BI/TRI PEDICLED ONCOPLASTY

The choice of the vascular pedicle for the nipple areola complex (NAC) in oncoplastic breast surgery is related to tumor location and breast morpho-volumetric characteristics. Good knowledge of the breast blood supply is essential for designing different potential pedicles to carry the NAC and reconstruct the defect. This chapter will discuss the use of multiple vascular pedicle for the NAC in oncoplastic breast conserving surgery and skin reducing NAC-sparing mastectomies. The vascular anatomy of the breast allows for the use of various pedicle options in breast conserving surgery, as the vertical pedicle (McKissock), and the double horizontal pedicle (Strömbeck). The vertical McKissock pedicle technique could be used for oncoplastic breast conserving surgery in medium-sized or large breasts for tumor located in the outer or inner quadrants or multiple resections of multicentric lesions located in both outer and inner quadrants. The double horizontal Strombeck techniques could be used for oncoplastic breast conserving surgery in medium-sized or large breasts for tumor located in the upper quadrants or lower quadrants or multicentric lesions located in both upper and lower quadrants. The preservation of the NAC in skin reducing mastectomies in large and ptotic breasts introduces unique challenges, regarding its vascular supply. With the aim of reducing the rate of necrosis the use of mul-tiple pedicles has been investigated in skin reducing NAC sparing mastectomies. The bi-pedicle tech-nique is a modified skin-reducing approach designed to preserve the NAC in large and ptotic breasts. It involves the creation of a bi-pedicle dermal flap, consisting of a superior pedicle and an inferior pedicle including the AICAP at the fifth intercostal space to ensure the vascularization of the NAC. The use of double pedicle techniques was inspired by McKissock’s approach to reduction mammoplasty, in which dual pedicles were used to ensure perfusion in large-volume reductions. Three-Pedicle Nipple-Sparing Skin-Reducing Mastectomy (TP-NSSRM) technique is the first documented approach with the use of a three subcutaneous-dermal pedicle-based nipple-sparing skin-reducing mastectomy, aiming to provide a reliable and aesthetically pleasing solution for patients with large and ptotic breasts. By utilizing permanent silicone gel implants and a pre-pectoral approach, this technique eliminates the need for acellular dermal matrices (ADMs) or synthetic meshes, reducing costs and minimizing complications. The evolution of multiple pedicle-based techniques in oncoplastic breast surgery reflects the ongoing quest to balance oncologic safety with optimal aesthetic and functional outcomes. From the initial use of single pedicle approaches, with their inherent limitations, to the advanced application of double and triple pedicle techniques, these innovations have significantly improved NAC preservation and overall patient satisfaction. By tailoring the choice of pedicle(s) to the patient’s anatomy and surgical needs, surgeons can achieve superior outcomes, even in complex or high-risk cases.