Oncoplastic Breast Reconstruction: Extreme Oncoplasty and Split Reduction Techniques

Introduction

For 100 years, starting in the 1870s, mastectomy reigned as the only treatment for breast cancer. Then, during the 1970s and 1980s, prospective randomized trials showed survival equivalence for breast conservation compared with mastectomy for patients with tumors <5 cm. Although survival was equal, there was a slightly higher local recurrence rate with breast conservation therapy. This was accepted in exchange for a better cosmetic result, and a happier, more intact patient.

During the last 30 years, there has been significant progress in breast cancer diagnosis and treatment. This includes earlier stage at diagnosis with improved imaging techniques, better hormonal treatment and chemotherapy, improved radiation therapy techniques, and an increased understanding of breast cancer biology and genomics. This progress has led to improved overall and breast cancer–specific survival. In addition, it has yielded decreased rates of local recurrence after both mastectomy and breast conservation. Recent prospective randomized trials have reported local recurrence rates less than 1.5% at 5 years for patients randomized to lumpectomy plus standard whole-breast radiation therapy. With local recurrence rates this low, breast conservation should be considered the default approach for breast cancer treatment, unless there are oncologic reasons to perform a mastectomy.

For patients with tumors <5 cm, a reduction mammoplasty using a Wise pattern can allow for successful breast conservation with a superior cosmetic result than can come from standard lumpectomy followed by radiation. A split reduction refers to breast conservation therapy using a standard Wise pattern mammoplasty for a lesion that falls outside the standard Wise pattern. During a split reduction, the anterior skin is taken over the lesion, as well as the posterior pectoralis muscle fascia, therefore eliminating worry for these margins at time of final pathology. In this modification, a portion of the inframammary crease incision is moved superiorly or cephalad to accommodate the skin over a lesion located in the upper inner, upper central, or upper outer quadrant of the breast ( Fig. 42.1 ).

Prospective randomized data supporting breast conservation exist only for patients with tumors ≤5 cm. Because of this, many patients with larger tumors are denied a chance to pursue breast conservation. When breast conservation is performed for patients with larger tumors, it requires a larger resection, which may yield a poor cosmetic result. Neoadjuvant chemotherapy, to reduce the size of the primary lesion, will convert some tumors to a more appropriate size for breast conservation therapy. For selected patients with larger tumor spans, the surgical answer may be extreme oncoplasty .

Extreme oncoplasty is a breast-conserving operation, using oncoplastic techniques, in a patient who, in most physicians’ opinions, requires a mastectomy. Extreme oncoplasty applies to breast conservation using a reduction mammoplasty technique in patients with larger lesions, with the goal of clear surgical margins, while maintaining or improving the cosmetic outcome. These lesions are generally large (>5 cm) multifocal, or multicentric tumors. They may be locally advanced, and many will have positive lymph nodes. Most of these patients will require radiation therapy, even if they are treated with mastectomy.

Oncoplastic reconstruction generally yields a cosmetic result superior to a mastectomy with immediate reconstruction and radiation therapy. There is less operative and postoperative morbidity with extreme oncoplasty, fewer surgeries are required, and finally, radiation therapy is far kinder to breast conservation than to mastectomy with reconstruction.

Indications

Historically, women were commonly left feeling deformed after breast cancer surgery when a lumpectomy cavity was left to form a seroma that later scarred down and led to dimpling after radiation therapy. In a typical lumpectomy, an incision is made over the tumor site, the tumor is removed, and no specific effort is made to fill the defect left with remaining breast tissue. Even when surrounding breast tissue is used to fill, with a small local tissue flap advancement, this can still lead to puckering or dimpling when the patient is out of the supine position and sitting or standing upright. Unfortunately, as many as 36% of simple excisions fail to achieve adequate margins in a single operation, leading to reexcision, worsening cosmesis, and conversions to mastectomy. Oncoplastic surgery, using a reduction mammoplasty, allows removal of the tumor, but also prevents undue distortion of the breast by allowing the defect to be filled with remaining breast tissue.

Oncoplastic surgery can be performed in tandem with a lumpectomy in most cases where the tumor is ≤5 cm. Extreme oncoplasty can be considered when women with tumors >5 cm are seeking an alternative to mastectomy, when oncologically feasible. In either case, oncoplastic surgery allows for breast-conserving therapy with a better cosmetic result. Oncoplastic surgery should be considered in all patients who are candidates for surgical treatment of breast cancer.