Background : Breast reconstruction generally involves autologous tissue transplantation and placement of a mammary prosthesis. When the patient’s breasts are extremely large and ptotic, breast reconstruction often results in significantly asymmetrical appearance. However, a good aesthetic outcome after reconstruction surgery following cancer resection is an important quality-of-life factor. We evaluated the efficacy of touch-up surgery, either reduction mammaplasty or mastopexy, performed on the contralateral breast for symmetrization. Methods : Reduction mammaplasty was performed on the contralateral breast in 2 patients and mastopexy was performed on the contralateral breast in 1 patient after reconstruction surgery following cancer resection, between 2008 and 2014. We reviewed each patient’s medical record for general clinical information and for the methods of breast cancer resection and breast reconstruction used, wait time between breast cancer resection and touch-up surgery, preservation of the sensitivity of the nipple-areola complex after the touch-up surgery, and aesthetic outcome (based on visual analog scale score). Results : Wait times in the 3 cases were 4, 9, and 18 months. Nipple-areolar sensitivity was well preserved in all 3 cases. Aesthetic outcomes were judged “excellent” or “very good.” Conclusion : Revision surgery on the contralateral breast 4 to 18 months after breast reconstruction substantially improves the aesthetic outcome

Abe, Yoshiro

Fukunaga, Yutaka

Hashimoto, Ichiro

Ishida, Soshi

Kashiwagi, Keisuke

Mineda, Kazuhide

Tsuda, Tatsuya

Yamashita, Yutaro

Yamato, Ryosuke

Yoshimoto, Sho

Tokushima University Institutional Repository

INTRODUCTIONThe incidence of breast cancer in Japan has been gradually in-creasing (1, 2). Although the age at which women are most sus-ceptible to breast cancer is lower than that for other cancers (3), the5-year post- treatment survival rate in breast cancer is favorablein comparison to that in many other cancers. Thus, the prognosisof patients with breast cancer is relatively good. Therefore, patients’postoperative quality of life is important, and a good aesthetic out-come after reconstruction surgery following cancer resection is amajor quality -of - life factor. Symmetrical appearance after breastreconstruction contributes mainly to aesthetic outcome. Someform of “touch-up” surgery is required before and/or after recon-structive surgery in order to improve breast symmetry and patientsatisfaction. Touch-up surgery is normally performed on the re-constructed breast and includes repositioning the mound, augmen-tation with fat grafting, and reduction with liposuction. However,it is sometimes performed on the contralateral breasts and includesmodifying the shape, position, and size of the contralateral breasts.Breast reconstruction is of two general types, namely autologoustissue transplantation and placement of a mammary prosthesis,which is generally a silicone implant. Autologous tissue transplan-tation is limited by the volume of available tissue, which is relatedto the patient’s body mass index (BMI). A mammary prosthesis canbe adjusted to the size of the breast, but for a markedly ptotic breast,the original appearance of the breast cannot be mimicked usinga mammary prosthesis. When the patient’s breasts are extremelylarge or ptotic, breast reconstruction can result in significantlyasymmetrical appearance. When obvious asymmetry results fromunilateral breast reconstruction, we apply reduction mammaplastyor mastopexy to the contralateral side as a delayed touch-up sur-gery. We reviewed touch-up surgeries performed at our hospital toevaluate the efficacies of reduction mammaplasty and mastopexyperformed for breast symmetrization on the contralateral side.PATIENTS AND METHODSWe performed unilateral breast reconstruction in 14 patientstreated with breast cancer resection at Tokushima University Hos-pital, between January 2008 and December 2014. Three of the 14patients underwent touch-up surgery for the contralateral breast.In two of these 3 patients, reduction mammaplasty was performedusing the method reported by Georgiade et al. (4). In the thirdpatient, mastopexy was performed using the method reported byWeiner et al. (5).We were granted access to the medical records of the 3 pa-tients by the Department of Plastic and Reconstructive Surgeryof Tokushima University Hospital. The study was approved by theethics committee of Tokushima University Hospital (No. 2607).We collected and evaluated the following patient information : age,height and weight, methods of breast cancer resection and breastreconstruction, the wait time (months) between breast cancer re-section and touch-up surgery, preservation of the sensitivity of thenipple-areolar complex after the touch-up surgery, and aestheticoutcome. The aesthetic outcome after the touch-up surgery wasevaluated using the visual analog scale (Table 1) proposed byTomita et al. (6).ORIGINALReduction mammaplasty and mastopexy for the contralateralbreast after reconstruction surgery following cancerresection : A report of 3 casesKeisuke Kashiwagi, Yoshiro Abe, Soshi Ishida, Kazuhide Mineda, Yutaro Yamashita, Yutaka Fukunaga,Sho Yoshimoto, Ryosuke Yamato, Tatsuya Tsuda, and Ichiro HashimotoDepartment of Plastic and Reconstructive Surgery, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, JapanSummary : Background : Breast reconstruction generally involves autologous tissue transplantation and place-ment of a mammary prosthesis. When the patient’s breasts are extremely large and ptotic, breast reconstructionoften results in significantly asymmetrical appearance. However, a good aesthetic outcome after reconstructionsurgery following cancer resection is an important quality-of-life factor. We evaluated the efficacy of touch-upsurgery, either reduction mammaplasty or mastopexy, performed on the contralateral breast for symmetrization.Methods : Reduction mammaplasty was performed on the contralateral breast in 2 patients and mastopexy wasperformed on the contralateral breast in 1 patient after reconstruction surgery following cancer resection, be-tween 2008 and 2014. We reviewed each patient’s medical record for general clinical information and for themethods of breast cancer resection and breast reconstruction used, wait time between breast cancer resectionand touch-up surgery, preservation of the sensitivity of the nipple-areola complex after the touch-up surgery,and aesthetic outcome (based on visual analog scale score). Results : Wait times in the 3 cases were 4, 9, and 18months. Nipple-areolar sensitivity was well preserved in all 3 cases. Aesthetic outcomes were judged “excellent”or “very good.” Conclusion : Revision surgery on the contralateral breast 4 to 18 months after breast reconstruc-tion substantially improves the aesthetic outcome. J. Med. Invest. 63 : 281-285, August, 2016Keywords : reduction mammaplasty, mastopexy, touch-up surgery, breast cancer, breast reconstructionReceived for publication November 30, 2015 ; accepted July 29, 2016.Address correspondence and reprint requests to Ichiro Hashimoto, MD,PhD, Department of Plastic and Reconstructive Surgery, TokushimaUniversity Graduate School, 3 -18 -15 Kuramoto, Tokushima 770-8503,Japan and Fax : +81-88 -633-7297.The Journal of Medical Investigation Vol. 63 2016281cbaReduction Mammaplasty ProcedureReduction mammaplasty is a procedure for reducing the size oflarge and ptotic breasts. It includes resection of excess breast pa-renchyma and transposition of the nipple-areola complex higheron the breast hemisphere. For reduction mammaplasty, a new,lifted-up nipple-areola complex position is determined preopera-tively and marked on the contralateral breast, with the patient ina standing position. During surgery, superfluous skin is markedand resected along with fatty tissue and part of the mammary glandaround the pedicle nipple-areolar flap. The blood supply for thenipple-areolar flap is from the inferior soft tissue pedicle containingperforator vessels on the pectoralis major muscle. The epidermisof the nipple-areolar flap is denuded, except for the nipple-areolacomplex itself. The nipple-areola complexis pulled up and suturedto the previously marked site. Ultimately, the skin envelope of thebreast is sutured below the elevated nipple-areola.Mastopexy ProcedureMastopexy is a procedure for lifting ptotic breasts by correctingthe breast contour and elevating the nipple-areola complex. It doesnot include volume reduction. For mastopexy, a new nipple-areolarsite is marked preoperatively on the patient’s contralateral breast,as described earlier. During surgery, superfluous skin is resected,but the mammary gland around the nipple-areolar pedicle is notresected. The nipple-areolar flap is nourished from the superiorsoft tissue pedicle containing perforator vessels on the pectoralismajor muscle. The nipple-areola complex is pulled up and suturedto the previously marked site. Ultimately, the skin envelope of thebreast is sutured below the elevated nipple-areola (Figure 1).RESULTSThe clinical characteristics, cancer resection surgeries, and touch-up surgeries with the results in all 3 patients are shown in Table 2.The patients were 51, 54, and 61 years of age. According to bodymass index (BMI), Patient 1 was of normal weight, Patient 2 wasoverweight, and Patient 3 was obese. Patient 1 had undergone Hal-stead radical mastectomy, by which the pectoralis major and pec-toralis minor were removed. Patient 2 had undergone modifiedradical mastectomy, in which both pectoralis muscles were pre-served. Patient 1 had undergone delayed reconstruction with apedicled transverse rectus abdominis musculocutaneous (TRAM)flap ; the left deep inferior epigastric vessels were anastomosedwith the left thoracodorsal vessels so that the entire flap wouldsurvive and the reconstructed breast could be made as large aspossible. Patient 2 had also undergone delayed reconstruction witha free deep inferior epigastric perforator flap ; the flap vesselswere anastomosed with the left thoracodorsal vessels so that thereconstructed breast could be made as large as possible. However,the reconstructed breast did not match the contralateral breast involume in either Patient 1 or Patient 2, so reduction mammaplastywas performed (Figures 2 and 3) at 4 and 9 months, respectively.Table 1. Visual analogue scale*ScoreBreast size 2 (symmetric) to 0 (asymmetric)Breast shape 2 (symmetric) to 0 (asymmetric)Breast scar 2 (barely visible) to 0 (clearly visible)NAC size, shape 1 (symmetric) or 0 (asymmetric)NAC color 1 (symmetric) or 0 (asymmetric)NAC position 1 (symmetric) or 0 (asymmetric)Most inferior point of breast 1 (symmetric) or 0 (asymmetric)Total 10 -9 : excellent, 8 -7 : very good, 6 -5 : good, 4 -3 : fair, 2 -0 : poorNAC : nipple -areola complex.*as described by Tomita K et al. (6).Figure 1. Schematic diagram of the mastopexy performed for patient 3.(a) Preoperative design : A new nipple -areola position and the excessiveskin to be resected are marked. (b) Intraoperative findings : Superfluousskin is resected, excluding breast parenchyma. The nipple -areolar com-plex is nourished from the superior pedicle on which the epidermis isdenuded (indicated with an arrowhead). (c) Immediate postoperativefindings : The nipple -areola complex is sutured to the same position asthe reconstructed breast. The skin envelope of the breast is sutured in areversed-T shape.282 K. Kashiwagi, et al. Contralateral mammaplasty/mastopexyabcFront viewOblique view Oblique viewPatient 3 had undergone nipple-sparing mastectomy and imme-diate reconstruction with a silicone implant. Ptosis of the contra-lateral breast was significant, so mastopexy was performed 18months after the mastectomy (Figure 4). The sensitivity of thenipple-areola complex was good in all 3 patients. The aestheticoutcomes were judged “excellent” or “very good”, according to thevisual analog scale.Table 2. Patients, procedures, and outcomesPatient 1 Patient 2 Patient 3Age (years) 51 61 54Height (cm) 159 151 152Weight (kg) 60 60 71Body mass index (kg/m2) 23.7 26.3 30.7Method of cancer excision Radical mastectomy Muscle -preservingradical mastectomyNipple -sparingmastectomyImmediate or delayed breastreconstruction Delayed Delayed ImmediateMethod of breast reconstruction Pedicled TRAM flap+supercharging Free DIEP flapTissue expanderimplantTouch-up surgery method ReductionmammoplastyReductionmammoplasty MastopexyPeriod between reconstructionand touch-up surgery 4 months 9 months 18 monthsNipple -areola sensitivity Preserved Preserved PreservedAesthetic outcome aftertouch-up surgery (VAS score)9/10Excellent9/10Excellent8/10Very goodTRAM : transverse rectus abdominis musculocutaneous ; DIEP : deep inferior epigastric perforator ; VAS : visual analogue scale.Figure 2. Patient 1 (reduction mammoplasty). (a) Before breast reconstruction. Rib bones can be seen under the thin breast skin because thepectoralis major and minor muscles were removed. (b) Three months after reconstruction of the left breast. The pedicled transverse rectus abdominismusculocutaneous flap was transplanted to the upper portion of the breast and axilla to fill the soft tissue defect. Breast on the contralateral side droopsconsiderably in comparison to the reconstructed breast. (c) Three years after reduction mammaplasty. The nipple -areola complex on the recon-structed breast was transplanted from the contralateral side when the reduction mammoplasty was performed.The Journal of Medical Investigation Vol. 63 August 2016 283abcabDISCUSSIONIn Western countries, reports on reduction mammaplasty andmastopexy for the contralateral breast after unilateral breast re-construction are fairly numerous (7-14). Touch-up surgery forcontralateral breasts has been rarely reported in Japan. As thebreasts of Japanese women are, on average, smaller than thoseof Western women, the reconstructed breast is usually providedadequate volume with a latissimus dorsi or rectus abdominis mus-culocutaneous flap. The 3 patients described herein all had largeptotic breasts with significant asymmetry after breast reconstruc-tion.Reducing the mammary gland and fatty tissue while preserv-ing both the original blood supply and sensitivity of the nipple-areola complex is key to successful reduction mammaplasty andmastopexy. Various techniques have been reported in attemptsto improve these important steps. The resulting procedures arecategorized according to the origin of the pedicle. Weiner et al. (5)described a procedure by which the nipple-areolar flap receives itsblood supply from the superior pedicle. Ribeiro (15), Robbins (16),Courtiss et al. (17), and Georgiade et al. (4) described the use of theinferior pedicle. McKisock (18) and Strömbeck (19) advocated theuse of a bipedicled flap for provision of more reliable blood supply.The 2 reduction mammaplasties we performed were according toGeorgiade’s procedure, that is, by the inferior pedicled flap method.We chose this procedure because it allows for preservation of bothnipple-areolar circulation and sensation (20) despite removal ofa large amount of breast tissue. Our third patient, whose breastswere considerably ptotic, underwent mastopexy performed ac-cording to Weiner’s procedure, that is, the superior pedicled flapmethod. We chose this procedure because it allows firm fixationof the nipple-areola complex at the elevated position, maintenanceof breast projection, and preservation of fullness at the upper site ofthe breast (21). Weiner’s procedure tends to result in loss of nipple-areolar sensitivity ; therefore, we elevated the superior pedicledflap without dissecting it from the pectoralis major muscle. Thisway, we were able to preserve the cutaneous branches of 3 to 5intercostal nerves and the sensitivity of the nipple-areola complexin our patient.Touch-up surgery for the contralateral breast is sometimes per-formed at the time of or even before the breast reconstructionsurgery (11-14). In our institute, we perform touch-up surgeries4 to 18 months after the breast reconstruction. In our 3 patients,objective evaluation after the touch-up surgery showed excellentoutcomes. We believe that symmetrical appearance can be attainedeasily with delayed touch-up surgery because the waiting periodallows for maturation of the scar of the reconstructed breast.CONFLICT OF INTERESTThis study was supported by departmental resources only. Theauthors have no conflicts of interest to report.Figure 3. Patient 2 (reduction mammoplasty). (a) Before the breastreconstruction. (b) Five months after reconstruction of the left breast.The left breast was reconstructed with a free deep inferior epigastricperforator flap. Breast on the contralateral side droops considerably incomparison to the reconstructed breast. (c) One year after reductionmammaplasty. The nipple -areola complex on the reconstructed breastwas transplanted from the contralateral side when the reduction mam-moplasty was performed.Figure 4. Patient 3 (mastopexy). (a) Six months after reconstructionof the left breast. Reconstruction with a silicone implant was performedimmediately after nipple -sparing mastectomy. Breast on the contralat-eral side droops considerably in comparison to the reconstructed breast.(b) Two months after the mastopexy.284 K. Kashiwagi, et al. Contralateral mammaplasty/mastopexyREFERENCES1. 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Reduction mammaplasty and mastopexy for the contralateral breast after reconstruction surgery following cancer resection : A report of 3 cases

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Reduction mammaplasty and mastopexy for the contralateral breast after reconstruction surgery following cancer resection : A report of 3 cases

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