Optimizing Cosmetic Outcomes for Breast Surgery

The adoption of breast-conserving therapy as an acceptable alternative to mastectomy opened the door to a wide and varied range of partial breast reconstruction techniques. The term oncoplastic breast surgery , as suggested by Werner Audretsch in 1993, describes the concept of local tissue rearrangement allowing for wide resection of tumors while preserving or improving breast cosmesis. A contralateral mammaplasty or mastopexy restores symmetry due to the volume loss from removal of the index cancer.

Traditionally, surgical oncologists were trained to remove the cancer at all costs, with less emphasis on the cosmetic result. Many women who have simple excisions appear to have a reasonable cosmetic outcome in the early postoperative period, but early results are sometimes misleading. Postoperative scarring, resolution of the seroma, and radiotherapy reveal the true esthetic outcome months or even years later.

Oncoplastic breast conservation surgery combines sound oncologic principles with plastic surgery techniques, allowing for wide excision of tumors with minimized risk of involved margins and simultaneous prevention of the deformities commonly associated with simple excisions and post radiotherapy fibrosis. It maintains a philosophy that the appearance and function of the breast after tumor excision is important, understanding that the patient will live with this result for the rest of their life. The goals of oncoplastic breast surgery include complete removal of the lesion with negative margins, a good to excellent cosmetic result, and the definitive procedure at a single operation. A comprehensive multidisciplinary oncoplastic approach is necessary for the surgical treatment of breast cancer, requiring coordination with the surgical oncologist, radiologist, plastic surgeon, medical oncologist, pathologist, radiation oncologist, and genetic counselor. As improved breast imaging and neoadjuvant chemotherapy allow a larger number of women to be considered for breast conservation, the combination of oncologic and plastic surgery disciplines also increases the number of women who may be treated with breast-conserving surgery by allowing larger excisions with more acceptable cosmetic results. These techniques are applicable to patients with both noninvasive (ductal carcinoma in situ [DCIS]) and invasive breast cancers. Furthermore, now that excision without radiation therapy is becoming an accepted treatment for some patients with biologically favorable DCIS, widely clear margins are of even greater importance than previously appreciated.

An important goal in caring for a woman with breast cancer is to go to the operating room once and perform a definitive procedure that does not require reoperation. The first attempt to remove a cancer is critical, offering the best chance to remove the entire lesion en bloc, evaluate its true extent and margin status, and achieve the best possible cosmetic result. The concept of a one-stage operation is important in the psychological and emotional recovery of a cancer patient. Fewer procedures allows the patient to quickly move on with her life and the next phase of treatment, if necessary. With this in mind, thorough staging of the cancer preoperatively is imperative to carefully plan the operation. The surgeon should review the patient’s stage, pathology, imaging, risk of recurrence, and risk of developing cancer in the contralateral breast. Whenever possible, the initial breast biopsy should be performed using a minimally invasive percutaneous technique. This provides ample tissue for diagnosis and biomarker analysis and should be possible in more than 98% of cases. Preoperative assessment of tumor biology often allows for neoadjuvant systemic therapy, which can downstage the tumor and convert the definitive operation from mastectomy to breast preservation.