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CORRESPONDENCE
Year : 2019  |  Volume : 15  |  Issue : 5  |  Page : 1173-1176

Adding bit of esthetics with science modification of batwing mastopexy for breast conservation in a young patient with giant fibroadenoma breast


Department of Surgical Oncology, St. John's Medical College, Bengaluru, Karnataka, India

Date of Web Publication4-Oct-2019

Correspondence Address:
N K Faslu Rahman
Department of Surgical Oncology, St. John's Medical College, Sarjapur Road, Bengaluru - 560 034, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_818_17

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 > Abstract 


A 19-year-old girl presented with a lump in her right breast and with a history of surgery for the similar complaint 3 years back. Ultrasound was suggestive of benign solitary lesion of size 16 cm × 10 cm. Core biopsy was suggestive of phyllodes tumor, and the histopathology report of previous surgery was also suggestive of phyllodes tumor. Wide excision of the tumor and reconstruction was done with batwing mastopexy and with a slight modification of the described technique so that to avoid contralateral reduction mammoplasty in a young unmarried girl. Postoperative histopathology was suggestive of fibroadenoma measuring 15 cm × 8 cm with all margins free of tumor, and it is probably one of the biggest fibroadenomas reported so far. On follow-up, no significant disparity noted between the appearances of both breasts.

Keywords: Batwing mastopexy, breast conservation surgery, giant fibroadenoma


How to cite this article:
Kumar H H, Rahman N K, Ramesh RS, Raghunandan G C. Adding bit of esthetics with science modification of batwing mastopexy for breast conservation in a young patient with giant fibroadenoma breast. J Can Res Ther 2019;15:1173-6

How to cite this URL:
Kumar H H, Rahman N K, Ramesh RS, Raghunandan G C. Adding bit of esthetics with science modification of batwing mastopexy for breast conservation in a young patient with giant fibroadenoma breast. J Can Res Ther [serial online] 2019 [cited 2019 Nov 22];15:1173-6. Available from: http://www.cancerjournal.net/text.asp?2019/15/5/1173/244476




 > Introduction Top


Fibroadenoma is a common benign tumor known to occur in young women. Excision biopsy is all that is required in primary setting. Fine-needle aspiration cytology and core-needle biopsy may not clearly differentiate between fibroadenoma and phyllodes tumor. Fibroadenoma differentiating to phyllodes tumor has been reported.[1] However, transformation of phyllodes tumor to fibroadenoma has not been reported so far in literature. In case of recurrent phyllodes tumor, wide excision has to be done to avoid chances of leaving any residual disease and recurrence.

In small fibroadenomas, observation can be done and addressed surgically only in case of increase in size of the lump or if associated with pain. Risk of malignancy in fibroadenoma lesions is reported to be 0.002%–0.0125%.[2],[3] Giant fibroadenomas are defined as the fibroadenoma larger than 5 cm in dimension. These may be addressed surgically to avoid unnecessary anxiousness in the patients, though the risk of malignancy is very less. Removal of such lesions will lead to breast deformity. Choosing the right technique among the various available surgical options including simple excision, local flaps, and reduction mammoplasty of opposite breast, prosthesis can sometimes be difficult in young patients. Modification of various available well-designed mastopexy techniques can be done to provide better cosmesis and reduce donor site morbidity in young patients with large benign tumors.


 > Case report Top


A 19-year-old girl presented with lump in her right breast since 3 months. On clinical examination, about 18 cm × 12 cm lump was noted in the right breast, mobile, not fixed to overlying skin. Ultrasound was suggestive of benign solitary lesion measuring size of about 16 cm × 10 cm. Core biopsy was suggestive of phyllodes tumor. She was operated earlier for similar complaint 3 years back with lumpectomy, and the histopathology report of previous surgery was also suggestive of phyllodes tumor. Hence, wide excision was done as it was a recurrent lesion. Defect was quite big and the reconstruction options left were prosthesis, regional flap, or mastopexy with opposite side reduction mammoplasty. Since, the regional flap would lead to donor site morbidity, which would be uncalled for, as it was a case of benign tumor in a young girl. Hence, reconstruction was done with batwing mastopexy with slight modification in the described standard technique. Modification was done to avoid contralateral reduction mammoplasty in a young unmarried girl. Postoperative histopathology was suggestive of fibroadenoma measuring 15 cm × 8 cm with all margins free of tumor, and it is probably one of the bigger reported fibroadenomas breast so far. On follow-up, no significant disparity was noted between the appearances of both breasts.

Technical details

Tumor was involving central and part of upper quadrant and was not involving the nipple, which is shown in [Figure 1]. The batwing mastopexy is a surgical approach that is most ideal for cancers located deep within or adjacent to the nipple-areolar complex but not directly connected with the areola, particularly in ptotic breasts.[4] Two closely similar half-circle incisions are made with angled wings to each side of the areola [Figure 2]. Thick flaps were made and nipple raised from underlying breast tissue [Figure 3] and breast tissue was mobilized from underlying pectoralis fascia [Figure 4]. Excision of tumor with 1 cm margin all around was done and the fibroglandular tissue was advanced to close the subsequent defect. Once the defect was closed, right nipple was at a higher level than the left. Hence, infraareolar region was de-epithelialized [Figure 5], and the areola was pulled down and sutured to the wound edge. The advantage of large amount of fat in the flap was taken to cover the defect, which would have been difficult in small-sized breasts. Specimen photograph is shown in [Figure 6]. On postoperative follow-up, no significant disparity in size and shape noticed between both breasts [Figure 7].
Figure 1: Preoperative photograph

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Figure 2: Closely similar half-circle incisions are made with angled wings to each side

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Figure 3: Nipple raised from underlying breast

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Figure 4: Tumor mobilized from pectoral fascia

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Figure 5: Excised specimen

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Figure 6: Deepithelialization of infra-areolar skin

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Figure 7: Postoperative day 14

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 > Discussion Top


Management of benign tumor of large size in young patients can be tricky. Various issues to be addressed in large benign tumors include asymmetry and deformity, pressure atrophy of surrounding normal parenchyma, fear of malignancy, and positive margins and recurrence in case of phyllodes tumor. Choosing the right technique among the various available options of treatment including simple excision, local flaps, reduction mammoplasty of opposite breast can sometimes be difficult. Age, affordability, and donor site morbidity can be confounding factors in choosing the ideal option. Various mastopexy techniques have explained in detail in the literature. Each technique has been well designed for tumors located in different quadrants. Adoption of the right technique is important. Slight modification of the available techniques can lead to better cosmesis.

The primary factor in selecting the most appropriate technique for an individual case is the quality of the breast parenchyma.[4] The rationale for breast-conserving therapy comes from a group of prospective randomized trials performed in the 1970s,[5],[6],[7],[8] where the maximum tumor size allowed was 5 cm. In the present case, tumor size was 15 cm. Still, the defect could be closed with reasonable cosmesis taking advantage of a large amount of fat in the flaps. Leaving adequate amount of tissue beneath the areola to avoid devascularization was one of the key steps.

Breast conservation surgery done for cancer is slightly different from the one for benign tumor. The margin status, addressing axilla, adjuvant radiation as well as application of clips to the tumor bed may not be required. Drain may be avoided, as the seroma formed would add to further bulk of the breast, which may eventually get absorbed.


 > Conclusion Top


Slight modification of various available well-designed mastopexy techniques can be done to provide better cosmesis, especially in the management of young patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Senniappan K, Sharma N, Ravi DK, Kumar M, Shukla M, Pandey M. Transformation of recurrent fibroadenoma to phyllodes tumour: A case report and review of literature. World J Surg Res 2012. p. 28-33.  Back to cited text no. 1
    
2.
Deschênes L, Jacob S, Fabia J, Christen A. Beware of breast fibroadenomas in middle-aged women. Can J Surg 1985;28:372-4.  Back to cited text no. 2
    
3.
Bazanowski Konarky K, Harrison EG, Payne WS. Lobular carcinoma arising fibroadenoma of the breast. Cancer 1975;35:450–6.  Back to cited text no. 3
    
4.
Anderson BO, Masetti R, Silverstein MJ. Oncoplastic approaches to partial mastectomy: An overview of volume-displacement techniques. Lancet Oncol 2005;6:145-57.  Back to cited text no. 4
    
5.
Fisher B, Bauer M, Margolese R, Poisson R, Pilch Y, Redmond C, et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985;312:665-73.  Back to cited text no. 5
    
6.
Veronesi U, Saccozzi R, Del Vecchio M, Banfi A, Clemente C, De Lena M, et al. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast. N Engl J Med 1981;305:6-11.  Back to cited text no. 6
    
7.
Lichter AS, Lippman ME, Danforth DN Jr., d'Angelo T, Steinberg SM, deMoss E, et al. Mastectomy versus breast-conserving therapy in the treatment of stage I and II carcinoma of the breast: A randomized trial at the national cancer institute. J Clin Oncol 1992;10:976-83.  Back to cited text no. 7
    
8.
van Dongen JA, Bartelink H, Fentiman IS, Lerut T, Mignolet F, Olthuis G, et al. Randomized clinical trial to assess the value of breast-conserving therapy in stage I and II breast cancer, EORTC 10801 trial. J Natl Cancer Inst Monogr 1992;(11):15-8.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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