Introduction to Oncoplastic Breast Surgery

Oncoplastic breast surgery has become a common option for women with breast cancer. Oncoplastic surgery is defined as tumor excision with a wide margin of resection followed by immediate or staged immediate reconstruction of the partial mastectomy defect. It differs from traditional breast conservation in that the margin of excision is significantly wider ranging from 1–2 cm rather than 1–2 mm. Oncoplastic breast surgery has been demonstrated to be safe and effective and results in high patient satisfaction. This introductory chapter will review the evolution and many of the milestones associated with ablative breast cancer surgery and how oncoplastic breast surgery has evolved as a primary option for women diagnosed with breast cancer.

History of Mastectomy

The management of breast cancer has been subject to several paradigm shifts over the past century. Before the era of William Stewart Halstead, the diagnosis of breast cancer was often associated with few options for management and poor patient survival. With the introduction of the radical mastectomy, the morbidity and mortality of breast cancer was markedly improved; however, the disfigurement following this operation was significant. The modified radical mastectomy (MRM), in which the pectoral major muscle was preserved and the axillary lymph node basin was dissected, maintained similar survival statistics with slightly less physical disfigurement. The simple mastectomy in conjunction with radiation therapy was introduced at the same time and continued to provide less aggressive surgical techniques. Further refinements in mastectomy techniques allowed for skin-sparing patterns that were demonstrated to equivalent local recurrence and survival rates. With the introduction of sentinel lymph node biopsy (SLNB) for breast cancer, the need to perform an axillary dissection was significantly reduced, and the simple mastectomy with SLNB has become a common mastectomy strategy. The most recent innovation has been the widespread acceptance of nipple-sparing mastectomy for malignant disease that has been applied to women in select situations.

The common feature of the early mastectomy techniques was that the breast was removed, and the likelihood of disfigurement was high. This ultimately led to the need for reconstructive techniques that could minimize this disfigurement. The advancements in breast reconstruction paralleled the advancements in mastectomy so these disfigurements could be eliminated. Reconstructive options have included prosthetic devices, musculocutaneous flaps, and perforator flaps. The evolution of these techniques has made a significant impact when it came to mastectomy and outcome; however, the breast conservation therapy (BCT) movement had been initiated and represented a new frontier in the management of breast cancer.

History of Breast Conservation

The breast conservation movement began to move forward as our understanding of the pathophysiology of breast cancer improved and optimal utilization of radiation therapy became standardized. The notion that total mastectomy was not an absolute requirement and that lumpectomy could be performed with equivalent safety and efficacy was a significant breakthrough. Benefits included preservation of the nipple–areolar complex in many cases as well as maintaining breast shape in the majority of women. Common to all patients having BCT is the need for postoperative radiation to eradicate microscopic disease that may be present.

Outcomes following BCT have been generally favorable with survival statistics that have remained essentially equal to that of MRM. However, local recurrence rates are slightly increased. Although the aesthetic outcomes following BCT have been good to excellent in the majority of women, some have required secondary procedures to improve the appearance and achieve symmetry.

History of Oncoplasty

In an effort to reduce the incidence of local recurrence and maintain natural breast contour, the concept of oncoplastic surgery was introduced. Oncoplastic surgery differs from standard BCT in that the margin and volume of excision is typically greater than that of lumpectomy or quadrantectomy. With BCT, an excision margin of 1–2 mm is usually sufficient; whereas with oncoplastic surgery, excision margins typically range from 1–2 cm and resection volumes typically range from 100–200 cm ³ . The resultant deformity is usually reconstructed immediately using volume replacement or displacement techniques; however, a staged immediate reconstruction can also be considered. Reconstructive options include adjacent tissue rearrangement, reduction mammaplasty, or distant flaps. When symmetry is desired, contralateral procedures can be performed immediately at the time of partial breast reconstruction or on a delayed basis and include reduction mammaplasty, mastopexy, or augmentation. Breast conservation using oncoplastic techniques has resulted in survival and local recurrence rates that are essentially equal to that of MRM.

The purpose of this introductory chapter is to review the history of these oncoplastic procedures and several of the landmark studies as well as highlight some of the surgeons that have made significant contributions to oncoplastic surgery. As oncoplastic surgery gains acceptance and popularity, an optimal and systematic approach to management is becoming increasingly necessary. This introductory chapter will review many of the relevant vignettes of oncoplastic surgery, and the subsequent chapters will expand upon many of the principles, concepts, and techniques.

Safety and Efficacy of Oncoplastic Surgery

The indications and patient selection criteria for oncoplastic surgery is now well appreciated and accepted. Oncoplastic surgeons should be aware of all aspects related to the indications, techniques, and recovery for women considering partial mastectomy. Safety in oncoplastic surgery requires an appreciation of tumor biology and an understanding of what constitutes an appropriate margin. The process begins by obtaining a diagnosis that can be accomplished using various techniques that include fine-needle aspiration, core needle biopsy, and excisional biopsy. The next step is the excision. The importance of obtaining a clear margin becomes evident when one considers that the relative risk of developing a recurrence is 15-fold higher in patients in whom the surgical margin was not clear of tumor. A positive margin can be related to the size of the primary tumor (T3 > T2 > T1) and to histological subtype (lobular > ductal). Preoperative identification of these women with infiltrating lobular carcinoma who may be at higher risk of a positive surgical margin can be sometimes made via mammography based on the presence of architectural distortion.

It is known that larger tumors have an increased likelihood of a positive margin; therefore, obtaining wider margins may decrease the likelihood of a positive margin. Kaur et al demonstrated that, as resection margins increase, the incidence of a positive margin is reduced, especially when comparing oncoplastic resection to standard quadrantectomy. Mean resection volume in this study was 200 cm ³ following oncoplastic resection and 117 cm ³ following quadrantectomy. Giacalone et al have demonstrated that, following oncoplastic resection, glandular removal was increased, histological margins were wider, and the need for re-excision was decreased. In addition, there was a trend toward fewer mastectomies following oncoplastic resection (2/42, 4.8%) compared with standard lumpectomy (12/57, 21.1%). Additional studies and supportive data will be reviewed in upcoming chapters.

Immediate Reconstruction of the Partial Mastectomy Deformity

The techniques currently used for the reconstruction of the partial mastectomy defect are based on two different concepts: volume displacement and volume replacement. Volume displacement procedures include local tissue rearrangement, reduction mammaplasty, and mastopexy. Volume replacement procedures include local and remote flaps from various regions of the body. These techniques are usually applied independently; however, new strategies can utilize them simultaneously.

The indications for volume displacement and replacement are different and, various algorithms have been devised to assist with the decision-making process. In general, women with smaller breasts with minimal ptosis were found to be better candidates for volume replacement procedures (e.g., local flap, latissimus dorsi, and lateral thoracic flap), whereas, in women with larger and more ptotic breasts, volume displacement procedures (e.g., adjacent tissue rearrangement, reduction mammaplasty, and mastopexy) are usually performed. The simultaneous use of replacement and displacement has recently been described for women with small to moderate breast volume in which parenchymal rearrangement is combined with the use of a small device. The history of these techniques as they relate to oncoplastic surgery will be further reviewed.

Volume Displacement with Reduction Mammaplasty

Reduction mammaplasty as an oncoplastic modality has been performed since the early 1980s. Over the years, this has become the principal method by which oncoplastic reconstruction has been performed. Clough et al reported on their 14-year experience in 101 women who were selected for oncoplastic resection because a standard lumpectomy would have resulted in a significant contour abnormality. The primary technique utilized was an inverted “T” with nipple–areolar complex based on a superior pedicle. A contralateral reduction mammaplasty for symmetry was performed immediately in 83% of women and secondarily in 17% of women. Mean tumor excision weight was 222 grams. The 5-year local recurrence rate was 9.4%, the overall survival rate was 95.7%, and the metastasis-free survival rate was 82.8%. Cosmetic outcome was satisfactory in 82% of women. It was demonstrated that cosmetic outcome tended to deteriorate when radiotherapy was delivered preoperatively compared with postoperatively.

Spear et al have reported on their 6-year multidisciplinary experience combining wide excision of tumor with immediate bilateral reduction mammaplasty. All women had mammary hypertrophy with a mean excision volume of 1085 grams per breast. Follow-up ranged from 1–6 years with a mean of 24 months. Complications included fat necrosis ( n = 3), nipple hypopigmentation ( n = 2), hematoma, and complex scar. Patient satisfaction was scored on a visual analog scale that ranged from 1–4 with a mean score of 3.3. A panel of independent observers also graded the outcomes and scored the pre-radiation outcome as a 2.9 and the post-radiation outcome as 3.03. No woman developed a local recurrence, although one woman died of metastatic disease. The principal conclusions from this study were that partial mastectomy followed by oncoplastic and contralateral reduction mammaplasty was oncologically safe and avoided the asymmetry that was typically observed following BCT alone or following total mastectomy with immediate total breast reconstruction.

Losken et al have reported on their 10-year experience utilizing reduction mammaplasty in the setting of oncoplastic surgery. A total of 20 women were included in this review. Mean tumor size was 1.5 mm, and the mean weight of the tumor specimen was 288 grams. The excised surgical margins were negative in 80%. The most common reduction technique was a superomedial or inferior pedicle. Postoperative abnormal mammograms were noted in eight women (40%), all of whom underwent additional biopsy. No woman was noted to have a recurrence with a mean follow-up of 23 months. Breast aesthetics and patient satisfaction were acceptable in all women.

These studies and others have demonstrated the utility of reduction mammaplasty in the setting of oncoplastic surgery. It is important to note that no two oncoplastic reduction procedures are the same and that oncoplastic reductions are different from standard breast reductions. Parenchymal displacement may take the form of a flap of vascularized parenchyma or as parenchymal rotation advancement. If there is doubt about obtaining a clear margin at the time of the primary excision, a staged immediate reconstruction can be performed following margin confirmation. Figs. 1.1–1.2 illustrate a patient before and after oncoplastic reduction mammaplasty.

Volume Displacement with Adjacent Tissue Rearrangement

Adjacent tissue rearrangement is the most common method by which the partial mastectomy defect is reconstructed. These techniques rarely require a two-team approach, as the ablative surgeon is usually able to use these techniques and close these defects. Adjacent tissue rearrangement is indicated when the partial deformity extends to the chest wall and there is sufficient adjacent tissue to close the defect and maintain a natural contour. Volume displacement is performed but without the need to create parenchymal flaps. Volume replacement is usually not necessary because there is sufficient local tissue. The primary goal of adjacent tissue rearrangement is to avoid the contour deformity that is sometimes seen with traditional breast conservation. With this method of oncoplastic reconstruction, the excision is usually extended to the chest wall, and the adjacent parenchyma is undermined and mobilized to permit the closure of small or large deformities without creating a contour abnormality.

Specific parenchymal rearrangement procedures include batwing mastopexy, radial segment quadrantectomy, donut mastopexy, and reduction mastopexy. Veronesi et al introduced the concept of segmental parenchymal wide excision including the overlying skin. This allowed for the quadrantectomy approach that was instrumental in establishing the feasibility of BCT. These operations were generally performed using a radial approach for tumors that were laterally based. An alternative to the radial approach was the periareolar approach initially described by Amanti et al. This permitted excisions that resulted in less conspicuous scars. With the introduction of the periareolar subcutaneous quadrantectomy, also known as the periareolar donut mastopexy, incisions could be created circumferentially around the nipple–areolar complex and remain relatively inconspicuous. Anderson et al. introduced various concepts that include skin incisions using a parallelogram pattern and batwing mastopexy. These parallelogram incisions allowed for wider excision margins while maintaining the natural contour of the breast. The batwing mastopexy is an extension of this concept and is used primarily for centrally situated tumors near the nipple–areolar complex. Clough et al introduced the technique of reduction mastopexy lumpectomy. This technique has been especially useful for tumors situated near the lower pole of the breast. Standard lumpectomy of these tumors would often result in an inferiorly displaced nipple–areolar complex.

Volume Replacement with Local and Remote Flaps

Local and remote flaps for volume replacement are most useful for defects in which volume displacement procedures would not be adequate due to small breast volume or due to extensive resection. The selection of a local or remote flap will depend upon the abilities of the reconstructive surgeon and the location of the defect. Flaps can be musculocutaneous and perforator-based and can be transferred on a vascularized pedicle or as a free tissue transfer. Many of these options will be reviewed in the subsequent chapters. What is provided in this chapter is a brief overview of the techniques and their origins.

The most common flap for immediate reconstruction following partial mastectomy has been the latissimus dorsi musculocutaneous flap. This flap is indicated for deformities of the superior, lateral, and inferior aspects of the breasts. There are several methods by which the latissimus dorsi flap can be harvested. The traditional technique involves making a posterolateral thoracic incision, whereas more modern techniques utilize an endoscope. With the endoscopic technique, the muscle is accessed through the breast and axillary incision without the need to incise or excise remote skin. Kat et al have reviewed their 3-year experience in 30 women who had oncoplastic surgery using the latissimus dorsi musculocutaneous flap. Flap survival was 100%, and all patients were pleased with aesthetic outcomes. Losken et al have reviewed their 5-year experience using the latissimus dorsi muscle flap harvested endoscopically in 39 women. Donor site morbidities occurred in 12 women (31%) and included a seroma in 7 women as well as skin necrosis, lymphedema, dehiscence, hypertrophic scarring, and a persistent sinus tract.

Harvesting the latissimus dorsi as a mini-flap is advantageous because the size of the flap can be tailored to fit the size of the defect. The LD mini-flap is generally harvested through an extended anterolateral breast incision that is used for the resection as well. Rainsbury has demonstrated that this flap extends the role of BCT and oncoplastic surgery; enables reconstruction for a deformity involving 20–30% of the breast; can be used for central, upper inner, and upper outer quadrant tumors; and can be performed immediately or on a delayed basis. Gendy et al have used the latissimus dorsi mini-flap for oncoplasty in 89 women and compared outcomes with immediate breast reconstruction following total skin-sparing mastectomy. Findings were favorable for the oncoplastic techniques with regard to postoperative complications (8% vs 14%), further surgical interventions (12% vs 79%), nipple sensory loss (2% vs 98%), restricted activities (54% vs 73%), and cosmetic outcome (visual analog score: 83.5 vs 72). Figs. 1.3–1.6 illustrate a patient following partial breast reconstruction with a latissimus dorsi musculocutaneous flap.