Introduction to oncoplastic breast surgery

Introduction

Oncoplastic surgery continues to evolve as a viable option for women with breast cancer who desire partial mastectomy. Oncoplastic surgery is defined as wide excision of a local tumor using oncologic principles followed by the immediate or staged-immediate correction of the defect using plastic surgical techniques. The feasibility, safety, and efficacy of oncoplastic surgery has been established and stems from our improved understanding of the biology of breast cancers, appreciation for quality of life, patient satisfaction, and the wide armamentarium of plastic surgery techniques for correction. Prior to oncoplastic surgery, breast conservation therapy (BCT) frequently resulted in higher rates of local recurrence, re-excision and breast distortion. Corrective procedures such as reduction mammaplasty, implant insertion, and tissue rearrangement were frequently associated with higher rates of morbidity that included delayed healing, fat necrosis, and capsular contracture. As such, post radiation management frequently required the use of a latissimus dorsi musculocutaneous flap.

Safety and efficacy of oncoplastic surgery

Oncoplastic surgery differs from standard BCT in that the margin and volume of excision is typically greater than that of lumpectomy or quadrantectomy. Excision margins typically range from 1 cm to 2 cm and resection volumes may range from 100 to 300 cm ³ . The reconstruction is performed immediately or on a staged-immediate basis using techniques of tissue rearrangement, volume displacement, and volume replacement. These will be discussed in greater detail in the subsequent paragraphs and chapters.

Safety in oncoplastic surgery requires selection of proper surgical techniques and attention to detail. The importance of obtaining a clear margin is especially important because the consequence of a positive margin following parenchymal reorganization usually includes reoperation, breast distortion or possible mastectomy. When surgical margins are in question following the initial ablative procedure, a staged-immediate approach can be considered. The relative risk of a tumor recurrence is 15-fold higher when the surgical margin is not clear. A positive margin is often 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.

Given that larger tumors have an increased likelihood of a positive margin, the benefit of wide excision with a 1–2 cm margin compared with lumpectomy with a 1–2 mm margin is recognized. When resection margins are increased, the incidence of a positive margin is reduced when comparing oncoplastic resection with standard quadrantectomy. With oncoplastic tumor excision, glandular resection is increased, histological margins are wider, the need for re-excision is decreased, and mastectomies are fewer. As a result, immediate reconstruction of the partial mastectomy is usually safe; however, as previously mentioned, when margin status is in question, a delayed approach is usually considered.

Immediate reconstruction of the partial mastectomy deformity

The techniques that are 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. The indications for each are different and various algorithms have been devised to assist with the decision process. These options will be described in the following chapters. In most cases, the specific technique is based on breast volume and defect size. In general, women with smaller breasts tend to be considered for volume replacement procedures, e.g., local flap, latissimus dorsi, lateral thoracic flap, whereas women with larger breasts are better candidates for volume displacement procedures, e.g., adjacent tissue rearrangement, reduction mammaplasty, mastopexy.