Local Excision, Lumpectomy, and Quadrantectomy  Surgical Considerations   Gregory M. Senofsky, Eugene D. Gierson, Pamela H. Craig, Parvis Peter Gamagami, and Melvin J. Silverstein    LUMPECTOMY AND WIDE EXCISION    We utilize lumpectomy and wide excision for suspected or known malignancy of the breast. Our preoperative opinion is formed using the same diagnostic techniques referred to in the prior discussion. Lumpectomy and wide excision is defined as resection of a breast mass with a significant margin of breast tissue left attached to the mass in all axes. This is performed in an attempt to completely clear the malignancy with free margins at the time of the initial operation. We use a 1-cm clearance grossly as the intended amount of nonmalignant tissue that we leave attached to the mass.  Lumpectomy and wide excision also has been referred to as partial mastectomy and is coded as such, using the current procedural terminology coding system. Every attempt is made to obtain the pathologic diagnosis before performing lumpectomy and wide excision because this procedure may cause slight breast deformity is occasional patients.     The incision for performing lumpectomy and wide excision is similar to that for local excision except that it is slightly larger. The only significant difference in the incision for performing lumpectomy and wide excision is that for inferior lesions, a vertical incision is used rather than a transverse incision (Fig. 5). This generally prevents puckering and dimpling of the inferior breast quadrant postoperatively.    When a biopsy has already been performed, the previous biopsy incision is excised as part of the performing lumpectomy and wide excision. The incision is made with a no. 15 blade and deepened sharply to the base of the subcutaneous tissue, unless the lesion is extremely superficial. Lesions that are extremely superficial should be ellipsed with a segment of skin that affords gross clearance of at least 1 cm for the lesion. Lumpectomy is performed with a scalpel or Metzenbaum scissors. The surgeon's fingers are used to guide and maintain a 1-cm gross clearance of the mass. The specimen is marked with different length sutures in order to tag at least three of the six axes of the mass for orientation purposes of for the pathologist.     The pathologist is asked for an immediate evaluation of the margins. All margins are inked or dyed (Fig. 6) and the tissue serially sectioned and sequentially processed (Fig. 7). Frozen sections are generally not used in our facility. However, margins that appear grossly closed immediately reexcised at the direction of the pathologist. The new margins may be evaluated by cytologic touch preparation. Generally, all tissue is processed (particularly with nonpalpable lesions). Prognostic markers are measured using immunohistochemistry on paraffin-fixed tissue rather than fresh frozen tissue.     Clips are used to mark the six quadrants of the remaining cavity for the radiotherapist (Fig. 8). Closure is only performed after the pathologist confirms that touch preparations of the edges are negative for malignancy. The decision for which edges to perform touch preparations or frozen section belongs to the pathologist. Enough emphasis cannot be given, however, to the exact orientation of the specimen and communications with the pathologist, in case further resection is needed.    The wound is irrigated and meticulous hemostasis is obtained by use of electrocautery. The cosmetic closure is performed exactly as stated n the previous section. In generally, no attempt is made to reapproximate the subcutaneous or deeper tissues because this may cause rather than prevent a deformity. Hemostasis must be meticulous because we prefer not to drain these cavities because of the cave-type type of deformity that may be created by suction drainage. If ultrasonography is performed a few days after biopsy, there is generally a small amount of fluid in the biopsy cavity. This will be reabsorbed as the cavity heals. The wound is dressed as stated previously. Lumpectomy and wide excision is performed as an outpatient procedure unless accompanied by axillary node dissection or there is another indication to admit the patient to the hospital overnight.    In large excisions, flap advancement with deep closure may become necessary. The technique of the flap advancement is discussed in the next section.    COSMETIC QUADRANTECTOMY    Cosmetic quadrantectomy is defined as a procedure that combines formal parenchymal quadrantectomy with flap advanced.  Our procedure differs from standard quadrantectomy in that we use a skin and subcutaneous tissue sparing approach. In addition, our flap advancement undermines the entire breast. This procedure may be performed when lumpectomy and wide excision would fail or has failed to obtain clear microscopic margins.     The steps are as follows: The incision and level of cosmetic deformity expected for cosmetic quadrantectomy is reviewed with the patient before surgery. In general, we use an elliptical incision that excises the previous biopsy incision with about 1-2 cm of normal skin in every direction (Fig. 9). The type of skin incision depends on the quadrant of the breast (Fig. 10).     After the breast has been sterilely prepared and draped, the incision is made with the no. 15 blade through the skin and subcutaneous tissue, down to the breast tissue (Fig. 11). Flaps are then developed. An approximately 24% quadrant resection of the breast is performed with either Metzenbaum scissors or a no. 10 or no. 15 blade (Fig. 12). The dissection is taken down to the pectoralis fascia. For deeper lesions the pectoralis fascia is included in the quadrant resection. The quadrantectomy is focused around the lesion and an attempt is made to have at least 1 to 2 cm of grossly clear margin left attached to the malignancy at all positions. Cytologic touch preparations are obtained and clips are placed to mark the boundaries of the resection. Deep retractors are used in order to retract the posterior breast surfaces (Fig. 13). A flap advancement is performed by dissecting the breast off the pectoralis major muscle via electrocautery (Fig. 14). The entire remainder of the breast is separated from the muscular fascia of the chest wall (Fig. 15). After hemostasis has been obtained, the breast is then reapproximated to facilitate a maximally round and natural-appearing breast. Sutures are placed in the deepest portion of the breast with 2-0 vicryl in order to maintain the posterior edges of the breast in this position. The remainder of the breast is then reapproximated with 4-0 or 5-0 absorbable sutures in the posterior dermis (Fig 16). The skin is closed with a subcuticular 4-0 Prolene suture.  Drains can be used such as those appearing in this patient's procedure; however, we have performed cosmetic quadrantectomy without the use of drains with excellent results (Fig. 17). The patient is then wrapped with a bias wrap in order to prevent bleeding and hematoma formation (Fig. 18). The postoperative results of this patient's cosmetic quadrantectomy can be seen here in oblique and frontal positions (Fig. 19 and Fig. 20). Note that the breast, although well shaped, is slightly smaller and the nipple-areola complex is slightly repositioned toward the quadrantectomy.    Axillary node dissection is frequently performed in concert with cosmetic quadrantectomy, as tis the case of lumpectomy and wide excision using sentinel node mapping techniques. If the quadrantectomy is performed for an upper outer quadrant lesion, quadrantectomy and axillary node dissection can be performed through the same incision.  Otherwise, a separate axillary node dissection incision is used with a separate drain. Cosmetic quadrantectomy is performed as an outpatient procedure unless axillary node dissection is performed, or if other medical problems necessitate hospital admission.    BRACKETING WIRE PROCEDURES     Bracketing wires is a concept that we have used since 1982 to aid in the complete resection of nonpalpable lesions. Before our development of the bracketing technique, we used a single hooked wire. However, because of the high incidence of positive margins (Fig. 21) and the need for reexcision or mastectomy after single hooked wire excisions, we have evolved to a system of placing multiple hooked wire around the perimeter of a lesion before excision (Fig. 22 and Fig. 23). Our incidence of complete excision with the bracketing hooked wire placement is significantly better than that obtained with the used of a single hooked wire before lumpectomy or quadrantectomy. When bracketing wires are used to delineate the boundaries of the lumpectomy or quadrantectomy, the initial incision should be based not on the wire entrance points at skin level, but rather on the three-dimensional assessment of the location of the lesion within the breast as delineated by the tips of the wire.  This can be done only after direct preoperative consultation with the radiologist placing the bracketing wires. When performing lumpectomies or quadrantectomies with bracketing wires, it is important to use a no 15. blade form dissection rather the Metzenbaum scissors in order to availed cutting the wires during the dissection. Specimen radiography is always performed before closure. For cosmetic quadrantectomies, confirmation of adequate specimen radiography also must be performed before flap advancement.          Written by: Gregory M. Senofsky, Eugene D. Gierson, Pamela H. Craig, Parvis Peter Gamagami, and Melvin J. Silverstein    Copyright--Surgery of the Breast: Principles and Art.    edited by Scott L. Spear    Lippincott-Raven Publishers, Philadelphia © 1998   Site created by InfoStat    www.info-stat.com