According to a 7-year observation study, the results of which were reported by Veronesi et al. [5
] in 1981, the comparison of a group where quadrantectomy was performed concomitantly with radiotherapy with a group that underwent modified radical mastectomy for breast cancer showed no significant difference in their survival rates. According to Fisher et al. [6
], in 1985, a comparison of modified radical mastectomy and breast-conserving surgery in cases of negative <4 cm axillary lymph node metastasis showed no significant differences in the local recurrence and survival rates of the two groups. Since then, breast-conserving surgery has been accepted as the primary treatment modality in patients with stages I and II breast cancer, unless there are specific contraindications [7
In an oncoplastic procedure, an expanded concept of breast-conserving surgery, the breast is shaped using the residual breast tissue following extensive resection of breast cancer, or is reconstructed using the adjacent tissue [8
]. It can improve the cosmetic outcomes of reconstruction while increasing the distance of the margins from the tumor. The comparison by Kaur et al. [10
] of the volumes of the resected tissue and the degrees of infiltration of the surgical margin in the oncoplastic procedure along with standard quadrantectomy in patients with breast cancer showed that the oncoplastic procedure can resect a larger quantity of tissue and thus wider negative surgical margin can be obtained of the surgical margin. Clough et al. [11
] reported that the oncoplastic procedure had satisfactory cosmetic and oncologic outcomes in 300 patients. Oncoplastic techniques allow extensive resections for breast-conserving surgery, with favorable cosmesis.
There are two techniques in oncoplastic surgery according to the volume of the excised breast tissue. One includes volume displacement procedures that combine resection with a variety of different breast-reshaping and breast-reduction techniques, and the other is a volume replacement procedure that replaces the volume of excised breast tissue using autologous tissue. To select the appropriate oncoplastic procedure, multiple factors should be considered including the breast size, the excised volume, and the location of the breast tumor. In cases in which the breast size is relatively large, the amount of the residual tissue after the resection of the tumor is sufficient. Therefore, satisfactory cosmetic outcomes can be obtained from the volume displacement procedures such as glandular reshaping and reduction mammoplasty. In cases in which the breast size is relatively small, volume displacement techniques can also be performed after the removal of a small tumor. In cases, however, in which the defect area is larger than moderate, satisfactory cosmetic outcomes can only be obtained after the defect area is restored using volume replacement techniques.
In this study, 5 volume replacement procedures were performed based on the excised volume of the breast and the location of the tumor. We used an LD myocutaneous flap for cases with a resection mass greater than 150 g. For cases with a resection mass less than 150 g, we used regional flaps such as a lateral thoracodorsal flap, a thoracoepigastric flap, or perforator flaps such as an ICAP flap or TDAP flap. If the resection mass was less than 150 g, we selected a lateral thoracodorsal flap or an ICAP flap when a tumor was located in the lateral quadrants. A thoracoepigastric flap or an ICAP flap can be chosen when a tumor is located in the inferior quadrants. A TDAP flap can be used for all breast quadrants.
A lateral thoracodorsal flap is a wedge-shaped transposition flap. Patients with lateral breast cancer and redundant lateral thoracic region might be candidates for this flap. The axis of the flap is in the lateral extension of the inframammary fold. The superior border of the flap begins at the point medial to the anterior axillary fold and extends laterally from there. In elevating the flap, the underlying fascias of the LD and the anterior serratus muscles must be included. This fascia provides viability to the flap because the flap vascular supply is derived from the lateral intercostal perforators and the muscular fascia [12
]. These flaps provide excellent skin and tissue matching to the native breast.
A thoracoepigastric flap is designed as a transposition flap. Its upper margin is at the inframammary fold, and its lower margin is drawn with consideration of the pedicle. It is supplied by the musculocutaneous perforating vessels from the superior epigastric artery and vein extending from the underlying rectus abdominis muscle. It can be elevated either above or below the rectus fascia and investing fascia of the external oblique musculature. This flap commonly has a rather broad base and is limited in mobility [13
]. It is usually indicated for defects in the lower quadrant of the breast.
An LD flap has excellent blood supply and provides both muscle for filling glandular defects and skin for cutaneous deficiencies. Its disadvantages include a difficult surgical technique as compared to regional flap, long surgical time, and postoperative complications at the donor site such as the restriction of shoulder movement and seroma.
Methods of decreasing donor site morbidity associated with the use of the LD flap have been suggested in several studies. Hamdi et al. [14
] recently described the use of a pedicled skin- and fat-only flap over the LD flap, based on the TDAP or ICAP vessels. Therefore, a TDAP flap, which spares the LD muscle, can reduce the occurrence of postoperative complications at the donor sites, and thus shorten the recovery period.
An ICAP flap is designed over the thoracic region at the level of the inframammary fold. The flap width depended on the expected defect and the flap length on the location of the defect. This flap is appropriate for lateral and inferior breast defects. The intercostal vessels form an arcade, which gives numerous perforators. The ICAP flap has a limited range of motion because it can only be used in the adjacent area due to its short perforator. Additionally, it sometimes provides an inadequate perforator, which leads to instability of the flap condition.
A TDAP flap is supplied by perforating vessels from the thoracodorsal artery, which provides the advantage of preserving the LD muscle [15
]. When an appropriate perforating vessel is selected, the dissection is continued through the LD muscle up to the thoracodorsal artery and vein. A tunnel is created between the anterior edge of the LD muscle and the defect, through which the flap passes. The flap is then placed on the breast defect. It is often used for defects in the lateral and central, and even medial breast regions.
In cases in which the breast size is relatively large, as in much of the Caucasian population, excellent cosmetic outcomes can be achieved using a volume displacement procedure, one of the oncoplastic procedures. In many cases, however, the breast size is relatively small, as in Korean women, and it is difficult to achieve satisfactory results using a volume displacement procedure. Accordingly, in these cases, the defect areas should be restored using a volume replacement procedure. This may be mandatory to obtain more satisfactory postoperative outcomes from a cosmetic perspective.