The document discusses the principles of oncoplastic breast surgery and mastectomy techniques. It provides a brief history of mastectomy and describes the physics of breast shape. It advocates for using the Wise pattern incision technique for mastectomies, as it better preserves the skin envelope and shape compared to transverse incisions. Clinical examples are presented showing reconstruction outcomes using implants, flaps and skin-sparing techniques based on these principles.

1. ONCOPLASTIC SURGERY… First Principles and Current Practice Joel A. Aronowitz, MD Clinical Chief, Division of Plastic Surgery Cedars Sinai Medical Center

7. Rationale for Skin Extirpation; Prevention of Local Progression

8. Early Detection of Breast Cancer

11. Breast shape or chest shape; Pectus Deformity

15. Law of LaPlace predicts pattern of breast shape Breast diameter is > in lower pole therefore the skin below the nipple is under greater tension and stretches the most. Nipple decent with the breast.

17. Severe Tubular Deformity Note medial tightness, large areola typical of tubular breast. 17 yo treated with 500 cc silicone gel prosthesis and keyhole pattern mastopexy

23. Ptosis due to relative paucity of breast volume Volume restored with prosthesis, skin envelope unchanged Restoration of Skin:Volume Proportion with Prosthesis

24. Relationship of Breast Skin to Volume Post-partum atrophy, lack of breast volume relative to skin envelope Reduction of skin envelope and adition of volume; ie, augmentation mastopexy

25. Excess Skin Envelope and Volume; Breast Reduction Excess breast volume and skin envelope. Rx; breast reduction, ie, a reduction of skin and volume

30. The Patchwork Effect of Flap Skin after Transverse Mastectomy Surgical textbook drawing of mastectomy skin excisions Lat dorsi skin paddle

31. Effect of Transverse Skin Excision on Breast Shape

32. How Transverse Incision Results in Typical Superior Pole Fullness

33. Typical Skin Envelope after Transverse Mastectomy

37. Volume replacement: TRAM flap Skin: Intact, Wise Pattern Mastectomy Opposite Breast: Wise pattern Reduction

42. Dissection of lateral flap

45. Latteral flap resection

48. The WISE Pattern; how it works

51. Volume: 450cc silicone gel implant Skin replacement: periareolar mastectomy, tissue expansion Opposite breast: bilateral

52. Operative Technique of Skin Sparing Mastectomy

53. Operative Technique of Wise Pattern Mastectomy and Reconstruction

54. Volume replacement Left: silicone implant Skin: intact, Wise pattern mastopexy Opposite breast: Wise pattern mastopexy

55. Volume: Silicone gel prosthesis Skin: intact, Wise pattern mastectomy Opposite Breast: bilateral

56. Volume replacement: TRAM flap Skin: original, Lat. Incision Mastectomy Opposite Breast: Keyhole mastopexy

57. Skin: intact, Wise Pattern Mastectomy Volume: Silicone gel Prosthesis Opposite Breast: bilateral

63. Types of Breast Implants MemoryGel ™ Implants Saline Implants

64. Textured Implant surfaces Smooth

65. Contour Profile ® Tissue Expanders

67. SSM with implant and bilateral latissimus reconstruction before after

68. Intraop SSM and TRAM

69. SSM and bilateral TRAM before after

70. Skin-sparing Mastectomy : A Survey Based Approach to Defining Standard of Care J Shen MD 1 , J Ellenhorn MD 1 , Dajun Qian PhD 1 , David Kulber MD 2 , J Aronowitz MD 2 1 City of Hope Medical Center, Duarte, CA 2 Cedars-Sinai Medical Center, Los Angeles, CA Southern California Chapter of the American College of Surgeons 19 th Annual Scientific Meeting January 18, 2008

71. Practice Patterns N = 370 Standard transverse elliptical N = 75 (20) Skin-sparing MOST of the time N = 224 (61) Mastectomy with immediate reconstruction N = 331 (89) No immediate reconstruction N = 39 (11) Skin-sparing SOME of the time N = 32 (9)

72. Safety No. (%) Greater flap necrosis Yes No 91 (25) 279 (75) Excision of biopsy incision is mandatory Yes No 31 (8) 339 (92) Higher rate of local recurrence Yes No 38 (10) 332 (90)

74. Perceptions by Clinical Setting * P-value ≤ 0.05 vs. Academic, Mixed, and HMO ** P-value ≤ 0.05 vs. HMO *** P-value ≤ 0.05 vs. Academic and HMO Private N = 260 Academic N = 30 Mixed N = 26 HMO N = 54 Skin-sparing mastectomy 158* (61%) 25 (83%) 23 (88%) 50 (93%) Feasibility 174** (67%) 24 (80%) 16 (62%) 48 (89%) Higher recurrence 29 (11%) 3 (10%) 3 (12%) 3 (6%) Improved cosmesis 166*** (64%) 29 (97%) 20 (77%) 42 (78%)

76. Oncologic Safety Chagpar AB. Am Surg 2004;70:425-32. Author Follow-up (mo) SSTM (# pts) SSTM LRR Non-SSTM (# pts) Non-SSTM LRR P -value Newman (1998) 50 437 6.2% 437 7.4% NS Kroll (1999) 72 114 7.0% 40 7.5% NS Rivadeneira (2000) 49 71 5.6% 127 3.9% NS Carlson (2003) 65 565 5.5% - - - Spiegel (2003) 118 221 4.5% - - -

83. Wise Pattern Mastectomy with Implant Reconstruction

84. IN CONCLUSION Based on 1 st Principles, Physics, History and Outcomes The Wise Pattern For Mastectomy is State of the Art