Patients should undergo standard preoperative history and physical, with the elements of gynecologic, family, and social history including smoking emphasized. Special attention should be given to any prior breast surgical history, including the placement of breast implants. Preoperative laboratory work, such as complete blood cell count, comprehensive metabolic panel including liver function tests, and tumor markers are generally obtained as initial staging tests, as is a two-view chest radiograph. Core biopsy should be performed and conclusive proof of malignancy documented, with mandatory internal review of all external pathology slides required at our institution.

Patients being considered for oncoplastic lumpectomy should undergo a standard preoperative breast imaging workup, which typically includes some combination of mammography, ultrasound, and in selected circumstances breast magnetic resonance imaging (MRI). Although mammography may underestimate the extent of ductal carcinoma in situ (DCIS) by as much as 1 to 2 cm, especially when the fine, granular microcalcifications generally seen with DCIS are present, it is still warranted and is often the initial diagnostic study (10).

Although controversial, the use of MRI may contribute greatly to the surgeon’s ability to preoperatively determine the extent of disease present, especially for more mammographically subtle or occult cancers. Compared with mammographic and ultrasound images, the extent of disease seen on MRI may correlate best with the extent of tumor found at pathologic evaluation. In addition, MRI has the lowest false-negative rate in detecting invasive lobular carcinoma (11). Although its sensitivity for detection of invasive breast cancer is high, MRI unfortunately has a low specificity of 67.7% in the diagnosis of breast cancer before biopsy (12). Up to one-third of MRI studies will show some area of enhancement that needs further assessment that ultimately proves to be histologically benign breast
tissue (3). A consensus statement from the American Society of Breast Surgeons updated in 2007 supports the use of MRI for determining ipsilateral tumor extent or the presence of contralateral disease, in patients with a proven breast cancer (especially those with invasive lobular carcinoma) when dense breast tissue precludes an accurate mammographic assessment (13). For cancers containing both invasive and noninvasive components, a combination of imaging methods (mammography with magnification views, ultrasonography, and/or MRI) may yield the best estimate of overall tumor size (14).

Once a patient commits to breast conservation, decisions regarding the use of preoperative wire localization for nonpalpable malignancies must be made. In planning oncoplastic resections, the surgeon needs to accurately identify the area requiring removal. Silverstein and colleagues (15) previously suggested the preoperative placement of 2 to 4 bracketing wires to delineate the boundaries of a single lesion. In a study by Liberman and colleagues, wire bracketing of 42 lesions allowed for complete removal of suspicious calcifications in 34 (81.0%) (16). It has been suggested that single wire localization of large breast lesions is more likely to result in positive margins, because the surgeon lacks landmarks to determine where the true boundaries of nonpalpable disease are located. For such scenarios, multiple bracketing wires may assist the surgeon in achieving complete excision at the initial intervention.

A comprehensive understanding of normal ductal anatomy, as well as its influence on the distribution of cancer in the breast, is critical to planning an oncoplastic partial mastectomy (3,6). The modern anatomic analysis of ductal anatomy suggests that the number of major ductal systems is probably fewer than 10 (17). The size of ductal segments is variable and while some ducts pass radially from the nipple to the periphery of the breast, others travel directly back from the nipple toward the chest wall (see Fig. 6.1A and B). In contrast, the well-collateralized breast vasculature allows the surgeon to remodel large amounts of fibroglandular tissue within the skin envelope without a major risk of breast devascularization and/or necrosis. The most common source of arterial blood supply in the human breast arises from the axillary and internal mammary arteries (see Fig. 25.2B). By maintaining communication with one of these two arterial connections and by limiting the degree of dissection between the fibroglandular tissue and skin, an adequate blood supply for the breast parenchyma is maintained during tissue advancement and mastopexy closure.

Before the procedure, skin landmarks should be marked with the patient in the upright, sitting position. Relevant landmarks to be identified include the inframammary crease, the anterior axillary fold at the pectoralis major muscle, the posterior axillary fold of the latissimus dorsi muscle, the sternal border of the breast, and the periareolar circle. Identifying these entities with the patient in the upright position is very important to the final cosmetic outcome, because these anatomic sites may prove challenging to accurately locate once the patient is anesthetized and lying supine on the operating room table (Fig. 24.1A and B).

For all oncoplastic techniques, the patient should be supine on the operating room table, with the arms abducted and secured. It is preferable to have both breasts prepped
and draped into the field so that visual comparison with the patient in a beach chair position is possible as the wound is closed. Such an approach allows the surgeon to identify any areas of unnecessary tugging or dimpling, which are inadvertently created so that they can be corrected.

A rounded parallelogram with two equal length lines is drawn, thus marking the skin island to be excised in conjunction with the underlying target lesion and surrounding tissues (Figs. 24.2A and 24.3A

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