• The patient was a 58 year old female who presented with multicentric invasive lobular carcinoma, grade 2, ER positive, PR negative, HER2 negative.
• The lesions were located in her right breast, one in the upper outer quadrant and one in the upper inner quadrant of her right breast measuring 3 cm and 3.7cm respectively.
• Oncoplastic excision of both lesions with an inferior pedicle wise pattern reduction was planned along with a sentinel lymph node biopsy. A simultaneous contralateral balancing reduction for the left breast was also planned.
• To localise the tumours, magnetic seeds were placed in the two lesions preoperatively. A handheld localization probe was used to create the lumpectomy specimen by locating the preoperatively placed magnetic seeds.
• Intraoperative radiography was performed on the lumpectomy specimen to ensure good margins and the removal of the localization markers.
• Surgical clips were placed throughout the lumpectomy cavity to assist with postoperative radiation planning.
• The epidermis was removed along the wise pattern in a process called de-epithelialization. This allowed for the inset of the inferior wise pedicle under the skin flap.
• The inferior pedicle was secured to the chest wall in the area of defect.
• The Wise pattern skin closure was performed along the vertical and horizontal lines creating the new IMF. The wise pattern skin closure was continued along the vertical line of the wise pattern leaving space for the nipple keyhole and NAC.
• A 42-mm nipple marker was used to mark the new location of the NAC, guided by pre-operative incision planning. The NAC was then inset and sutured to the new areolar opening.
• The treatment was followed up with postoperative radiation, guided by the intraoperatively placed surgical clips.

The Breast Surgical Oncology chapter is supported by Judy Winberg and Andy Pollack through the Winberg Foundation.