analysis

with a frozen section to aid in decisions regarding the

resection of additional segments of tissue, thus is not our

policy.

Multicolored inking performed by the surgeon in the

operating room helps to improve margin identification.

Inking kits are now available with six colors (black, blue,

yellow, green, orange, and red), which are very useful for

labeling all of the surgical margins (superior, inferior,

medial, lateral, superficial, and deep) (Fig. 12.5). Clear

uniformity between the surgeon and the pathologist in terms

of what color means what margin is required, especially

when inadequate margins are identified that require

reoperation.

Although the historical gold standard for a negative

surgical margin has been 10 mm, what constitutes a true

negative margin differs widely from center to center,

with 3 mm or greater accepted at our institution. Low local

recurrence rates after breast conservation therapy, espe-

cially in the era of postlumpectomy irradiation, can be

achieved with an intermediate surgical margin width

between 1 and 10 mm [1, 2]. If re-excision is needed for

inadequate surgical margins following the initial resection,

both the surgical approach and the timing of the operation

must be considered [3]. When the positive margin involves

a minority of the specimen, the entire biopsy cavity does not

need to be re-excised, and instead can be directed toward

the inadequate region. If re-excision is delayed for

34 weeks, the previous seroma cavity may be nearly

reabsorbed, which leaves a fibrous biopsy cavity that can be

easily located by intraoperative palpation. With noninvasive

cancer, Silverstein et al. [14] have suggested that it is fea-sible to delay re-excision for up to 3 months, at which point

the seroma cavity has been fully reabsorbed.

When all the resection margins are positive, mastectomy

may be needed to attain satisfactory surgical clearance. In

this instance, it may be technically challenging to include

both the initial oncoplastic incision and the NAC in a

subsequent total mastectomy, and consultation with the

plastic surgeon in the event of immediate postmastectomy

reconstruction is mandatory. Despite a clear ability to resect

widely with these central oncoplastic techniques, inade-

quate margins remain an issue. Although reports remain

sparse, reported rates of inadequate margins following ini-tial resection range from 8 to 22 % [19, 20, 2328]. The

decision between a re-excision and a mastectomy must be

based on the operating surgeons ability to appropriately

localize the involved region, and with more advanced

resections this may only be possible with breast sacrifice.

Although large studies of long-term outcomes specifi-

cally addressing oncoplastic approaches in breast conser-

vation are lacking, the limited available results continue to

look promising. One investigation from Europe followed

148 women for a median of 74 months (range

10108 months) and only two were lost to follow-up.

Among the 146 individuals available for analysis, there

were only five women (3 %) who had an ipsilateral in-

breast cancer recurrence after 5 years and all had either T2

or T3 tumors at presentation. Rietjens et al. [29] argued that

recurrence rates for women with oncoplastic resections and

concurrent radiation therapy were comparable to the in-

breast recurrence rates reported with standard breast con-

servation techniques. Studies of more limited follow-up

recently reported no in-breast local recurrences at

26 months [19], 38 months [20], and 34 months [16],

Fig. 12.5 Specimen inked by the surgeon to designate anterior,posterior, medial, lateral, inferior, and superior margins



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although some distant recurrences were reported. These

results appear equivalent to those for women treated with

traditional lumpectomy and should serve to allay any fears

of cosmesis being favored over cancer control.

12.8 Conclusions

Although shown to be a reasonable alternative to mastec-

tomy for the appropriately selected breast cancer patient,

traditional scoop and run lumpectomy may result in poor

cosmesis. Central oncoplastic techniques, including central

lumpectomy, batwing mastopexy lumpectomy, donut mas-

topexy lumpectomy, and variations of reduction mastopexy

lumpectomy have been developed to address this issue. By

combining large-volume tumor removal with breast-flap

advancements, the oncoplastic approaches allow wider

margins of resection and better breast shape and contour

preservation. Candidates are those felt to be standard

lumpectomy candidates and include those with no evidence

of multicentric disease.

Standard preoperative workup, including dedicated

breast imaging, and preoperative wire localization are

necessary to aid the surgeon in successful resection. Com-

plications of tissue necrosis are fortunately rare, despite

sometimes significant remodeling of the fibroglandular tis-

sues due to the breasts rich blood supply. Outcomes appear

at least equivalent to those for standard breast conservation

techniques, although large case series are lacking. Despite

this paucity of long-term results, oncoplastic lumpectomy

can be learned by individuals familiar with breast surgical

techniques and generally results in better cosmesis and

equivalent oncologic outcomes.

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14 Central Quadrant Technique

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