Safety and Feasibility of Oncoplastic Reconstruction in the Setting of Prior Breast Reduction

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Breast reduction is a risk-reducing procedure for breast cancer, albeit there is still a risk of developing malignancy of residual tissue. The literature suggests 0.3% to 1.1% of patients who undergo previous reduction mammoplasty develop breast cancer after surgery.¹ Oncoplastic breast surgery combines breast reduction techniques with tumor resection to facilitate larger volumes of tissue removed (typically >200 g) compared with lumpectomy alone (typically 40-50 g) without aesthetic compromise.² This broadens the indications for breast conservation therapy to include multifocal and multicentric tumors and even tumors >5 cm.³ In order to achieve symmetrization, contralateral breast reductions are an intrinsic component of oncoplastic surgery.  

In a review of over 10 000 breast procedures, the number of oncoplastic breast reconstructions increased approximately 4-fold between 2007 and 2014.⁴ Despite this drastic increase, only a single study described an isolated oncoplastic reduction in the setting of prior breast reduction.⁵ Patients who have undergone prior breast reductions and desire oncoplastic reduction present unique considerations for the preservation of nipple-areolar complex (NAC) vascularity. Further complicating the matter is when the pedicle used in the prior breast reduction is unknown.

We performed an oncoplastic reduction on a 62-year-old female who presented with a 2 × 3 × 3-mm invasive ductal carcinoma in the upper outer quadrant of the left breast. She had undergone bilateral breast reduction over a decade ago, but the operative report and pedicle used was unavailable (Figure 1). Of note, she had no prior chest or breast radiation. During the operation, the lump was excised and a superomedial pedicle was developed. The same operation was repeated on the right side. Breast tissue resected from the right and left breasts was 236 g and 231 g, respectively. The nipples were well perfused and viable after closure. At 3 months follow-up, there was no evidence of vascular compromise (Figure 2). She began radiation at 4 months postoperatively and completed her regimen within 1 month. Since that time, she maintained good symmetry at 10 months follow-up (Figure 3).

Figure 1. Preoperative markings and identification of previous breast scarring.

Figure 2. Three-month postoperative photo. The nipple areola complex was viable. 

Figure 3. Ten-month postoperative photo. Radiation was completed 6 months prior. The patient has maintained good symmetry.

Oncoplastic breast surgery can be defined as a tumor-specific immediate breast reconstruction method that applies aesthetically derived breast reduction techniques to the field of breast cancer surgery and allows for higher volume excision with no aesthetic compromise.⁶ However, contralateral breast symmetrization should be regarded as an intrinsic component of the oncoplastic surgery. Both breast and plastic surgeons agreed in a recent survey that oncoplastic reconstructions were best performed in a collaborative approach, with margin concerns and aesthetic benefits being the major driving forces in both groups. Given that most breast cancers present at earlier stages, breast conservation therapy should be more common than mastectomy, and oncoplastic surgery in the appropriate patients can allow surgeons to reach these goals.

The concept of performing breast reductions in the setting of prior breast reduction has been described several times in the literature. One study by Losee et al described utilizing different techniques in 7/10 re-reductions, of which 3/7 had pedicle transections, and 2/3 of pedicle transections experienced a delay in wound healing.⁷ This led them to recommend free nipple grafting in re-reductions where the prior pedicle was unknown or to develop the same pedicle when known. In a more recent study by Ahmad et al, they utilized a superior pedicle to transpose the NAC in 43 breasts that were previously reduced (the pedicle used in the first reduction was known in approximately half the patients). The axial intercostal vessels were transected from the prior surgery, but utilizing a superior pedicle enabled the skin to survive as a random pattern flap fed by the subdermal plexus. They discovered no significant differences in complication profiles between patients whose prior pedicle was known versus unknown.⁸ Another study by Mistry et al found only 2 complications in 90 patients undergoing re-reduction using a random pattern blood supply to the NAC, and these were attributed to excessive de-epithelialization and utilizing a medial pedicle rather than random pattern de-epithelialization.⁹

Our result adds to the isolated literature showing that superiorly based pedicles are reliable even when the primary pedicle is unknown. Additionally, nipple transposition is minimal and de-epithelialization is limited, which limits devascularization of the NAC. Oncoplastic reduction, like lumpectomy, does not delay starting adjuvant treatment. Additionally, radiation did not influence our choice for utilizing a superior pedicle in this patient. However, larger prospective studies of outcomes following oncoplastic re-reductions are needed to substantiate this result.

Oncoplastic reductions balance the oncologic and aesthetic treatment of breast cancer. Superiorly based pedicles can be utilized in oncoplastic reductions whenever a breast reduction was performed previously. This relies on the delay phenomenon principle in which neovascularization of the underlying wound bed augments the blood supply the dermis and in turn the NAC.