The Dogan Technique for Lower Inner Quadrant Breast Tumors: A Novel Volume Displacement Oncoplastic Approach

Background

Oncoplastic techniques in the treatment of breast cancer have expanded the indications for breast-conserving surgery while improving cosmetic outcomes. ¹ Oncoplastic surgery has also been shown to provide favorable cosmetic and patient-reported outcomes while maintaining acceptable oncological safety, making it an increasingly important approach in breast surgery. ² Despite these advantages, the success of oncoplastic reconstruction depends largely on tumor location, breast size, parenchymal distribution, and the expected extent of skin or glandular resection. However, in patients with small breast volume and relatively large tumors, achieving clear surgical margins while preserving satisfactory aesthetic outcomes remains a major challenge. ³

In particular, tumor location is a key factor in both surgical planning and aesthetic outcomes, as different quadrants require tailored reconstructive approaches. ⁴ Breast tumors located in the lower inner quadrant present additional challenges for oncoplastic surgery, as volume deficiency in this region may more easily result in unsatisfactory aesthetic outcomes. ⁵

Given these challenges, we present a novel oncoplastic technique for lower inner quadrant tumors that prioritizes patient satisfaction while aiming to overcome the reconstructive limitations associated with this region.

Method

Procedure

This technique was designed for tumors located in the lower inner quadrant (at the 4-5 o’clock position in the right breast and the 7-8 o’clock position in the left breast), distant from both the areola and the inframammary fold, and requiring skin resection. In non-palpable lesions, preoperative skin marking is performed under ultrasound guidance by centering the tumor location and drawing a circular marking with a 1-cm radius. The medial and inferior borders are determined using the sternum medially and the inframammary fold inferiorly as anatomical landmarks. A triangular pyramid design is then planned with its base positioned along the inframammary fold. One of the key principles of the design is the intersection of the peak point of the triangular pyramid with the superior margin of the tumor (Figure 1).OPEN IN VIEWER

Figure 1.

Preoperative marking and triangular design

The defined pyramid is divided into two components, resulting in a parallelogram and a triangular segment. The inferior triangular area represents the region designated for de-epithelialization. The superior parallelogram is designed as the resection area (Figure 2). In non-palpable tumors, intraoperative specimen imaging may be performed to confirm adequate tumor resection (Figure 3). A separate mini-axillary incision was used for sentinel lymph node biopsy.OPEN IN VIEWER

Figure 2.

Inferior triangular area designated for de-epithelialization

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Figure 3.

Tumor resection within the planned resection area

Following tumor resection, a superior glandular flap is created (Figure 4). After achieving hemostasis, the surgical cavity is marked with clips, and a silicone drain may be placed when necessary. The glandular flap is mobilized in the subcutaneous and prepectoral plane to provide adequate tissue mobility (Figure 5).OPEN IN VIEWER

Figure 4.

Superior glandular flap prepared after tumor excision

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Figure 5.

Subcutaneous and prepectoral mobilization of the glandular flap

To achieve complete closure of the surgical defect, the glandular flap is sutured to the superior margin of the de-epithelialized area using 2-0 Vicryl sutures. The superior skin incision line is then approximated to the inferior border of the de-epithelialized area using 3-0 rapid absorbable sutures (Figure 6). This technique results in a concealed scar positioned along the inframammary fold (Figure 7).OPEN IN VIEWER

Figure 6.

Advancement of the superior glandular flap to obliterate the surgical defect

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Figure 7.

Immediate postoperative appearance with inframammary incision

Cosmetic Assessment

Cosmetic outcomes were independently evaluated by two breast surgeons using standardized postoperative photographs obtained at the 30-day follow-up visit. Breast symmetry, breast contour, scar visibility, and nipple–areola complex position were assessed. Based on the overall aesthetic appearance, cosmetic results were classified as excellent, good, fair, or poor (Figure 8 and 9).OPEN IN VIEWER

Figure 8.

Postoperative day 7

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Figure 9.

Postoperative day 30

Results

The Dogan Technique was applied to 5 patients with lower inner quadrant breast tumors between January 2025 and March 2026. The planned surgical design was successfully achieved in all cases. Negative surgical margins were obtained in all patients, confirming adequate oncologic resection. No major postoperative complications, including wound dehiscence, infection, or nipple–areola complex ischemia, were observed. Early postoperative evaluation demonstrated satisfactory breast contour and symmetry in all patients (Figure 5, Fig. 6). Cosmetic assessment performed by two independent breast surgeons demonstrated excellent results in 3 patients and good results in two patients. No patient was rated as fair or poor.

Discussion

Variations in breast tissue distribution across different quadrants make it more challenging to achieve both oncologic safety and satisfactory cosmetic outcomes in tumors located in the lower inner quadrant compared to other regions of the breast. Therefore, appropriate selection of the surgical technique is critical. ⁶ Although several oncoplastic approaches have been described for tumors in the lower quadrants, the Dogan Technique may represent a valuable alternative within the current literature.

In the postoperative period, placement of the incision within the inframammary fold and avoidance of additional breast incisions may contribute to improved cosmetic satisfaction. Satisfactory outcomes have been achieved across all breast sizes. One of the significant challenges of oncoplastic surgery is the risk of ischemia in the nipple–areola complex. When innovative techniques are compared with traditional approaches, they are associated with fewer cutaneous vascular complications and a lower incidence of ischemia. ⁷

Several volume displacement techniques have been described for lower inner quadrant tumors, including therapeutic mammoplasty, dermoglandular rotation flaps, and glandular advancement procedures. These approaches are effective in restoring breast shape after wide excision; however, many require extensive parenchymal rearrangement, long skin incisions, or repositioning of the nipple–areola complex. Depending on the amount of tissue mobilization and skin resection, changes in nipple position, visible breast scars, and tension-related wound complications may occur.

The Dogan Technique was developed to address selected lower inner quadrant defects while preserving the native position of the nipple–areola complex. Unlike many reduction mammoplasty-based techniques, no centralization or transposition of the nipple–areola complex is required. Preservation of the original nipple position allows maintenance of the natural breast appearance and avoids surgical manipulation of the areolar complex. In addition, the incision is located within the inframammary fold, reducing scar visibility on the breast surface and providing a more concealed postoperative appearance.

Another characteristic of the technique is the use of a superior glandular flap with relatively limited tissue rearrangement. Rather than relying on extensive parenchymal redistribution, the defect is closed using mobilized local glandular tissue planned according to a geometric design. This approach aims to restore breast contour while maintaining symmetry and minimizing distortion of the remaining breast tissue.

The Banana Incision technique, previously described by our group for lower inner quadrant tumors, can be applied to a broad range of breast sizes and similarly utilizes volume displacement principles. ⁸ However, that technique requires de-epithelialization and recentralization of the nipple–areola complex. In contrast, the Dogan Technique preserves the nipple–areola complex in its original position while maintaining adequate tissue coverage of the resection cavity. Although both techniques are based on established volume displacement principles, the Dogan Technique preserves the nipple–areola complex in its native position and allows scar concealment within the inframammary fold without the need for areolar recentralization.

Nevertheless, this technique should not be regarded as a universal solution for all lower inner quadrant tumors. Adequate residual tissue between the tumor and the inframammary fold is required to allow safe glandular flap mobilization and tension-free closure. For tumors extending to or immediately adjacent to the inframammary fold, other reconstructive approaches may be more appropriate. Therefore, careful patient selection remains one of the key determinants of successful surgical and aesthetic outcomes.

This study has several limitations. First, the small sample size and single-center retrospective design limit the generalizability of the findings. Second, the short follow-up period precludes a comprehensive assessment of long-term oncologic outcomes, cosmetic durability, and patient satisfaction. Third, cosmetic outcomes were assessed by two independent breast surgeons; however, validated objective aesthetic assessment tools and patient-reported outcome measures were not used. Finally, the absence of a comparison group prevents direct evaluation of the advantages and disadvantages of the Dogan Technique relative to established oncoplastic approaches. Therefore, the findings should be considered preliminary and hypothesis-generating. The present study is intended primarily as a technical presentation of the procedure. As clinical experience and patient numbers increase, prospective studies with larger cohorts and longer follow-up will be required to further evaluate the oncologic safety, reproducibility, and aesthetic outcomes of this technique.

Conclusion

The Dogan Technique appears to be a feasible oncoplastic option for selected patients with lower inner quadrant breast tumors, a region associated with significant reconstructive challenges. In this preliminary series, negative surgical margins were achieved without major complications, and early aesthetic outcomes were satisfactory. Preservation of the nipple–areola complex and placement of the incision within the inframammary fold may provide advantages in terms of vascular safety and scar concealment. However, given the small sample size, retrospective design, absence of a comparison group, and limited follow-up period, these findings should be interpreted with caution. Further studies involving larger patient cohorts, longer follow-up periods, and comparative analyses are required to confirm the oncologic safety, reproducibility, and aesthetic outcomes of this technique.