Dual-Layer Rotation: A Versatile Therapeutic Mammoplasty Technique

Abstract

Background: Multifocal or complex breast lesions are a challenge for breast-conserving surgery, particularly surgery in small breasts or those located in the upper inner quadrant. The dual-layer rotation technique exploits the idea of manipulating the skin and glandular tissue in separate layers to fill the resection cavity via vertical mammoplasty if skin excision is not required, except in the central area.

Methods: The authors performed a retrospective review of consecutive breast cancer patients who underwent DLR mammoplasty between 2017 and 2019 at a single institution. Clinical data, reoperations, surgical complications, delays in adjuvant treatments, and the need for late revisional surgery were evaluated. Aesthetic outcomes were evaluated objectively and subjectively from photographs.

Results: The study included 46 breasts of 40 patients. Tumors were located in the UIQ (30%, 14/46) or in multiple quadrants (22%, 10/46). One third (33%, 13/40) of the patients had a small breast cup size (A-B). Negative margins were primarily achieved in 45 of the 46 breasts. Major complications occurred in three patients, who needed reoperation, and adjuvant therapy was delayed for one of these patients. Late refinement surgery was needed for two patients. The objective and subjective aesthetic outcomes were good or excellent regardless of the tumor position.

Conclusion: As a novel oncoplastic approach, DLR mammoplasty offers a one-step procedure to treat selected breast cancer patients with challenging resection defects due to different breast sizes or lesion locations. The technique preserves the breast's natural appearance.

Fig. 1

Flow chart showing study population of dual-layer rotation technique

Fig. 2

Illustration of the dual-layer rotation mammoplasty technique. a Preoperative drawings with the subject in the upright position. The footprint is shown with a dashed blue line. The meridian of the breast and mid-torso is shown in black, the desired highest part of the areola in red, and the vertical opening sketch in a dashed red line. b The skin incision is made to the vertical limb only on the tumor side, and a 1-cm back cut is made to the bottom of the opposite vertical limb. c The skin is released from the parenchyma above the tumor down to the vertical opening. d After removal of the tumor, the glandular layer is excised from the peripheral end of the tumor and curved toward the vertical opening until the flap can be rotated (blue arrow) to fill the tumor defect. e–h Schematic drawings showing how the glandular tissue is rotated in patients with peripheral tumors (e, f) or central tumors (g, h). i, j The skin layer is rotated (i: blue arrow) in the opposite direction toward the meridian of the breast and temporarily fixed (j). k Excess skin is ink-marked in purple. l, m Illustration of the ink-marked area after release of the temporary fixation and de-epithelization (l) followed by skin closure and drainage (m)

Fig. 3

A 49-year-old woman with bilateral breast cancer (multifocal ductal carcinoma and atypical ductal hyperplasia in the right breast and a large 4.3 × 3.2 × 2.7-cm area of ductal carcinoma in situ associated with invasive ductal carcinoma in the left breast). The dual-layer rotation (DLR) technique was used on both breasts. a The tumor areas were ink-marked preoperatively on the skin. b Orientation map showing the tumors and planned resection areas in black, the glandular tissues to be manipulated in red, and the skin in green. The direction of glandular flap rotation is shown with blue arrows. c–e Postoperative photographs taken 2 years after surgery showing excellent aesthetic results according to BCCT.core software and subjective evaluation