Batwing Lumpectomy with Skin Resection
This case shows a 64-year-old woman with two non-palpable lesions at 9 o’clock and 12 o’clock deep near the major thoracic muscle and about 6 cm distance between their projections on the skin surface. A J wire was inserted mammographically at the 9 o’cloc
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Batwing Lumpectomy with Skin Resection Elias E. Sanidas
6.1
Patient
This case shows a 64-year-old woman with two non-palpable lesions at 9 o’clock and 12 o’clock deep near the major thoracic muscle and about 6 cm distance between their projections on the skin surface. A J wire was inserted mammographically at the 9 o’clock lesion, and another J wire was US guided inserted intraoperatively at the 12 o’clock lesion. Preoperative staging was negative.
6.2
Surgery
• The patient underwent lumpectomy including the above lying skin, sentinel node biopsy with blue dye-only technique, and immediate axillary dissection due to palpation of multiple enlarged nodes. • The technique gives the possibility to excise 2 (or more) multifocal or multicentric lesions including the overlying skin. Furthermore it is possible to lift the breast in case of a ptosis. • Preoperative drawings are done with the patient sitting upright. The lateral drawing
Fig. 6.1 Preoperative drawings are done with the patient sitting upright. The lateral drawing lines have to outweigh the round central diameter in length
E.E. Sanidas, MD, FACS Department of Surgery, Herakleion Crete Medical School, Herakleion, Crete, Greece e-mail: [email protected], [email protected]
lines have to outweigh the round central diameter in length (Fig. 6.1). • The preoperative drawing lines were fully incised; the cranial resection margin was first developed by vertical dissection down to the
© Springer-Verlag Vienna 2015 F. Fitzal, P. Schrenk (eds.), Oncoplastic Breast Surgery: A Guide to Clinical Practice, DOI 10.1007/978-3-7091-1874-0_6
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E.E. Sanidas
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Fig. 6.2 Preoperative drawing lines fully incised
Fig. 6.4 After insertion of drain and suturing
6.3
Fig. 6.3 Defect closed
pectoralis fascia. Thereafter, the dissection is carried out between the nipple-areola complex and the segment, and under palpable control, the segment including the skin is excised (Fig. 6.2). • Without further dissection between the skin and the breast, the defect is simply closed (Fig. 6.3). • After the insertion of a drain, suturing is done after approximation with interrupted PDS 3.0 sutures in two layers (deep and superficial) followed by continuous subcutaneous PDS 3.0 and intradermal Monocryl 3.0 (Fig. 6.4).
Outcome (Clinical and Cosmetic)
The final histology showed a high-grade DCIS with 5 mm in diameter at 9 o’clock and an invasive ductal adenocarcinoma pT1c G2 R0 resection with negative lymph nodes pN0 (0/25), ER 85 % (2+), PR 30 % (1+), and Her2 negative at the 12 o’clock position. The patient underwent adjuvant breast radiotherapy and endocrine treatment with an aromatase inhibitor. The cosmetic result was considered very good (Fig. 6.5) from the patient and the physician 12 months after surgery.
6.4
Author’s Comment
This oncoplastic technique can be applied to all ptotic breasts. However, there must be a “logical” relation between the ptosis and the breast area to be excised. If the ptosis is small and the excision area big, we will end up with a
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