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General Surgery

Oncoplastic Breast Surgery

The innovative developments in medical technology have provoked the oncoplastic surgeon’s use of plastic surgical techniques to improve cosmetic outcomes in breast conservation surgery. The integration of oncoplastic techniques with breast surgery allows extensive resections and results in favorable aesthetic outcomes.

Oncoplastic breast surgery is a novel surgical approach to the treatment of breast cancer. The word ‘oncoplastic’ is derived from the Greek words ‘onco’ meaning tumor and ‘plastic’ which means to mold. Plastic surgical techniques are employed in order to reshape the remaining breast or reconstruct the breast after appropriate wide excision of the breast cancer. The result is seamless specialist breast cancer surgery in which ablation of the cancer is merged with reconstruction. The close collaboration between the breast surgeon and the plastic surgeon is essential in order to obtain the total ablation of the tumor and an aesthetic result that limits psychological trauma to the woman.

The objective of breast conservation surgery is to remove the whole tumor with a clear margin of healthy tissue around it. A conflict exists between a wide enough resection in order to achieve optimal oncological control and not removing so much breast tissue as to leave a deformed or asymmetric breast. Oncoplastic surgery has emerged as a new approach for extending breast conserving surgery possibilities, potentially reducing both mastectomy and resection rates, while avoiding breast deformities.

The ultimate goal is to achieve both oncologic and cosmetic success. These are the major factors one considers before deciding to have breast cancer surgery.

Oncoplastic breast surgery is a relatively new and rapidly growing field of surgery. It is more technically complex and does requires more time to carry out than the traditional breast surgery. A well trained surgeon in this area has the skills to offer all the surgical options without any cosmetic or oncological drawbacks. The size of the tumor in relation to the size of the breast is the most important factor when predicting the potential cosmetic result. The location of the tumor (center, inferior, or medial) within the breast plays a vital role in aesthetic outcome. This may manifest itself as a concave deformity, skin puckering or nipple displacement/deviation.

Oncologic breast surgery combines the latest plastic surgical techniques with breast surgical oncology. It is a discipline that requires vision, passion, anatomical knowledge, aesthetic and symmetrical understanding and functions of the breast.

Following breast cancer treatment, overall survival is associated with the cosmetic consequences of the breast surgery. The reconstructive plastic surgery aims to improve the appearance of the patient.

Selection of patients for oncoplastic surgery:

An ideal patient for breast conserving surgery will have a favorable tumor to breast size ratio and be suitable for conventional forms of wide local excision in which the tumor is excised with an approximately 1 cm margin of surrounding breast tissue. Oncoplastic procedures allow extensive resection of tissue, increasing the possibility of achieving tumor-free margins, without affecting the aesthetic outcome.

The reconstruction method to be performed depends on the size and location of the expected tumor resection and an appreciable ratio of breast volume to resection volume.

Techniques of oncoplastic surgery:

Breast reconstruction following breast-conserving surgery may be carried out using volume replacement or volume displacement techniques.

Volume replacement technique: Autologous (patient’s own) tissue is harvested and transferred into the resection defect, replacing the volume of excised breast tissue. As the volume is restored, contralateral surgery is rarely required to achieve symmetry. The major complication includes donor site morbidity.

Volume displacement technique uses the remaining breast tissue after breast conserving surgery by glandular reshaping or reduction methods for better cosmetic results. This leads to a loss in breast volume and the potential need for a simultaneous contralateral reduction to improve symmetry. The drawbacks include flap necrosis, wound failure, and potential cosmetic failure.

Volume displacement techniques:

This is a simple technique which eliminates the need for another surgery which derives autologous grafts. The purpose is to incorporate the remaining breast tissue to fill the defect resulting from excision of the tumor. Displacement techniques reshape the breast through advancement, rotation or transposition of existing parenchyma and skin with a resultant decrease in overall breast volume.

The various options of oncoplastic volume displacement include:

1. Upper pole of breast
(a) Crescent Mastopexy
(b) Batwing Resection
(c) Hemibatwing Resection

Crescent, batwing or hemi-batwing excisions are best suited for lesions in the upper hemisphere (10 o’clock to 2 o’clock going clockwise). The incision permits correction of breast ptosis (sagging breasts) by elevating the nipple areolar complex.

2. Lower pole of breast
(a) Triangle Incision
(b) Reduction Mastopexy
(c) Inframammary (does not remove skin)

These incisions are employed to treat lesions in the lower hemisphere of the breast (3 o’clock to 9 o’clock, going clockwise). Large amounts of breast tissue can be removed with excellent cosmetic results and generally widely clear margins.

3. Any segment of the breast
(a) Radial–ellipse segmentectomy
(b) Circumareolar approach for segmental resection (does not remove skin)
(c) Donut or round block mastopexy
(d) Wise pattern reduction

The Other Breast:

The contralateral breast may be reconstructed to improve symmetry. This can be achieved simultaneously with the same procedure (single surgery) or as a second surgery. The disadvantages are:

  • Unknown final pathology and marginal status of the treated breast
  • Post-surgical radiotherapy may sometimes result in shrinkage or edema (swelling) of the breast.

Six to twelve months is the ideal time for the breast to heal following surgery and radiotherapy. Therefore, symmetrization of contralateral breast is preferred to delay for a certain period of time.

Oncoplastic breast surgery provides the correct approach concerning breast volume, tumor volume, substantiality of the treatment, and aesthetic outcome.