Modern Plastic Surgery, 2013, 3, 57-64
http://dx.doi.org/10.4236/mps.2013.32011 Published Online April 2013 (http://www.scirp.org/journal/mps) 57
Oncoplastic Breast Surgery Using Spindle Shaped-Partial
Mastectomy for Early Breast Cancer in the Upper
Quadrant Area*
Yuko Kijima#, Heiji Yoshinaka, Munetsugu Hirata, Yoshiaki Shinden, Sumiya Ishigami,
Akihiro Nakajo, Hideo Arima, Takaaki Arigami, Hiroshi Okumura, Shoji Natsugoe
Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University Graduate School of Medical and Dental Sci-
ences, Kagoshima, Japan.
Received February 25th, 2013; revised March 27th, 2013; accepted April 4th, 2013
Copyright © 2013 Yuko Kijima et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: Oncoplastic surgery is becoming more common, however, only several reports have been published in
Japan. We report the results of simple oncoplastic surgery for Japanese patients with early breast cancer in the upper
quadrant area. Methods: In seven patients with a past history of breast-feeding and ptotic breasts, we performed on-
coplastic surgery involving partial mastectomy and the resection of excess skin and parenchymal tissue. Results: None
of the patients received a contralateral operation to produce symmetrical breasts. The width of the resected excess skin
tissue ranged from 20 to 50 mm, with the mean width being 30 mm, and its length ranged from 50 to 90, with the mean
length being 77 mm. The width of the resected gland tissue ranged from 40 to 65 mm, with the mean width being 53
mm, and its length ranged from 70 to 100 mm, with the mean length being 97 mm. The cosmetic results were excellent.
Conclusions: Oncoplastic surgery using spindle shaped-resection was successfully performed in patients with upper
quadrant lesions, and the cosmetic results were excellent.
Keywords: Breast Cancer; Spindle-Shaped Resection; Breast-Conserving Surgery; Oncoplastic Surgery; Reduction
Mammoplasty
1. Introduction
Oncoplastic Breast Surgery (OBS), which combine the
concepts of oncologic and plastic surgery, are becoming
more common, especially in Western countries [1,2].
Ther e are man y diff erent on coplastic surgical techniques,
one of which involves careful planning of skin and par-
enchymal excisions, reshaping of the gland after the par-
enchymal excisions, and repositioning of the nipple are-
ola complex (NAC) to the center of the breast mound
with or without correction of the contralateral breast to
achieve better symmetry [3-5]. We have reported that
oncoplastic surgery combining partial mastectomy and
recentralization of the NAC with/without a contralateral
operation produced excellent results in Japanese patients
with ptotic breasts as well as Western women [6-8]. On
the other hand, the resection of upper deformities fol-
lowed by immediate volume replacement using a local
flap or a distant autologous graft resulted in good out-
comes [9,10].
We herein report our early experiences of oncoplastic
surgery involving partial mastectomy and the resection of
excess skin tissue without a contralateral operation in six
Japanese patients with early breast cancer in the upper
quadrant regi o n of their pt ot ic breasts.
2. Patients
From June 2006 to May 2009, seven Japanese patients
were diagnosed with early breast cancer and received
successful breast conserving surgery without any preop-
erative systemic therapy. The indications for spindle-
shaped resection of breast tissue and excess skin tissue
were as follows: 1) the patient had ptotic (the nipple level
was beneath the inframammary line) or large breasts; 2)
*Conflict of interest statement: We declare that there are no financial
relationships or other interests with regard to this manuscript that might
be construed as constituting a conflict of interest for any author.
Informed consent: Written informed consent from each patient has been
received before submission.
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Oncoplastic Breast Surgery Using Spindle Shaped-Partial Mastectomy
for Early Breast Cancer in the Upper Quadrant Area
58
the cancer lesion was restricted to the upper-outer or up-
per-inner quadrant; and 3) informed consent was ob-
tained preoperatively after an explanation of the surgical
procedure. A digital camera with a resolution of 14.1
megapixels was used, and a blue panel was used as the
background. Photographs were taken in four positions
with the patient standing on floor marks: facing the cam-
era with their arms down, facing the camera with their
arms up, from the left side with their arms up, and from
the right side with their arms up.
None of the seven patients who agreed to undergo
spindle-shaped p artial mastectomy combined with excess
skin removal, received preoperative systemic chemo- or
endocrine therapy. The mean patient age was 72.4 years
(range: 57 - 84). All patients were postmenopausal and
had experiences of breast feeding 2 to 4 children, with
the mean number of breastfed children being 2.6. The
mean size of the tumor was 11.9 mm (range: 7 - 27) (Ta-
ble 1). The results of tumor histology are shown in Table
1. Axillary lymph adenectomy was performed for one
patient with a clinical diagnosis of T2N0M0. Sentinel
lymph node (SLN) biopsy using the radioisotope (RI)
method and dye method was performed in the remaining
6 patients, who were preoperatively diagnosed with
T1N0M0 tumors. In these six patients, the SLN were
intraoperatively revealed to be negative, so axillary con-
servatio n w as perfo rmed (Table 2).
3. Surgical Procedure
3.1. Design
The patients were seen by the breast surgeon two days
before the surgery so that he could plan the operation,
make drawings, and explain the different surgical options
to the patient, e.g., other oncoplastic surgical techniques
such as immediate volume replacement using a free graft
or local flap, which were described previously. For spin-
dle-shaped partial mastectomy and resection of excess
skin tissue, the incision lines were drawn with the patient
in a standing position after marking the resection area
together with a surgical margin of at least 20 mm with
the patient in a sup ine position (Figure 1).
3.2. Sentinel Lymph Node Biopsy and Axillary
Lymphadenectomy
In one patient who received axillary lymphadenectomy
and two of six patients who underwent SLN biopsy, an-
other incision was made in the axillary area to allow SLN
biopsy or axillary lymphadenectomy. In the remaining
four patients, the SLN were biopsied via the same inci-
sion as was used for the partial mastectomy.
Table 1. Patients’ clinical data.
Case Age Laterality Location Height Weight %IBW No. of childrenPtosisSystemic diseaseDistance to nipple Tumor size (mm)
1 84 Right Upper-inner141 48 113 4 YesNone 35 27
2 76 Left Upper-inner152 61 108 4 YesNone 80 12
3 63 Left Upper-inner160 80 149 2 YesDiabetes 60 7
4 71 Left Upper-inner144 52 112 2 YesArrhythmia 50 12
5 57 Right Upper-inner158 70 108 3 YesNone 60 8
6 80 Right Upper-outer157 59 114 2 YesNone 30 9
7 76 Left Upper-outer151 51 101 1 NoNone 90 8
Table 2. Surgical findings.
Case Surgical margin
(to lateral side)
mm
Surgical
margin
(to nipple) mm
Skin size
(width)
mm
Skin size
(length)
mm
Size of
resected gland
(width) mm
Size of
resected gland
(length) mmAx*Operative
period
(min)
Bleeding
(ml)
Cosmesis
Score
(JBCS)
Cosmesis
Score
(ABNSW)
1 25 40 35 85 80 110 Yes90 15 10 11
2 20 50 20 50 65 110 SLN** 80 5 11 13
3 20 60 30 90 40 100 SLN** 149 15 10 12
4 20 20 25 80 50 100 SLN** 131 10 11 13
5 20 40 25 70 50 70 SLN** 106 5 11 14
6 25 25 30 80 60 100 SLN** 162 20 11 12
7 20 40 50 90 50 100 SLN** 92 20 12 15
*Axillary lymphadenectom y; **Sentinel lymph node biopsy without axillary lymphadenectomy.

Oncoplastic Breast Surgery Using Spindle Shaped-Partial Mastectomy
for Early Breast Cancer in the Upper Quadrant Area 59
3.3. Spindle Shaped-Partial Mastectomy
On the day of surgery, both breasts were placed into the
operative field to allow evaluation of their symmetry
during the operation. The partial mastectomy consisted
of the removal of tissue from the breast containing the
tumor together with a tumor-free margin of at least 2 cm,
including a spindle-shaped area of skin above the tumor
and the pectoral fascia below it (Figures 2(a)-(c)).
During the operation, the surgical margins were his-
tologically examined to ensure that they did not include
the cancer lesion. It took 30 - 50 minutes to obtain the
results from the pathologist, and this time is included in
the total operative period shown in Table 1. For both
tumor types; i.e., the upper-outer and upper-inner quad-
rant tumors, SLN biopsy was performed using the same
incision as was used for the partial mastectomy.
3.4. Reconstruction of Defects
After washing them with saline, the inner and lateral
glandular flaps were lined up and sutured together to
cover the excision defect (Figures 2(d)-(f)). A closed
suction drainage line was placed onto the surface of the
pectoralis major muscle and/or the axillary defect in each
case.
3.5. Adjuvant Therapy
In all patients, pathological margins of over 10 mm were
maintained from the ed ge of the resected area to the can-
cer lesion. The treated lesions included both invasive and
intraductal lesions. No patient displayed metastatic dis-
ease or received postoperative radiotherapy to the rem-
nant gland. Six of them received aromatize inhibitor (1
mg/day of anastrozol or 2.5 mg/day of letrozol) as an
adjuvant hormone therapy.
4. Cosmetic Evaluation
The cosmetic assessment after the breast-conserving
therapy was performed according to the method reported
by Sawai’s group, which was supported by the Japanese
Breast Cancer Society [11]. This assessment contains
eight items: 1) breast size; 2) breast shape; 3) wound scar;
4) softness of the breast; 5) shape and size of the nip-
ple-areola complex; 6) color of the nipple-areola com-
plex; 7) level of the nipple (difference in distance from
the suprasternal notch between the bilateral nipples); and
8) the lowest point of the breast (difference between the
bilateral breasts). The cosmetic outcome was evaluated
as excellent when the total score was 12 points, good
when it was 9 to 11, fair when it was 5 to 8, and poor
when it was 0 to 4.
Breast shape was also subjectively assessed by two of
the authors and scored using the ABNSW system report-
ed by Yamashita et al. [12]. The ABNSW contains five
items: asymmetry (A), breast shape (B), nipple deforma-
tion (N), skin condition (S), and wound scar (W). The
score in each category is graded as fo llo ws: 3—excellen t:
at first sight, there was no visible difference between the
breasts; 2—good: there were few differences between the
bilateral breasts and these were only apparent from close
observation; 1—fair: there were marked differences be-
tween the bilateral breasts from a distance; 0—poor:
there were severe, ugly differences between the bilateral
breasts. We scored all five items from 0 to 3 to produce
the total score. The cosmetic outcome was evaluated
as excellent when the total score was 15 points, good
(a) (b) (c)
Figure 1. Case 1, a 76-year-old patient with a T1 tumor in the upper-inner quadrant of her left breast. Preoperative findings.
(a) Bilateral ptotic breasts with the nipple-areola complex (NAC) beneath the inframammary line; (b) Lesions were detected
by ultrasonography with the patient in a supine position (red circle). Two cm lateral surgical margins were maintained. A
spindle shaped resection area, measuring 6.5 × 11 cm, was marked using a dotted black line. The spindle shaped incision line
was drawn in red; (c) With the patient in a standing position, the spindle shaped resected area and skin island became rec-
tangular and measured 5 × 15 cm.

Oncoplastic Breast Surgery Using Spindle Shaped-Partial Mastectomy
for Early Breast Cancer in the Upper Quadrant Area
60
(a) (b) (c)
(d) (e) (f)
Figure 2. (a) Preoperative marking. The incision line and surgical margin of the gland were drawn as a black line and dotted
line, respectively; (b) A spindle shaped area of skin was also removed; (c) A spindle shaped area of columnar tissue was re-
sected together with the fascia of the pectoral major muscle; (d) Medial and lateral glandular flaps were sutured using 3-0
vicryl sutures; (e) and (f) Subcutaneous 4-0 PDS sutures were also added. Mj: Pectoral major muscle.
when it was 11 to 14, fair when it was 6 to 10, and poor
when it was 0 to 5.
5. Results
The patients’ clinical data are shown in Table 1. No ad-
ditional resections due to a positive margin were neces-
sary. The total operative period ranged from 92 to 162
minutes, with the mean period being 116 minutes. The
suction drainage period required for each breast ranged
from 3 to 5 days postoperatively.
The postoperative observation period ranged from 5 to
60 months (median: 20 months). There were no compli-
cations in any of the treated breasts, and no local or dis-
tant recurrence was seen in any case (Figures 3 and 4).
In the objective assessment (Japanese Breast Cancer
Society), the total cosmetic score ranged from 10 to 12;
the score was 12 in one patient, 11 in four, and 10 in two
patients. In the subjective assessment (ABNSW), the
total cosmetic scores ranged from 12 to 15; the score was
15 in one patient, 14 in one, 13 in two, 12 in two, and 11
in one patient. The cosmetic outcomes were excellent or
good in both cosmetic assessments.
6. Discussion
The final cosmetic result of breast conserving therapy is
dependent on many factors, including tumor size, tumor
site, breast volume, the extent of surgery, chemotherapy,
radiotherapy, hormone therapy, and age [13-17]. Tumor
size in relation to breast size is one of the most important
factors to consider when attemptin g obtaining a cosmeti-
cally favorable result. Performing a resection that is wide
enough to obtain optimal oncologic control often requires

Oncoplastic Breast Surgery Using Spindle Shaped-Partial Mastectomy
for Early Breast Cancer in the Upper Quadrant Area 61
(a) (b)
Figure 3. (a) The resected spindle-shaped area of columnar tissue and excess skin; (b) One-year postoperative findings (Case 1 ).
(a) (b)
(c)
Figure 4. Case 6, a 76-year-old patient with a T1 tumor in the upper-outer quadrant of her left breast. Preoperative and
postoperative findings (a) and (b) Preoperative findings after marking. A spindle shaped area of skin and gland tissue with a
surgical margin of least 2 cm was drawn as a black line; (c) One-year postoperative findings.

Oncoplastic Breast Surgery Using Spindle Shaped-Partial Mastectomy
for Early Breast Cancer in the Upper Quadrant Area
62
removing so much breast tissue that it will leave a de-
formed breast or a large discrepancy compared with the
contralateral breast. Quadrantectomy increases the risk of
a poor aesthetic result if no partial breast reconstruction
is performed [18-20]. The impact of tumor surgery on
cosmesis in BCT has also been emphasized by leading
surgeons: surgical technique may influence the aesthetic
outcome to a greater extent than radiation effects [21].
Postquadrantectomy deformities include localized de-
fects in skin and glandular tissue, distortion and/or dislo-
cation of the areola, and retraction of the breast tissue.
Perhaps the most prominent and frequent failure in
achieving a good aesthetic outcome is due to a lack of
breast symmetry [22]. Surgical techniques used to ad-
dress the conflicts between oncological and cosmetic
results, including both total and partial mastectomy, can
be classed under the general term of oncoplastic surgery,
which is a new surgical approach that allows wide exci-
sion but prevents breast deformities by reconstructing
large resection defects immediately [13]. Several on-
coplastic surgical procedures have been discussed in pre-
vious reports. Hoffmann classified all breast surgeries
into 12 subgroups according to a two-type, six-tier clas-
sification system comprising 12 main categories [23]. In
breast conserving surgery, ranging from simple excision
up to quadrantectomy, defect repair without tissue mobi-
lization is regarded as grade 1 complexity, and complex
oncoplastic or reconstructive breast cancer procedures
involving pedicled or free distant flap reconstruction and,
where indicated, microvascular anastomosis for defect
coverage are regarded as grade 6. Our procedure, a spin-
dle shaped partial mastecto my in which excess g land and
skin tissue are removed, is regarded to be of grade 1
complexity according to their classification. In fact, it is
easier than other oncoplastic breast surgical techniques
that we described previously, such as volume replace-
ment or reduction type breast surgery.
Masetti et al. outlined several important aspects of
oncoplastic breast surgery procedures: first, careful plan-
ning of skin incisions and parenchymal excisions must be
made, following the templates used for reduction mam-
maplasty and mastopexy; second, the gland must be re-
shaped after the parenchymal excision; third, the nip-
ple-areola complex must be repositioned in the center of
the breast mound; and fourth, the symmetry of the con-
tralateral breast must be corrected. Another researcher
highlighted four integral features of oncoplastic surgery
[3]. All of these require planning with respect to the
placement and closure of wounds and careful assessment
of the oncological need and aesthetic aim [24].
We reported good results for immediate volume re-
placement surgery using a free dermal fat graft for the
treatment of upper-inner lesions [10,25,26]. This is thought
to be sufficient for slim ladies with non-ptotic, small
breasts, e.g., average Japanese ladies. It is easy to per-
form; however, there are some disadv antages to this pro-
cedure, for example, it is difficult to maintain softness,
and an additional scar is made at the donor site. In such
cases with breast cancers on upper quadrant lesion on
ptotic breasts, OBS combining with partial mastectomy
and reduction type mammoplasty brought excellent cos-
metic results, although surgical techniques might be
more complicated than former ones [27].
We performed oncoplastic surgery involving spindle-
shaped partial mastectomy and excess skin removal in
several older ladies in this series, and all procedures were
successful. We produced satisfactory cosmetic results,
and the observation period was thought to be sufficient.
One drawback of this technique is the length of the scar it
leaves. In particular, hypertrophic scars in the upper-
inner quadrant area will reduce cosmesis. In this series,
the patients’ satisfaction was high because the symmetry
of the bilateral breasts was well maintained, esp ecially in
the position of NAC, and the softness of the who le breast
was also retained by avoiding tissue mobilization to re-
pair the breast defects.
The number of cases in this paper was not so large,
and the follow-up period was short; however, we have
revealed that oncoplastic surgery using spindle shaped-
partial mastectomy combined with the removal of excess
skin for patients with upper quadrant lesions in ptotic or
large breasts produced excellent cosmetic results via a
simple technique. This simple oncoplastic technique is an
excellent procedure that yields very satisfactory cosmetic
results, and it should b e considered a suitable therapeutic
option.
7. Conclusion
OBS involving spindle-shaped partial mastectomy com-
bined with excess skin removal was successfully per-
formed and is expected to become more popular for the
treatment of aging patients.
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