“No Man’s Land”: Addressing the Upper Inner Quadrant in Oncoplastic Breast Surgery: A Review of Contemporary Techniques

Background: Partial breast reconstruction options following breast-conservation surgery are dictated by multiple factors, including the volume and composition of tissue removed, the size and ptosis of the premorbid and contralateral breast, and tumor location. Defects of the upper inner quadrant (UIQ)—referred to as “no man’s land”—are notoriously difficult because of inadequate residual parenchyma, visible scarring, and limited locoregional flap options. This review aims to collate historical and contemporary oncoplastic techniques for the UIQ, including their indications, limitations, and documented outcomes. Methods: An extensive online database search (PubMed, Google Scholar, Cochrane) was conducted using relevant prompts to identify articles that discussed reconstruction of the UIQ. The final yield was 23 published, digitally available articles, of which 14 were original case series. Results: Of the 14 original series, patient data were extracted and tabulated. The remaining expert commentaries and narrative reviews were also referenced. The most common techniques were inferior pedicle–based reductions and round-block mastopexies. Most of these cohorts were small—the largest included 46 patients who underwent inferior pedicle mammoplasty. Complications and cosmetic outcomes were widely varied and inconsistently reported across studies. Conclusions: Important considerations for UIQ reconstruction include the size and form of the premorbid breast, patient expectations, any prior breast procedures, the timelines of adjuvant treatment, and resection volume. Reconstruction options include level 1 OPS in select cases; level 2 procedures (batwing, round block, matrix rotation techniques, and therapeutic mammoplasties); and finally, regional volume replacement techniques (including variations of the latissimus dorsi flap, perforator-based flaps, and omental flap reconstruction).