Discussion: The Expanded Use of Autoaugmentation Techniques in Oncoplastic Breast Surgery
In this article, Losken et al. present their experience with various “autoaugmentation” pedicles to fill the extirpated defect. The authors borrow this term from massive weight loss patients and mastopexy procedures, in which a pedicle is used to reposition the breast parenchyma instead of purely resecting the underlying breast tissue. Given that this is not truly an augmentation, the procedure perhaps may be aptly described as a “pedicled partial breast reconstruction” or, using the more traditional term, “oncoplastic breast reconstruction,” which is consistent with previous reports.
Various reports in the literature discuss oncoplastic techniques. Many of these published reports are in the surgical oncology journals and not concentrated in plastic surgery publications. For plastic surgeons, this trend should certainly be noteworthy. To maintain an involved role in these procedures, it is important that our field continues to advance and publish these commonly used procedures, something that Losken et al. have been able to accomplish. Although this article does not necessarily describe new techniques, it does compare them to the more standard oncoplastic approaches used in breast reduction procedures while showing equivalent outcomes.
Losken et al. particularly contribute to the strengthening role of an oncoplastic approach in a smaller breast. In these patients, using an extended pedicle or additional pedicle can fill a remote defect and presumably avoid hollowing and skin dimpling that develops after radiation-induced contracture. Losken et al. show a statistical difference correlating size of the breast to the need for a pure reduction pattern resection versus an autoaugmentation pedicle.
Similar to various institutions that use a multidisciplinary approach to breast cancer patients, our breast surgical oncologists are liberal in plastic surgery involvement, not only in patients in whom a traditional breast reduction pattern would apply, but also in those who would benefit from mastopexy alone in a smaller breast, or those with various grades of breast ptosis. Our experience suggests that even in a small breast with grade 1 or 2 ptosis, a combined oncoplastic approach is beneficial in preventing post–radiation therapy deformities. Our experience also confirms use of multipedicle approaches designed creatively to benefit the aesthetic outcome and preserve parenchymal blood flow, regardless of breast ptosis.
It is important to keep in mind that breast parenchyma generally has poor blood flow and, although source vessels are consistent, the interconnections are less predictable.3 This can therefore potentially lead to problems when designing random pattern pedicles or extending standard nipple-areola complex pedicles. As stated in the article, care must be taken to avoid back-cuts and designing too narrow of a pedicle. Ultimately, caution should be used to evaluate blood flow in these pedicle modifications, and any poorly vascularized tissue should not be included.
Given that these patients carry the risk of breast cancer recurrence, development of fat necrosis and resulting scar tissue can be a real cause for concern in these patients.