Breast cancer: breast conservation techniques instead of traditional mastectomy

Partial Breast Reconstruction techniques using Chest wall perforator flaps have actually saved a significant number of women from undergoing unnecessary and amputating mastectomies (with or without reconstruction). Thus, women with multifocal/polycentric breast cancer or disproportionately large tumor size relative to their breast size can now undergo oncologically safe, aesthetically acceptable breast conservation surgery.

These techniques are nowadays the most modern and safe oncoplastic tumor replacement techniques after major breast conservation surgery (>20%). They require excellent knowledge of anatomy, surgical breast oncology and fine plastic surgery skills. The first such surgery in Greece was performed at the "Agios Loukas" Clinic in May 2019.

These flaps have become particularly popular because they keep the underlying muscles through which the vessel passes intact, and consist essentially only of skin and subcutaneous fat. Most women have adipose tissue in abundance under the armpit or breast, which can be used for reconstruction after tumour removal. They are easily displaceable skin-fat vascular flaps that irrigate their blood supply from either perforating branches of the lateral intercostal artery (LICAP, lateral intercostal perforator flap), the anterior intercostal perforator flap (AICAP), the lateral thoracic perforator flap (LTAP) or the thoracodorsal perforator flap (TDAP). Tumours located in the outer quadrants of the breast are particularly suitable for LICAP or LTAP flaps, whereas tumours located in the inner breast hemisphere may well be treated with an AICAP flap.

Preoperatively, the day before or even on the morning of surgery, the transcatheter arteries are detected using a portable unidirectional Doppler device using an 8 MHz Doppler head (Figure 1). This is an easy, inexpensive, painless and, most importantly, patient-friendly method. For this reason, it is widely used and is always used to map the position and flow of the branches of all flaps just prior to the start of surgery. Personally, I have come to use the Doppler device infrequently now and rely entirely on intraoperative anatomical identification, preservation and final selection of the appropriate radiating branches after thorough surgical preparation using bipolar diathermy. The LTAP penetrating branches are found in the 3rd and 4th intercostal space within 2 cm of the outer lip of the breast, whereas the LICAP penetrating branches are most commonly found in the 5th to 7th intercostal space, approximately 2.5 and 3.5 cm from the anterior lip of the dorsalis lateralis muscle.

Figure 1:
Portable one-way 8 MHz Doppler device

In preoperative flap planning, it is crucial to assess the recipient area in terms of the dimensions and composition of the tissues to be replaced, as well as to estimate the extent of the skin island, the thickness of the fat substrate and the total volume of tissue required. The flap is always planned with the patient in a sitting position and then in a supine lateral position, with the upper limb in flexion and at a 90 degree angle, simulating the patient's final position on the operating table.

These techniques have pushed the boundaries of breast conservation surgery in women who previously would have been led without a second thought to a mastectomy with or without direct/advanced reconstructive techniques, and potentially to even more procedures on the unilateral breast.

Figure 2 (a, b):
Postoperative image of AICAP flap (1 month after radiotherapy)

- These women now have the opportunity of a single safe surgical treatment, usually shorter surgical time (2-3 hours), faster and immediate post-operative recovery (1 day hospitalization), less costly and with excellent aesthetic results.

- These techniques allow wide resection of larger tumours with safe tumour margins, and the flexible flap can be shaped to the desired shape to fill the breast volume deficit.

- Such a wide excision implies a lower rate of infiltrated resection margins, which in turn means a reduction in the rates of additional resections or local recurrences.

- The rate of postoperative complications is significantly lower compared to a simple mastectomy or mastectomy with reconstruction.

- In addition, the extraordinary cosmetic advantage of such a breast conservation surgery makes these procedures an extremely effective surgical alternative to mastectomy.

- There is no visible scar on the chest (except in some cases where it may be necessary to remove the skin on the breast if the underlying cancer is close to the skin and is infiltrating it). The postoperative donor site scar is carefully hidden in the submastric groove (AICAP) or in the posterior line of the breast (LTAP, LICAP, TDAP) (Figures 2a, 2b and 3a, 3b).

- No second or third corrective procedures are required (symmetrization of the unilateral breast, removal of the breast implants, replacement of the insert, lipomodelling, etc.).

- Other advantages include the preservation of the thoracoracic stem and dorsalis pedis (for possible future use) and of course minimal morbidity of the donor and recipient area.

Figure 3 (a, b):
Postoperative image of LICAP flap (1 month after radiotherapy)

The absolute indications for mastectomy are decreasing every day worldwide and recent studies support that breast conservation procedures are as safe and effective as (if not better than!) mastectomy. Perhaps the time has come to shift the focus of the debate to de-escalating surgical manipulations involving the breast itself, which will have the woman herself as the sole and undeniable winner.

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