Overview
Definition:
Oncoplastic batwing mastopexy lumpectomy is a surgical technique that combines breast cancer tumor excision (lumpectomy) with immediate breast reshaping and lifting (mastopexy) using a specific "batwing" or "dual-sail" incision pattern
This approach aims to achieve oncologic safety (complete tumor removal) while simultaneously improving breast aesthetics, particularly in cases of moderate to significant breast ptosis or asymmetry, by excising excess skin and glandular tissue
It is particularly suited for central or lower pole tumors where skin laxity is a concern.
Epidemiology:
Breast cancer remains a leading malignancy in women globally and in India
The incidence of early-stage breast cancer amenable to breast-conserving surgery (BCS) is increasing due to improved screening
Oncoplastic techniques, including those utilizing mastopexy principles, are becoming more prevalent to address the aesthetic concerns of patients undergoing BCS, with studies indicating their use in a significant percentage of BCS cases in specialized centers.
Clinical Significance:
This technique is crucial for improving patient satisfaction and quality of life after breast cancer surgery
By addressing both tumor removal and aesthetic deformities concurrently, it enhances body image and reduces the need for secondary reconstructive procedures
For DNB and NEET SS candidates, understanding the indications, techniques, and outcomes of oncoplastic procedures is vital for managing breast cancer patients holistically and demonstrating advanced surgical skills.
Indications
Oncologic Indications:
Locally excised breast tumors requiring significant tissue removal
Tumors located centrally or in the lower breast pole where skin redundancy is present
Patients desiring improved breast shape and lift post-lumpectomy.
Aesthetic Indications:
Moderate to severe breast ptosis (grades II-III)
Asymmetry between breasts
Desire for breast augmentation or reshaping concurrent with tumor removal
Patients with significant skin excess post-weight loss or aging.
Contraindications:
Large tumors with poor cosmetic outcome potential even with oncoplastic reconstruction
Patients with poor wound healing potential
Active infection at the surgical site
Very small breasts with limited tissue for reshaping
Significant comorbidities that preclude extensive surgery.
Preoperative Preparation
Patient Assessment:
Detailed history, including breast cancer stage, previous surgeries, and aesthetic goals
Thorough physical examination to assess breast size, ptosis, skin quality, and tumor location
Mammography, ultrasound, and potentially MRI for accurate tumor delineation
Biopsy confirmation of malignancy.
Imaging And Marking:
Preoperative imaging to determine the precise extent of resection
Careful marking of the skin incision, planned lumpectomy margins, and the desired new breast contour, incorporating the mastopexy elements
The batwing pattern involves superior and inferior dermal flaps designed to reshape the breast and close skin deficit.
Surgical Planning:
Selection of appropriate oncoplastic technique based on tumor size and location, breast ptosis grade, and patient preference
Consideration of sentinel lymph node biopsy
Discussion of potential outcomes, risks, and benefits with the patient
Photographic documentation for before-and-after comparison.
Anesthesia And Consent:
General anesthesia is typically required
Informed consent covering surgical procedure, potential complications, oncologic outcomes, aesthetic results, and the possibility of revision surgery.
Procedure Steps
Incision And Exposure:
The characteristic batwing incision is made, typically forming a superiorly based pedicle and incorporating a wider inferiorly based dermal flap
This creates two wings of skin that allow for significant mobilization and reshaping.
Lumpectomy:
The tumor is excised with adequate margins according to oncologic principles, guided by preoperative markings or intraoperative imaging
The specimen is oriented for pathological assessment.
Glandular Rearrangement:
The remaining breast parenchyma is reshaped and repositioned
The inferior dermal flap is often utilized to provide support and bulk to the lower breast pole, while the superior pedicle helps reshape the upper pole
Decisions regarding glandular transposition or de-epithelialization are made based on breast anatomy and desired outcome.
Skin Closure:
The superior and inferior skin flaps are advanced and closed in layers
The closure is designed to achieve symmetry, lift the breast, and obliterate dead space, resulting in the characteristic appearance of the mastopexy component
Drains are typically placed.
Sentinel Lymph Node Biopsy:
Performed concurrently if indicated, usually through a separate axillary incision.
Postoperative Care
Pain Management:
Analgesics as needed, typically opioid analgesics initially followed by non-opioid medications
Regional blocks may be used.
Drain Management:
Surgical drains are monitored for output and removed when output is less than 30 mL per 24 hours
Careful monitoring for hematoma or seroma formation.
Dressing And Support:
Compression dressing or surgical bra to provide support and minimize swelling
Instructions on wound care and hygiene
Antibiotics may be prescribed prophylactically.
Activity Restrictions:
Avoidance of strenuous activity, heavy lifting, and certain arm movements for 4-6 weeks to allow for adequate healing and prevent flap dehiscence or implant displacement if performed concurrently.
Complications
Early Complications:
Hematoma and seroma formation
Infection
Wound dehiscence and skin flap necrosis
Partial or complete nipple-areolar complex (NAC) ischemia or necrosis
Unsatisfactory initial aesthetic outcome.
Late Complications:
Asymmetry of breast size or shape
Scarring irregularities
Ptosis recurrence
Chronic pain
Changes in nipple sensation
Distant metastasis or local recurrence of cancer.
Prevention Strategies:
Meticulous surgical technique, careful flap design, preservation of vascularity
Effective hemostasis
Appropriate drain placement and management
Postoperative compression
Smoking cessation counseling
Patient selection and realistic expectation setting.
Prognosis
Factors Affecting Prognosis:
Stage of breast cancer at diagnosis
Histological grade and subtype of tumor
Completeness of surgical margins
Response to adjuvant therapies
Patient's overall health and adherence to treatment.
Outcomes:
Good to excellent aesthetic outcomes are achievable with proper patient selection and surgical technique, leading to improved patient satisfaction and body image
Oncologic safety is paramount, with rates of local recurrence comparable to standard lumpectomy when adequate margins are achieved.
Follow Up:
Regular follow-up appointments are essential for monitoring wound healing, assessing aesthetic results, and for long-term surveillance for cancer recurrence
This includes clinical breast examinations, mammography, and potentially other imaging modalities as per established breast cancer follow-up guidelines.
Key Points
Exam Focus:
Understand the specific incision pattern of the batwing mastopexy and its role in skin redundancy management
Key indications are moderate-to-severe ptosis in conjunction with lumpectomy
Differentiate from other oncoplastic techniques like Wise pattern mastopexy or therapeutic mammoplasty.
Clinical Pearls:
Preserving a robust vascularized dermal pedicle is critical for flap viability
Meticulous closure of the deep dermis is essential for breast shape and support
Patient selection for realistic aesthetic goals is paramount
Consider intraoperative frozen section for margin assessment to optimize resection.
Common Mistakes:
Inadequate tumor margins leading to positive margins and re-excision
Over-reliance on the mastopexy component without adequate oncologic resection
Poor flap design leading to ischemia or necrosis
Underestimating the degree of ptosis or skin redundancy
Failure to achieve symmetry with the contralateral breast.