Breast Augmentation Technique (Biplanar) for Oncoplasty

Conflict of Interest Statement

No funding was provided for this chapter. Dr. Barnea is a speaker for Johnson Medical.

Introduction

Breast conservation therapy (BCT) has become the mainstay in surgical breast oncology practice and is now a routine technique for the treatment of early-stage cancers. Improvements in diagnostic technology and mammographic screening as well as increased use of preoperative local and systemic therapies have extended the indications for BCT, with reported rates of 58% in the UK and 60–75% in the United States. Although BCT has enabled a less extensive tissue resection consisting of lumpectomy with tumor-free margins followed by radiation therapy, major contour irregularities have been observed following these procedures. Poor cosmetic results of BCT have been reported in 5–40% of patients. The surgical dead space created from the lumpectomy defect with added postoperative radiation effects may sometimes lead to substantial distortions in breast shape and size as well as nipple position. The management of breast deformities secondary to BCT in such cases can pose considerable difficulties, particularly when operating in a radiated field with poor tissue compliance. Several oncoplastic breast surgery techniques were introduced in an attempt to optimize the balance between the risk of local recurrence and the cosmetic outcome in BCT. The combined plastic surgery techniques of tissue replacement or tissue rearrangement involve a wider local excision while achieving enhanced breast shape and symmetry, and reduced surgical dead space.

Patients with small volume breast and relative large lumpectomy volume are at risk of developing severe breast deformity and breast asymmetry following BCT, thus presenting a unique surgical challenge. Regional flaps can be used to replace the volume loss in small-breasted patients, but many of them are reluctant to undergo this procedure due to additional scarring and morbidity, leading them to forgo oncoplastic reconstruction altogether or to undergo mastectomy and immediate reconstruction. The use of a prosthetic device for volume replacement in small breasts may seem appealing, but it has been largely rejected on the basis of studies that cited high complication rates following radiation therapy. One such study showed that subcutaneous implant placement in the immediate setting led to high incidences of capsular contracture and other complications. Nevertheless, there is reason to believe that with increasing surgical expertise and improved radiation delivery methods, implant-based procedures in patients planned for radiation therapy might have a better outcome compared with earlier experience. Judicious selection of the radiotherapy technique can reportedly help to improve the dose distribution and cause fewer radiation-induced side effects. Recent studies have advocated immediate implant-based reconstruction for patients receiving post-mastectomy radiotherapy, especially those who may not be candidates for autologous reconstruction. Moreover, patients with previous breast augmentation who later undergo BCT were reported to have good to excellent outcomes following their radiation treatment.

With growing experience and refinement in breast tissue rearrangement techniques, together with implant-based reconstruction and modern radiation therapy methods, more consistent results may be offered to breast cancer patients with small volume breasts who are considering BCT by means of the oncoplastic biplanar breast augmentation technique. This technique consists of immediate local glandular tissue rearrangement after a lumpectomy procedure and the use of bilateral subpectoral breast augmentation of different size and projection implants to compensate for the lumpectomy-caused volume loss. The technique aims to achieve immediate correction of shape and volume before radiotherapy without the added morbidity associated with the use of autologous flaps or delayed BCT reconstructions.