Immediate and Delayed Contralateral Symmetrization in Oncoplastic Breast Reduction: Patients’ Choices and Technique Formulation

91 Ahmad Kaviani, MD Amin Safavi, MD Department of Surgery Tehran University of Medical Sciences Tehran, Iran; and Department of Research Kaviani Breast Diseases Institute Tehran, Iran Rasool Mirsharifi, MD Department of Surgery Tehran University of Medical Sciences Tehran, Iran Sir: O breast surgery (OBS) has opened a new chapter in breast conservation for breast cancer treatment and, as implied by its name, combines principles of oncologic and plastic surgery techniques. The comprehensive features of OBS promise a much better aesthetic result compared with conventional approaches, through which the “oncologic surgery” portion excises the tumor with adequate margins, the “plastic surgery” portion repairs the excision defects, and in case these features lead to breasts asymmetry, as the third feature, “contralateral procedures for symmetrization” are performed so that finally both breasts look identically alike. Accordingly, OBS not only saves patients’ lives but also returns back their beauty and quality of life.1 Regarding contralateral procedures for symmetrization, there are notable issues often debated that if are considered well may significantly improve final aesthetic outcomes and patients’ satisfaction. These issues include the indications for contralateral procedures, the appropriate timing for procedures, patients’ possible choices, and to achieve optimal aesthetic results, appropriate technique formulation. We aim to discuss these points in this article. FOR WHOM ARE CONTRALATERAL PROCEDURES ARE INDICATED? In OBS, based on the proportions of breast volumes to be excised, the techniques are categorized into 2 levels. Level-I OBS applies for less than 20% excisions in which the skin is incised over the tumor (but not resected), and by a scoop-like resection, the tumor with its adequate margin is removed. The excision defects here are repaired using simple tissue reapproximation. Level I is applicable for any tumor locations within the breast, and with this small proportion to be excised, shape deformities and asymmetries are unlikely, whereas level II is for larger 20–50% excisions and comprises a variety of techniques for different tumor sizes and locations. The techniques used in the plastic surgery portion of level II are mainly determined by the extent of defects made through oncologic resections, so smaller defects are refilled by tissue displacement techniques (glandular reshaping), larger defects by tissue replacement techniques (flaps), and when the defects cannot be repaired by displacement-replacement techniques, “breast reduction” is then performed making a smaller and rounder breast.2–4 Due to size reductions of the diseased breast because of volume excisions, contralateral symmetrizing procedures are mainly breast reductions. According to the above-mentioned technical facts, 2 groups are indicated for contralateral reductions for symmetrization. One includes the patients undergoing level-II OBS in whom the defects cannot be repaired using tissue displacement or replacement techniques; in them, the diseased breast (and the contralateral one for symmetrization) necessarily needs to be reduced (curative breast reduction). The other group includes those with very large breasts having small proportionate tumors that a displacement or replacement technique (either level-I or level-II OBS) may simply repair the excision defects, but the very large sizes of their breasts are a serious aesthetic concern. In this group, breast reduction is aesthetically indicated (aesthetic breast reduction) and definitely is a patient’s option.