Benefits of Oncoplastic Surgery

The benefits of oncoplastic surgery have been well described; the principle benefit is that total mastectomy can be avoided in properly selected patients. The oncoplastic approach also broadens the indications for BCT. Patients with small breasts or subareolar tumors are often poor candidates for BCT alone because of the severe distortion of breast tissues as a result of radiotherapy. Oncoplastic techniques may provide options using strategies of volume displacement and replacement to minimize distortion and avoid total mastectomy.

The psychological advantages of breast preservation in the management of breast cancer are well established. Patient satisfaction has been demonstrated to be superior compared with that of mastectomy in most cases. ³ – ⁶ In many women the NAC is preserved, eliminating the need for nipple reconstruction. Oncoplastic surgery is advantageous compared with BCT, because parenchymal defects are immediately reconstructed and contour abnormalities of the breast are significantly minimized or eliminated altogether. It is expected that 5% to 40% of women who undergo breast conservation will have a contour abnormality. ⁷ Typically, these defects are more difficult to correct because of the adverse effects on tissue vascularity and the fibrosis that occurs after radiotherapy. Secondary correction of these irradiated deformities sometimes results in delayed healing and poor aesthetic outcomes. With the current concepts regarding oncoplastic tumor resection and plastic surgical closure, immediate reconstruction has minimized the incidence of these contour abnormalities, has allowed a wider margin of tumor resection, and has decreased the number of subsequent operations required. All of these factors have improved oncologic and aesthetic outcomes.

The oncologic safety and efficacy of oncoplastic surgery are adequately discussed in Chapter 7. Although local recurrence rates may be increased compared with those of total mastectomies, the early detection and management of these tumors have not had an adverse influence on survival. It is recognized that local recurrence is closely correlated with the margin of resection—the wider the margin, the less likely the local recurrence. Studies have demonstrated that resection margins of 1 cm or more have a recurrence rate equal to that of mastectomy. ⁸ With oncoplastic surgery, margins of 2 to 3 cm are not uncommon, because the resultant deformity is immediately corrected. Hence an additional benefit of the oncoplastic approach includes the ability to take wider resection margins. Although it is not the driving force behind choosing oncoplastic approaches, tissue sampling of the opposite breast may help to diagnose contralateral occult breast cancer when reduction techniques are applied. Others have suggested that reduction techniques provide further risk reduction by removing additional breast tissue; however, studies of this are limited. ⁹

The oncologic feasibility of oncoplastic surgery is well appreciated. ¹⁰ , ¹¹ To best understand the safety and efficacy of this approach, comparison studies to SSM followed by immediate breast reconstruction have been performed. In a study of mastectomy and immediate reconstruction from the University of Texas MD Anderson Cancer Center, 1694 women were reviewed to determine the incidence of local recurrence. ¹² A recurrence was documented in 39 women (2.3%). Of the women with recurrence, 28 cases (72%) involved the skin or subcutaneous tissues, and 11 (28%) involved the chest wall. Metastatic disease was documented in 57% of the women with superficial recurrences and in 91% of those with deep recurrences. Among the women who had a recurrence, the metastases-free survival was 52% at 2 years, 42% at 5 years in women who had a recurrence in the skin or subcutaneous layer, and 24% at 2 and 5 years in women who had a chest wall recurrence.

In contrast to mastectomy and immediate reconstruction, oncoplastic techniques result in similar survival and recurrence rates. Clough et al ¹³ reviewed 101 women who underwent oncoplastic surgery in which a partial mastectomy was followed with immediate reduction mammaplasty. The margin of resection was at least 1 cm of normal tissue. The median follow-up was 46 months (range 7 to 168 months). The recurrence rate at 5 years was 9.4%. The 5-year actuarial survival was 95.7%, and the 5-year metastases-free survival was 82.8%.

Studies evaluating patient satisfaction have demonstrated that women report higher satisfaction scores after an oncoplastic approach than they do with a SSM and immediate breast reconstruction. ¹⁴ The reasons for this are mainly related to the preservation of the natural breast mound and NAC.

In studies evaluating women’s satisfaction after undergoing reconstruction of the NAC, total satisfaction based on projection, texture, color, and appearance was obtained in only 13% of patients. ¹⁵

After oncoplastic surgery, the appearance and behavior of the NAC is usually retained, and this seems to lead to a higher degree of patient satisfaction. These satisfaction results are favorable regarding the various approaches to oncoplastic surgery, such as reduction mammaplasty and latissimus dorsi flap reconstruction. ¹³ – ¹⁹

NA, Not assessed.

In six well-established studies in which latissimus dorsi reconstruction or reduction mammaplasty was performed, patient satisfaction ranged from 84% to 100%. In three of the six studies, the patient satisfaction was 100% following both techniques, despite a complication rate that ranged from 8% to 38%. These complications included seromas, infection, delayed healing, fat necrosis, sensory changes of the breast and NAC, disruption in activities of daily living, and fibrosis. In a recent meta-analysis comparing BCS alone (N = 5497) to the oncoplastic approach (N = 3165), the patient satisfaction was higher in the oncoplastic group (90% oncoplastic reduction and 92% oncoplastic flap) compared with 83% in the BCT-alone group (p <0.001).