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Discussion. Shaping the breast in aesthetic and reconstructive breast surgery: an easy three-step principle. Part III--reconstruction following breast conservative treatment.

R of natural breast shape, contour, and position following breast cancer surgery has long been the goal of plastic and reconstructive surgeons. The past 40 years have been witness to a variety of techniques that have facilitated our ability to attain these goals. These include prosthetic devices, autologous tissues, internal rearrangements, and reduction mammaplasty. We have learned much over the years, often through trial and error, with outcomes that have ranged from terrible to excellent. We have learned that the application of principles and concepts is as important as the techniques we use. Our goal has always been to gain a better understanding and appreciation of the tools at hand that would enable us to achieve results that are predictable and reproducible. With the popularity of breast conservation therapy, there has been a significant interest in the reconstruction of the partial mastectomy deformity. Although this may seem to be simple and straightforward, it is actually complex because it requires a different analysis and approach than that of the total mastectomy deformity. This is further complicated because virtually all of these patients will or have received radiation therapy. Blondeel et al. have elegantly described their philosophy, conceptual approach, and management algorithm to the management of the partial mastectomy deformity following breast conservation therapy.1 The authors have described the principle of the footprint, the conus, and the skin envelope as the basis for their treatment algorithms. There are several points in this article that warrant highlighting. Having operated on many patients like the ones described, one can appreciate many of the principles and concepts that are outlined. As one reads through the article, there is a strong emphasis on patient safety and sound decision making. The significance of radiation and the progressive effect it has on the skin and parenchyma is well appreciated. Waiting at least 6 to 12 months before making any assessment is critical following radiation therapy. At the appropriate time, an estimation of breast volume and defect dimensions is important and proper planning is paramount. When planning the reconstruction, it should include 25 percent more volume than expected because of the shrinkage that occurs following radiation. In cases of a suspected positive margin following partial mastectomy, delayed reconstruction is appropriately recommended. A detailed explanation of these points is provided in the article. One of the strengths of this article is that it outlines many of the corrective procedures for these deformities based on size. Deformities less than oneeighth the glandular volume are relatively easy to correct based on the principles of internal tissue rearrangement and reduction mammaplasty. In contrast, deformities that are greater than oneeighth and less than three-eighths of the glandular volume are more difficult to correct and usually require local flaps such as the pedicle thoracodorsal artery perforator flap, the muscle-sparing latissimus dorsi flap, and the intercostal artery perforator flap. When the glandular resection exceeds three-eighths, a nipple-sparing mastectomy and free flap reconstruction is recommended. The reason for this is that the large partial mastectomy defect will require the use of large distant flaps that may be better used in cases requiring a total mastectomy. It is not recommended to burn that bridge for a partial mastectomy deformity. A description of delayed and immediate concepts is provided, with an emphasis on the increased difficulties associated with delayed reconstruction. It