Practical Guidelines for Repair of Partial Mastectomy Defects Using the Breast Reduction Technique in Patients Undergoing Breast Conservation Therapy

Sir: There is at present an increasing body of evidence in the form of clinical studies suggesting that conservative breast surgery reconstruction is a safe procedure.1–5 The article published by Kronowitz et al.1 has been well presented in a scientific fashion in a cohort and retrospective study. The authors have proved their hypothesis and the guideline, at least in Houston. Reduction mammaplasty using a variety of pedicle type designs is widely practiced. The principal message is that tumor location had a significant effect on the design of the pedicle. In my experience, the majority of procedures are predictable and allow the breast-shaping process, even with the superior pedicle technique.2,3 Safety is enhanced by preoperative planning, raising flaps of suitable thickness, and performing resection by observing the principles that reduce the risk of compromise of pedicle circulation.2–4 Contrary to what has been observed by the authors, I usually prefer breast remodeling by means of the superior pedicle technique.2,3 The widespread use of the superior pedicle technique in Brazil has made surgeons more familiar with this technique and more comfortable with modifying its design. Concerning the cosmetic outcome, I disagree with the statement that a more favorable aesthetic result is achieved with an inferior pedicle technique. It has been my impression that the inferior pole projection can be maintained with all techniques, and the same results can be achieved with the superior pedicle technique. Although it is encouraging to see that more favorable outcomes were achieved using an inferior pedicle technique, this observation likely rests on favorable preoperative breast volume/shape and glandular resection in this selected, small group of nonrandomized patients within the inferior pedicle technique (n = 27) and superior pedicle technique (n = 5) cohorts. Therefore, one must wonder whether there is selection bias in the population reported in this series, which should be considered in assessing the authors’ experience with both techniques. Indeed, inherent in the design of all retrospective studies is the inability to draw any conclusions about the cause and presence or absence of an observed effect. Another important issue is related to the follow-up. The mean time intervals between radiotherapy and photography were 20 months (excellent/good) and 27 months (fair or poor). Despite the good results observed (except Fig. 6), it has been my impression that a longer follow-up is required for significant conclusions, because breast shape continues to change and a skin radiation effect may be a cause of secondary asymmetry. As stated in the article, the authors feel that the low rate of positive tumor margins alleviates concerns regarding the potentially awkward situation of trying to locate the position of a positive tumor margin. In their series, 7 percent of the patients had a positive tumor margin, which is less than the 10 percent rate observed in the National Surgical Adjuvant Breast and Bowel Project B-06 trial, and much less than the 48 percent rate observed in the European Organization for Research and Treatment of Cancer trial.5 Comparisons of retrospective studies from different institutions are therefore difficult, as the studies are unlikely to be comparable in subsets of tumor site, glandular/skin resection, and stage. In this study, the authors were obviously successful in selecting low-risk breast cancers, whereas in other studies selection criteria were different. This reflects accurate staging, effective selection, and good techniques. However, although the absolute numbers are low, a longer follow-up would be necessary for significant conclusions to be drawn. Thus, an evidence-based dialogue should solely strengthen our understanding of the important relationships between tumor biology, patient selection, and appropriate surgery. With the increase in the prevalence of conservative breast surgery, it has become essential for plastic surgeons to better select and preoperatively prepare patients to decrease the procedure-related morbidity. Currently, there are no clear guidelines from the leading breast and plastic surgery societies as to whether early breast cancer patients should undergo reconstruction. Alexandre Mendonça Munhoz, M.D.