Introduction

Oncoplasty is a popular technique for managing partial mastectomy defects that continues to gain momentum among plastic surgeons and oncologic breast surgeons alike. It is now widely accepted as a superior approach for reconstructing partial mastectomy defects, especially in the setting of postpartial mastectomy radiation. The advantages are that oncoplasty expands the candidacy for breast conservation therapy to patients with larger tumors who would otherwise require a mastectomy. Oncoplasty reduces the chances of having positive margins by increasing surgical exposure and allowing for a larger more comprehensive resection. The reconstructive component of oncoplasty significantly improves the cosmetic outcomes compared with lumpectomy or partial mastectomy alone. Larger defects can be reconstructed with local breast tissue to obliterate any dead space created by the partial mastectomy. This creates a stable breast mound that can better tolerate external beam radiation.

By expanding the role of breast conservation therapy, oncoplasty provides patients with a less invasive option. This option eliminates the need for an overnight stay in the hospital and decreases both the operative time as well as the time for recovery. There is no need for either an external breast prosthesis or an internal breast implant that might be required for a mastectomy reconstruction. Oncoplasty also often allows patients to maintain nipple sensation following their reconstruction. These characteristics all contribute to the popularity that oncoplasty has gained as a successful reconstructive option.

There are a variety of methods by which oncoplastic breast reconstruction can be performed. These include volume replacement techniques as well as volume displacement techniques. Volume replacement methods include the use of remote flaps such as the latissimus dorsi or the thoracodorsal artery perforator flaps and are usually performed in women with smaller breast volumes. Volume displacement methods include the use of adjacent tissue rearrangement, mastopexy, and reduction mammaplasty, and are usually performed in women with moderate to large breast volume.

Reduction mammaplasty is arguably the most common form of oncoplastic reconstruction and can be performed in a variety of ways. Although standard reduction mammaplasty techniques are diverse and can be performed using a variety of pedicles, oncoplastic reduction is different in that the orientation of the pedicle will depend on the location of the partial mastectomy defect. In other words, a superior defect is usually repaired with an inferiorly based pedicle. This chapter will review the fundamental principles and concepts associated with oncoplastic reduction mammaplasty.

Patient Assessment

When a patient is diagnosed with breast cancer, they are usually given two treatment options: either a partial mastectomy in conjunction with external beam radiation or a mastectomy that may or may not require radiation based on lymph node involvement. Most patients who opt for the partial mastectomy or lumpectomy choice are candidates for oncoplasty. Evaluating these patients typically amounts to three key factors:

• 1.
  

  Tumor location and characteristics

  
  
• 2.
  

  Need for adjunct therapy

  
  
• 3.
  

  Goals and overall health of the patient

Once these three factors have been evaluated and discussed with the patient and the treatment team, then a successful oncoplastic plan can be formulated.

Tumor Location

The location of the tumor or the area needing resection is key to designing the best approach to reduction mammaplasty oncoplasty. For strategic purposes the breast can be divided into seven areas as shown in Fig. 8.1 . Preoperative magnetic resonance imaging is extremely useful to determine the extent of the tumor in the breast or if there is any other underlying pathology, like ductal carcinoma in situ (DCIS), in another area of the breast that would also benefit from resection. Once all the areas that require resection have been delineated and pathology has been confirmed or ruled out by core needle biopsy, then the extent of the defect can be categorized to one or more of the seven areas.

Stock figure showing circumvertical and inverted T patterns.

Operative Technique

Reduction mammaplasty techniques for oncoplastic breast reconstruction are based on volume displacement. These techniques utilize advancement, rotation, or transposition of the remaining breast tissue following a resection to obliterate the dead space created by the resection. Conceptually, it is a strategic breast reduction where the part of the breast that is normally discarded contains the pathological breast tissue needing resection.

Numerous reduction mammaplasty techniques have been described in the plastic surgery literature, and they are all certainly applicable in oncoplasty. For the purposes of this chapter, it is helpful to simplify the approach to the skin pattern and distill down the reduction mammaplasty techniques to three approaches that can be utilized successfully in almost every partial mastectomy. If the requirements for resection and reconstruction cannot be met by these techniques, then the patient is likely not a good candidate for oncoplasty and would be better served with a mastectomy.

One of the most important considerations when performing oncoplastic reduction mammaplasty patterns is an appreciation of the vascularity of the breast. There are several dominant sources that can perfuse the breast in a segmental fashion. The vascularity to the breast is primarily derived from the internal and lateral mammary perforators as well as the thoracoacromial trunk, intercostal perforators, and thoracoepigastric systems. The primary blood supply to the nipple–areolar complex is via the fourth intercostal, aka artery of Wuringer, that courses through the horizontal septum. The third and fourth perforators derived from the internal mammary system will also contribute to the vascularity when a superomedial or medial-based pedicle is used.