الفهرس 
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Abstract
Summary
In the plastic surgery literature, oncoplastic surgery typically refers to large partial mastectomy combined with myocutaneous flap reconstruction, such as the Latissimus Dorsi flap or the Transverse Rectus Abdominis myocutaneous (TRAM) flap.
For breast conservation to be efficacious, the surgeon needs (1) to obtain complete excision of the cancer with adequate surgical margin width and (2) to achieve a surgical result that maintains the breast’s shape and appearance over time.
For larger cancers, it can be technically challenging to simultaneously address both of these goals in the same operation. Simple flap advancement “mastopexy” techniques developed by plastic surgeons for breast reduction can reshape the breast immediately after larger breast cancer resections.
By contrast, small- or intermediate-sized cancers can generally be managed nicely using simple oncoplastic techniques that facilitate wide excision of the cancer and preserve the shape and appearance of the breast.
In oncoplastic surgery, by advancing locally available fibroglandular tissue along the chest wall, the defect created by partial mastectomy is closed with a breast “fibroglandular flap,” called mastopexy closure.
(Lisa Jacobs, etal 2011)
A circumferential incision was made without excision of the periareolar skin, and subcutaneous
dissection was extended to the entire breast. The wound could be widened and moved onto the distant tumor by application of a wound retractor. Partial mastectomy was then performed under direct vision. The wound was easily closed without tension.
(Elsevier, etal.,2013)
Resection of inferior pole breast cancers commonly produces inferior cosmetic results, particularly when resection of skin is required. The triangle resection with mastopexy is one of several oncoplastic breast surgical techniques that enable resection of inferior pole lesions with preservation if not improvement of breast cosmoses.
(Dennis R. Holmes, etal., 2012)
Multiple technically simple techniques have been described; Parallelogram mastopexy lumpectomy, Batwing mastopexy lumpectomy, Donut Mastopexy Lumpectomy, the reduction mastopexy lumpectomy
(Chin-Yau Chen, etal., 2011_) Also modified round block technique (Hisamitsu Zahaetal., 2013) and triangle Resection with Crescent Mastopexy. (Melvin J. Silverstein, etal., 2012)
The parallelogram mastopexy lumpectomy offers a technically simple method for designing full-thickness segmental resection . Localized and/or small segmental cancers can be excised using this procedural design. Skin incisions in the upper breast should follow transverse Kraissl’s lines; those in the lower half (including the 3-o’clock and 9-o’clock positions) of the breast should be radial. With the help of wire localization or preoperative
sonogram, the location and distribution of the tumor are marked.
The batwing mastopexy lumpectomy is an ideal approach for resection of cancers that are located deep or adjacent to, But that do not directly involve, the nipple.
Two similar half-circle incisions are made with angled wings on each side of the areola.
Full-thickness excision is then performed, and the fibroglandular tissue is advanced to close the subsequent defect.
Because this approach causes some upward deviation of the nipple, excessive asymmetry may require a contralateral lift at a later time to restore symmetry.
The donut mastopexy lumpectomy uses a modification of the skin-sparing mastectomy in which only a segment of the breast is removed, because it is a more complex operation involving wide skin-sparing dissection, the donut mastopexy lumpectomy should not be undertaken until the more basic oncoplastic techniques are fully understood and mastered.
It’s a unique breast resection technique in which a segmental area of tissue is removed through a periareolar incision, for segmentally distributed cancers of the upper or lateral breast, donut mastopexy lumpectomy can offer complete cancer excision without sacrifice of too much skin or nipple-areolar deviation.
Round block technique (RBT) is often utilized in breast-conserving surgery, but has problems of late onset scar widening and changes in the shape or the position of the areola. It was modified RBT (MRBT) to resolve those
problems. A circumferential incision was made without excision of the periareolar skin, and subcutaneous dissection was extended to the entire breast. The wound could be widened and moved onto the distant tumor by application of a wound retractor. Partial mastectomy was then performed under direct vision.
The wound was easily closed without tension forty breast cancer patients were treated with MRBT. The median distance between the nipple and the tumor was 5.2 cm, and the median areolar size was 2.8 cm. Cosmetic results were satisfactory with minimal scar formation. There were neither subsequent changes in the shape nor the position of the areola. MRBT is a useful oncoplastic technique in patients with small areola, and/or when the tumor location is distant from the nipple.
The triangle resection with mastopexy is one of several oncoplastic breast surgical techniques that enable resection of inferior pole lesions with preservation if not improvement of breast cosmoses. This procedure may be combined with unilateral or bilateral mastopexy to further improve breast cosmoses in patients with mild to moderate ptosis.
The design of the traditional lumpectomy commonly used in the United States originated mainly from the NSABP (National Surgical Adjuvant Breast and Bowel Project) B-06 study initiated in 1976 under the direction of Dr. Bernard Fisher. This large trial helped establish the equivalency of breast-conserving surgery and mastectomy in terms of survival. In the traditional lumpectomy, a curvilinear incision is placed directly over the cancer, no skin island is removed, the cancer is excised in a minimalist fashion with the intention of obtaining negative but not necessarily wide margins, and
the skin is closed without any formal attempt to obliterate the lumpectomy pocket. In the B-06 trial, there was no predefined amount of normal tissue to be removed around the tumor; a tumor-free margin of 1 mm or even less was considered adequate.
Fisher hypothesized that breast cancer is fundamentally a systemic disease, and in the course of doing so, he minimized the issues surrounding local control of disease. With the use of more limited resections, a higher risk of local recurrence would be expected.
Multiple studies have confirmed this hypothesis. In the Milan trial, for example, 705 patients were randomized to receive lumpectomy (excision with narrow margin) or quadrantectomy (excision of surrounding normal tissue of 2 to 3 cm). Even though the rates of distant metastases and survival were no different between the two groups, the rate of local recurrence at 5 years was much higher in the lumpectomy group (7% compared with 2.2%). However, since lumpectomy was developed for breast conservation.
Oncoplastic surgery offers a better chance of wide anatomic resection while preserving overall cosmoses.
Oncoplastic Partial Mastectomy in breast conservative surgery, margin width has been shown to be the single most important predictor of local recurrence.