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Reconstruction of the partial mastectomy defect has become increasingly popular becaue of poor cosmetic results in select patients. The purpose of this series was to try to create a treatment algorithm based on patient selection, diagnosis, margins, and recurrence in an attempt to maintain oncologic safety, as well as to improve esthetic outcome.A retrospective review of all patients treated at Emory University Hospital with partial mastectomy and reduction/mastopexy was performed. Reconstruction was performed either simultaneously or following confirmation of negative histologic margins.Sixty-three women were included in the series. Histology was invasive carcinoma (n = 33), ductal carcinoma in situ (DCIS) (n = 20), fibroadenoma (n = 6), and benign breast tissue (n = 4). The Wise pattern was used 84% of the time (n = 53/63). The most common tumor location was upper outer quadrant, and the various pedicles used were superomedial (n = 22), inferior (n = 20), central (n = 7), and other (n = 14). Eight patients had reduction/mastopexy once final pathology confirmed negative margins. The average biopsy weight was 236 g. Total specimen weight on the tumor side was 762 g and 858 g on the contralateral side, to accommodate for radiation fibrosis. Immediate complications were seen in 22% of cases and included delayed healing (n = 9), infection (n = 1), partial nipple loss (n = 1), hematoma (n = 1), and skin necrosis (n = 1). In patients with breast cancer (n = 53), 26% required either fine needle aspiration or excisional biopsy for cancer surveillance postoperatively. Oncoplastic surgery was the definitive procedure 93% of the time. Completion mastectomy with reconstruction was required in 4 patients, 3 for positive margins extensive DCIS and 1 for residual microcalcifications (stereobiopsy DCIS) despite adequate specimen radiograph and negative margins initially. All 4 patients who failed the combined approach were younger women with the diagnosis of extensive DCIS. The locoregional recurrence rate was 2%, and all patients had no evidence of disease at an average follow-up of 3.25 years.Therapeutic mammaplasty is a useful procedure for shape and symmetry preservation in women with large or ptotic breasts. Versatility exists using various pedicles and skin patterns to reconstruct all breast shapes and defect locations. Younger patients with extensive DCIS are poor candidates for simultaneous reconstruction, and should be deferred until confirmation of negative margins. If surgical management of residual disease requires completion mastectomy, immediate reconstruction is possible, with skin preservation and no adverse effects.