Oncoplastic procedures to allow breast conservation and a satisfactory cosmetic outcome

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Oncoplastic procedures to allow breast conservation and a satisfactory cosmetic outcome

Richard M. Rainsbury, Krishna B. Clough, Gabriel J. Kaufman, Claude Nos and J. Michael Dixon

Part 1

Volume replacement techniques to improve cosmetic outcomes after breast-conserving surgery

Richard M. Rainsbury

Introduction

Breast-conserving surgery (BCS) combined with radiotherapy has become the treatment of choice for the majority of women presenting with primary breast cancer over the last 20 years.

A number of prospective randomised trials have compared BCS with mastectomy, showing a survival rate that is unrelated to the type of surgery performed,1–4 although local recurrence (LR) rates smay be higher when the breast is conserved.¹

The risk of LR is related to a number of factors, including positive margins, tumour grade, extent of in situ component, lymphovascular invasion and age. Whole-breast section analysis techniques have been used to show the likelihood of complete excision of unicentric carcinomas using different margins of excision (see Chapters 4 and 15).

Holland et al.⁵ showed that a margin of 2 cm would eradicate all microscopic disease in about 60% of cases compared with a margin of 4 cm, which increases this figure to about 90%.

Local recurrence and cosmetic outcome

The margins of clearance and to a lesser degree the extent of local excision during BCS are strong predictors of subsequent LR.⁶

The extent of local excision remains a controversial issue in BCS. The wider the margin of clearance, the less the risk of incomplete excision and thus potentially of LR (Table 6.1), but the greater the amount of tissue removed, the higher the risk of visible deformity leading to an unacceptable cosmetic result. This clash of interests⁸ is most evident when attempting BCS in patients with smaller breast–tumour ratios, for example when planning BCS for a 10-mm tumour in a 200-g breast or a 5-cm tumour in a 700-g breast.

Table 6.1

	Quadrantectomy	Wide local excision
Margin (cm)	2–4	1–2
Clearance (%)*	< 90	< 58
Recurrence (%)^†	2	7
Cosmesis	Fair	Good

^*Holland et al.⁵

^†Veronesi et al.⁷

The chances of a poor cosmetic outcome are increased still further when the tumour is in a central, medial or inferior location.⁹^,¹⁰ Cosmetic failure is more common than generally appreciated, occurring in up to 50% of patients after BCS.^11–15 A number of factors are responsible, including volume loss of more than 10–20% leading to retraction and asymmetry, nipple–areola displacement or distortion, the use of ugly and inappropriate incisions, and the local effects of radiotherapy. Volume loss underlies many of the most visible and distressing examples of poor cosmetic outcome and the effects may be compounded by associated displacement of the nipple–areola complex (NAC). Poor surgical technique leading to postoperative haematoma, infection or breast tissue and fat necrosis will increase the amount of scarring and retraction, and add to the risks of deformity. Moreover, the use of suction drains, inappropriate incisions and en bloc resections can worsen the cosmetic result still further.

Role of oncoplastic surgery

The interrelationship between breast–tumour ratio, volume loss, cosmetic outcome and margins of clearance is complex, and the widespread popularity of BCS has focused attention on new oncoplastic techniques that can avoid unacceptable cosmetic results. Until now, surgical options have been limited to BCS or mastectomy, the choice depending on fairly well-defined indications and factors. Oncoplastic techniques provide a ‘third option’ that avoids the need for mastectomy in selected patients and can influence the outcome of BCS in three respects:

1. Oncoplastic techniques allow wider excision of breast cancers without risking major local deformity.

2. The use of oncoplastic techniques to prevent deformity can extend the scope of BCS to include patients with 3–5 cm tumours, without compromising the adequacy of resection or the cosmetic outcome.

3. Volume replacement can be used after previous BCS and radiotherapy to correct unacceptable deformity ¹⁶ and may prevent the need for mastectomy in some cases of local recurrence when further local excision would result in considerable volume loss.

Choice of oncoplastic technique

The choice of technique depends on a number of factors, including the extent of resection, position of the tumour, timing of surgery, experience of the surgeon and expectations of the patient. Reconstruction at the same time as resection (breast-sparing reconstruction) is gaining in popularity. As a general rule, it is much easier to prevent than to correct a deformity that has developed as the sequela of previous surgery. Immediate reconstruction at the time of mastectomy is associated with clear surgical,¹⁷ financial¹⁸^,¹⁹ and psychological²⁰ benefits, and similar benefits are seen in patients undergoing immediate breast-sparing reconstruction after partial mastectomy.

Resection defects can be reconstructed in one of two ways: (i) by volume replacement, importing volume from elsewhere to replace the amount of tissue resected; or (ii) by volume displacement, recruiting and transposing local dermoglandular flaps into the resection site. Volume replacement techniques can restore the shape and size of the breast, achieving symmetry and excellent cosmetic results without the need for contralateral surgery. However, these techniques require additional theatre time and may be complicated by donor-site morbidity, flap loss and an extended convalescence. In contrast, volume displacement techniques require less extensive surgery, can limit scars on the breast and limit donor-site problems. These procedures may be complicated by necrosis of the dermoglandular flaps and contralateral surgery is usually required to restore symmetry as volume loss is inevitable (Table 6.2).

Table 6.2

Comparison of techniques for breast-conserving reconstruction

	Volume replacement	Volume displacement
Symmetry	Good	Variable
Scars	Breast + back	Periareolar inverted-T
Problems	Donor scar Seroma flap loss	Parenchymal necrosis Nipple necrosis Volume loss
Theatre time (hours)	2–3	1–2 (per side)
Convalescence (weeks)	4–6	1–2
Timing	Immediate or delayed	Immediate > delayed
Mammographic surveillance	Possibly enhanced	Unaffected

A number of factors need to be considered when making the choice between volume replacement and volume displacement. Volume replacement is particularly suitable for patients who wish to avoid volume loss and contralateral surgery after extensive local resections. They must be prepared to accept a donor-site scar and be made aware of the possibility of complications that may result in prolonged convalescence. Volume replacement is equally well suited to immediate and delayed reconstruction and is the method of choice for correcting severe deformity after previous breast irradiation.

Volume displacement techniques are particularly useful for patients with large ptotic breasts who gain benefit from a ‘therapeutic’ reduction mammaplasty that incorporates wide removal of the tumour. Volume displacement is less reliable in irradiated breasts, and patients need to be warned about the risk of asymmetry that may require simultaneous or subsequent contralateral surgery.

Volume replacement techniques

Several different approaches to volume replacement have been developed over the last 10 years, including myocutaneous, myosubcutaneous, perforator and adipose tissue flaps, lipomodelling and implants. Autologous latissimus dorsi (LD) flaps are the most popular option because of their versatility and reliability.

The myocutaneous LD flap carries a skin paddle that can be used to replace skin which has been resected at the time of BCS or as a result of contracture and scarring following previous resection and radiotherapy ¹⁶ (Fig. 6.1). Although the skin paddle adds to the replacement volume, it can lead to an ugly ‘patch’ effect because of the difference in colour between the donor skin and the skin of the native breast.

Figure 6.1 Latissimus dorsi myocutaneous miniflap.

A myosubcutaneous LD miniflap ²¹ circumvents this problem by harvesting the flap in a plane deep to Scarpa’s fascia. This produces a bulky flap without a skin island and includes a layer of fat on its superficial surface that is used to reconstruct defects following wide excision with preservation of the overlying skin (Fig. 6.2).

Figure 6.2 Latissimus dorsi myosubcutaneous miniflap.

Transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps are used much less frequently, as the greater risk of these procedures renders them a less attractive choice than LD flaps in this particular situation. Moreover, fat necrosis is a more common complication of abdominal flaps, creating the potential for diagnostic confusion on follow-up.

Perforator flaps ²²^,²³ based on thoracodorsal artery perforators (‘TDAP flaps’) and lateral intercostal artery perforators (‘LICAP flaps’) are gaining popularity. They provide skin and subcutaneous fat for volume replacement, are relatively quick to perform, and appear to be associated with a faster recovery and less morbidity than LD flaps. As the LD is relatively undisturbed, the LD muscle can be used for breast reconstruction if a mastectomy is required for a subsequent local recurrence. TDAP flaps are most suitable for lateral and upper pole defects, while LICAP flaps can be used to reconstruct small to medium-sized lateral pole defects. Neither flap can be transposed sufficiently to reconstruct medial pole defects, which are more suitable for reconstruction by an LD miniflap that has been fully mobilised following divison of the tendon, all the serratus anterior branches of the vessels and all remaining fascial attachments to terres major. Other flaps, such as the lateral thoracic adipose tissue flap, have been described²⁴ but their clinical utility is unclear.

Lipomodelling techniques ²⁵ have been used to correct rather than to prevent deformity after BCS.²⁶ Stem cells harvested from fat are injected around the defect, into underlying pectoralis muscle and overlying subcutaneous fat, avoiding the breast parenchyma. This helps to avoid the confusing mammographic images resulting from areas of calcified fat necrosis in the vicinity of the tumour bed. The theoretical risk of tumour induction by injected stem cells remains a concern, and has led to the somewhat cautious introduction of this innovative technique into clinical practice.²⁶ Some surgeons have started to use lipomodelling at the same time as wide local excision but no long-term results of this technique have yet been reported.

Non-autologous volume replacement with saline or silicone implants has been tried with mixed success.²⁷^,²⁸ Implants can be placed directly into the resection defect or under pectoralis major. They cannot be moulded to fit the resection defect and they form localised capsules, particularly in irradiated tissues. This may interfere with clinical examination and also mammographic surveillance, although there are techniques to allow mammaplasty in breasts with implants and magnetic resonance imaging (MRI) follow-up is an option in such patients. If using implants, low height and low projection implants placed low in the treated breast combined with lipomodelling gives the best results. If there is deformity and significant nipple deviation then a myocutaneous flap is preferred. Autologous tissue transfer is usually the best option for most patients and results in a lifelike breast of normal shape and size.

A number of innovative surgical procedures have evolved that facilitate volume replacement at the time of BCS or at a later date:

1. Resection through a radial incision and LD harvest through an axillary incision.²⁹

This was the original description by Noguchi et al. of the use of LD myocutaneous flaps to reconstruct resection defects during BCS in small-breasted Japanese patients. Radial incisions are not the incisions of choice.

2. Conventional LD myocutaneous flap harvest for correction of major resection defects.¹⁶

3. Resection through a circumferential incision and endoscopic LD flap harvest and reconstruction through an axillary incision.³⁰

4. Resection, LD harvest and reconstruction through a single lateral incision.²¹

Indications for volume replacement

Volume replacement should always be considered when adequate local tumour excision leads to an unacceptable degree of local deformity in those patients who wish to avoid mastectomy or contralateral surgery.

Resection of more than 20% of breast volume, particularly from central, medial or inferior locations, significantly increases the likelihood of a significant and unsightly local deformity,³¹ which results in psychological morbidity.³² In these patients, volume replacement can extend the role of BCS and avoid mastectomy when resecting up to 70% of the breast.

Breast conservation with or without reconstruction was formerly reserved for patients with unifocal tumours, but the much wider excision achieved in patients undergoing immediate volume replacement allows resection of multifocal disease with clear margins and excellent local control.³³ Volume replacement may be inappropriate in those with more widespread disease or locally advanced T4 tumours. Likewise, LD volume replacement is hazardous in patients with a history suggesting damage to the thoracodorsal pedicle or to the LD muscle, and alternative methods should be considered (Box 6.1). Patients should be informed that using LD for breast conservation precludes its subsequent use for later breast reconstruction. If a mastectomy is required to treat recurrent disease, the options include a variety of free flaps or subpectoral implant-based reconstruction.

Timing of procedures

Ideally, reconstruction of the partial mastectomy defect should be performed immediately or within a few weeks of the tumour resection in order to prevent deformity rather than to correct deformity months or years later. The emergence of the multiskilled ‘oncoplastic’ breast surgeon will in future help to circumvent the current problems encountered when organising a ‘two-team’ approach involving breast and plastic surgeons. Moreover, immediate reconstruction is associated with fewer technical problems and complications than delayed procedures. Delayed reconstruction may be compromised by previous radiotherapy, leading to reduced tissue viability and an increased risk of fat necrosis, infection and delayed wound healing.

Immediate reconstruction can be carried out as a one-stage procedure,²¹^,³⁴ which involves simultaneous resection and correction of the resulting defect. This requires perioperative confirmation of complete tumour excision using frozen-section techniques. As an alternative, the procedure can be split into two steps.³⁵ The first step involves excising the cancer and performing a sentinel node biopsy if the nodes are clinically and radiologically normal and the second step includes axillary dissection if required, flap harvest and reconstruction, and is carried out a few days later after confirmation of clear tumour resection margins. Patients undergoing a one-stage procedure must be informed that a mastectomy with or without reconstruction may be required if subsequent histopathological analysis confirms incomplete tumour excision.

Volume replacement with latissimus dorsi miniflaps

There are many similarities between the different surgical approaches used in breast-conserving reconstruction and these can be best illustrated by summarising the main steps involved in LD miniflap reconstruction, which has been described in detail elsewhere.³⁶^,³⁷ This procedure involves the use of a myosubcutaneous flap of LD for immediate reconstruction of a partial mastectomy defect, most commonly in the central zone but also in the upper outer and upper inner quadrants of the breast. The term ‘miniflap’ is somewhat misleading, as the flap needs to be of sufficient volume to replace resection defects resulting from the excision of 150–350 g of breast tissue. Moreover, the miniflap needs to be bulky enough to allow for a small degree of postoperative flap atrophy.

When planning immediate volume replacement, the patient needs to be fully informed about the nature of the procedure and the possibility that a subsequent total mastectomy may be required if partial mastectomy results in incomplete excision. Careful preoperative mark-up of the tumour, the margins of resection and the line of incision are essential. The operation allows simultaneous partial mastectomy, axillary dissection, mobilisation of part of LD (the miniflap) and reconstruction of the resection defect through a single lateral incision. The procedure is greatly simplified by high-quality equipment, which is essential when developing the narrow optical spaces behind the breast and on the superficial and deep surfaces of the miniflap.

The operation involves tumour resection, axillary dissection, flap harvest and reconstruction. First, the tumour is resected in a subcutaneous plane by separating the skin envelope overlying the tumour-bearing quadrant from the underlying breast disc by sharp dissection, using the preoperative skin marks to determine the exact extent of dissection. By developing a mirror-image retromammary space deep to pectoralis fascia, the mobilised tumour-bearing quadrant is gripped firmly between fingers and thumb and resected with a generous margin of normal breast tissue. Four biopsies taken from opposite poles of the resection defect are sent for frozen-section analysis to allow intraoperative assessment of completeness of excision. The cavity wall is inked in situ with methylene blue to identify the inner surface, and then can be re-excised in its entirety if considered necessary. Further bed biopsies can also be examined after re-excising the cavity wall if frozen-section examination of the initial biopsies shows incomplete excision. A mastectomy is performed if these further bed biopsies fail to confirm complete excision. Next, appropriate axillary surgery (sentinel node or axillary dissection) is carried out and the vascular pedicle is prepared.

The third step involves mobilisation of the LD miniflap by developing superficial and deep perimuscular spaces that mirror each other. The myosubcutaneous flap carries a layer of fat on its superficial surface to increase its volume and this is achieved by developing the superficial pocket just deep to Scarpa’s fascia. Division of the miniflap around the perimeter of the dissection pocket and division of the tendon of the LD near its insertion ensures unrestricted transposition of the miniflap into the resection defect. Finally, reconstruction of the resection defect is completed by careful use of sutures to model the flap, before fixing it to the cavity walls.

Perioperative outcomes

The time required for breast-conserving immediate reconstruction with a miniflap lies somewhere between BCS alone and total mastectomy combined with immediate LD reconstruction. Early postoperative complications include infection, flap necrosis, haematoma formation and transient brachial plexopathy,³⁴ although postoperative stay and disability are similar to other types of BCS. Breast oedema is common, particularly after extensive resection, but usually settles within 6–8 weeks. It may be caused by division of multiple afferent lymphatic pathways during retromammary dissection. Donor-site seroma formation occurs in almost all patients, and can be reduced by ‘quilting’ or delaying drain removal. Flap necrosis is rare, and can be avoided by gentle resection and handling of the pedicle and by taking care to prevent traction and twisting injuries during transposition and fixation of the flap after tendon division.

Late sequelae of volume replacement include lateral retraction of the flap, leading to distortion and hollowing of the resection site, and flap atrophy. Flap retraction can be avoided by division and fixation of the tendon and careful suture of the flap into the resection defect. Detectable flap atrophy occurs in a minority of patients followed for up to 10 years.³⁸ It can be counteracted by over-replacement of the resected volume with a fully innervated flap that has been harvested with a generous layer of subcutaneous fat, by using a myocutaneous flap or by later lipofilling.¹⁶

Frozen-section analysis of bed biopsies has been found to correlate closely with the adequacy of excision determined by formal histopathology.³³ Moreover, the use of LD miniflap reconstruction leads to a significant fall in the number of incomplete excisions compared with BCS alone²⁴ without compromising the cosmetic outcome. Sensory loss following miniflap reconstruction is minimal compared with the loss following total mastectomy.³⁹ The sensory innervation of the breast and NAC is largely intact, except over the resected quadrant. Finally, volume replacement preserves symmetry, avoiding the need for alterations to the contralateral breast in almost all patients (Fig. 6.3).

Figure 6.3 (a) Latissimus dorsi myocutaneous miniflap. (b) Latissimus dorsi myosubcutaneous miniflap.

Mammographic surveillance

The mammographic appearance of the partially reconstructed breast compares favourably with the appearances after routine BCS. Symmetry is preserved and the fibres of the isodense flap may be detectable, often associated with a variable zone of radiolucency that corresponds to the layer of surface fat. Flaps may be indistinguishable from the surrounding breast tissue, and important radiological characteristics such as skin thickening, stellate lesions and microcalcifications are easily visualised after flap transfer. Volume replacement does not compromise the early detection of LR,⁴⁰ which typically develops at the junctional zone between muscle and breast parenchyma. The appearance of miniflap on mammograms contrasts with the radiodense distorting stellate scars that are a common source of diagnostic confusion following conventional BCS. Lastly, very few patients develop clinically detectable flap atrophy, with the majority of flaps remaining bulky and functional throughout the period of follow-up.

Future prospects

The role of breast-conserving volume replacement is set to increase as more precise, image-guided resection of specific zones of breast tissue becomes possible. Increasingly sophisticated imaging techniques, such as high-frequency ultrasound and contrast-enhanced dynamic magnetic resonance imaging,⁴¹ may in future enable exact delineation and excision of all malignant and premalignant changes. Endoscopically assisted techniques⁴² may increase the ability to harvest more bulky myosubcutaneous flaps, allowing the reconstruction of more extensive resection defects. This will require the further development of novel techniques for endoscopic dissection,³⁰ including the use of balloon-assisted techniques⁴²^,⁴³ and carbon dioxide insufflation to maintain the epimuscular optical cavities. Current progress is hampered by the use of non-flexible straight endoscopes to carry out dissection over the rigid convex surface of the chest wall.

Deformities following breast-conserving surgery

Until recently, little attention has been paid to the cosmetic sequelae of BCS, as most patients are relieved not to lose their breast and many surgeons are unfamiliar with the plastic surgery techniques that can eliminate postoperative deformities. Moreover, there has been a tendency to recommend delayed reconstructive surgery some time after completion of radiotherapy. Although this is possible, partial reconstruction of the breast after surgery and radiotherapy is technically challenging and requires sophisticated techniques, with cosmetic results that are often disappointing.

In order to better assess the surgical approach for these patients, a classification of the cosmetic sequelae after BCS has been published by Clough et al.⁴⁴^,⁴⁵ This simple classification defines three groups of patients based on clinical examination (Fig. 6.4). The advantage of this classification is that it is a valuable guide for choosing the optimal reconstructive technique, but it is also a good predictor of the final cosmetic result after surgery.

Figure 6.4 Deformities after conservative treatment of breast cancer. (a) Type I: a symmetrical breast with no deformity of the treated breast. (b) Type II: deformity of the treated breast, compatible with partial reconstruction and breast conservation. (c) Type III: major deformity of the breast requiring mastectomy. Reproduced from Clough KB, Claude N, Fitoussi A et al. Oncoplastic conservative surgery for breast cancer. In: Operative techniques in plastic and reconstructive surgery. Philadelphia: WB Saunders, 1999; pp. 50–60. With permission from Elsevier.

• Type I deformities: patients have a treated breast with a normal appearance but there is asymmetry between the two breasts.

• Type II deformities: patients have a deformity of the treated breast. This deformity can be corrected by partial breast reconstruction and breast conservation, with the irradiated breast tissue being spared in the reconstruction.

• Type III deformities: patients have a major distortion of the treated breast, or diffuse painful fibrosis. These sequelae are so severe that only a mastectomy can be considered.⁴⁴

For type I deformities, a contralateral mammaplasty is performed to restore symmetry, avoiding any surgery on the irradiated breast. This is a simple and reliable approach, the irradiated breast serving as the model for a contralateral breast lift or breast reduction. Type II sequelae are almost always postoperative and are the most difficult to treat. A wide range of techniques can be used to repair these defects, from recentralisation of the nipple to the insetting of a flap to reconstruct a missing quadrant. Type III sequelae require treatment by mastectomy and immediate reconstruction with a myocutaneous flap.

Poor remodelling is one of the reasons for an ugly deformity after lumpectomy or quadrantectomy.⁴⁶^,⁴⁷ Some surgeons perform no remodelling at all, leaving an empty defect and relying on a postoperative haematoma to fill the dead space. This may produce acceptable results in the short term but breast retraction of larger defects invariably occurs with longer follow-up, leading to major deformities that are increased by postoperative radiotherapy.¹⁰^,⁴⁴^,⁴⁸^,⁴⁹

Reshaping of the breast is required after any tumour excision in order to recreate a normal breast shape in one operative procedure. In most cases this can be achieved with a simple unilateral approach, mobilising glandular flaps to close the defect or by recentralising the NAC. In other cases, a bilateral approach incorporating a bilateral mammaplasty will be the only way to perform a wide excision with no deformity.⁵⁰ This graded approach to breast reshaping is discussed below.

Conclusion

Breast-conserving partial breast reconstruction extends the role of BCS by enabling complete excision of a greater range of tumours without compromising cosmesis, postoperative surveillance or symmetry. Volume replacement and displacement techniques are likely to become increasingly popular as an alternative to mastectomy in patients with small breast–tumour ratios and localised disease who wish to avoid more major surgery and the use of implants. Further experience of these techniques will lead to a better understanding of their role in the surgical management of primary breast cancer and in the management of local relapse and cosmetic deformity after previous breast-conserving procedures.

Key points

• Local recurrence following BCS is related to margin involvement that is less when wider excisions are performed.

• Deformity following wide local excision even for large cancers can be avoided by breast-sparing reconstruction using volume replacement or volume displacement.

• Volume replacement is most suitable for patients with small or medium-sized breasts who wish to avoid contralateral surgery. It can also be used for the correction of deformity following previous BCS.

• Breast-conserving reconstruction may be carried out as a one-stage or two-stage procedure.

• The type of breast-sparing reconstruction selected will be determined by the site and extent of resection, and by the patient’s size, morphology and personal preference.

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37. Rainsbury, R.M. The mini latissimus dorsi flap. In: Querci della Rovere G., Benson J.R., Nava M., eds. Oncoplastic and reconstructive surgery of the breast. New York: Informa Healthcare; 2011:96–104.

38. Laws, S.A.M., Cheetham, J.E., Rainsbury, R.M. Temporal changes in breast volume after surgery for breast cancer and the implications for volume replacement with the latissimus dorsi miniflap. Eur J Surg Oncol. 2001; 27:790.

39. Gendy, R.K., Able, J.A., Rainsbury, R.M., Impact of skinsparing mastectomy with immediate reconstruction and breast-sparing reconstruction with miniflaps on the outcomes of oncoplastic breast surgery. Br J Surg 2003; 90:433–439. 12673744

40. Monticciolo, D.L., Ross, D., Bostwick, J., et al, Autogenous breast reconstruction with endoscopic latissimus dorsi with musculo-subcutaneous flaps in patients choosing breast-conserving therapy: mammographic appearance. Am J Radiol 1996; 167:385–389. 8686611

41. Gilles, R., Guinebretiere, J.-M. Magnetic resonance imaging. In: Silverstein M.J., ed. Ductal carcinoma in situ of the breast. Baltimore: Williams & Wilkins; 1997:159–166.

42. Bass, L.S., Karp, N.S., Benacquista, T., et al, Endoscopic harvest of the rectus abdominus free flap: balloon dissection in the fascial plain. Ann Plast Surg 1995; 34:274–279. 7598384

43. Van Buskark, E.R., Krehnke, R.D., Montgomery, R.L., et al, Endoscopic harvest of the latissimus dorsi muscle using balloon dissection technique. Plast Reconstr Surg 1997; 99:899–903. 9047218

44. Clough, K.B., Cuminet, J., Fitoussi, A., et al, Cosmetic sequelae after conservative treatment for breast cancer: classification and results of surgical correction. Ann Plast Surg 1998; 41:471–481. 9827948 The original classification of types of deformity following partial mastectomy and the use of therapeutic mammaplasty to avoid rather than correct deformity.

45. Clough, K.B., Thomas, S.S., Fitoussi, A.D., et al, Reconstruction after conservative treatment for breast cancer: cosmetic sequelae classification revisited. Plast Reconstr Surg. 2004;114(7):1743–1753. 15577344

46. Petit, J.-Y., Rigault, L., Zekri, A., et al, Poor esthetic results after conservative treatment of breast cancer. Techniques of partial breast reconstruction. Ann Chir Plast Esthet 1989; 34:103–108. 2472100

47. Rose, M.A., Olivotto, I.A., Cady, B., et al, Conservative surgery and radiation therapy for early breast cancer. Long-term cosmetic results. Arch Surg 1989; 124:153–157. 2916935

48. Berrino, P., Campora, E., Leone, S., et al, Correction of type II breast deformities following conservative cancer surgery. Plast Reconstr Surg 1992; 90:846–853. 1410038

49. Petit, J.-Y., Rietjens, M. Deformities following tumourectomy and partial mastectomy. In: Noone B., ed. Plastic and reconstruction surgery of the breast. Philadelphia: BC Decker, 1991.

50. Clough, K.B., Kroll, S., Audretsch, W., An approach to the repair of partial mastectomy defects. Plast Reconstr Surg 1999; 104:409–420. 10654684 Pooled experience of breast-conserving reconstruction from France, USA and Germany using volume replacement and volume displacement techniques.

Part 2

Breast displacement techniques to increase resection volumes for breast-conserving surgery

Krishna B. Clough, Gabriel J. Kaufman, Claude. Nos and J. Michael Dixon

Introduction

Breast-conserving surgery (BCS) combined with postoperative radiotherapy has become the preferred locoregional treatment for the majority of patients with early-stage breast cancer, with equivalent survival to that of mastectomy and improved body image and lifestyle. The success of BCS for breast cancer is based on the tenet of complete removal of the cancer with adequate surgical margins while preserving the natural shape and appearance of the breast. Achieving both goals together in the same operation can be challenging, and BCS does not produce good cosmetic results in all patients. The limiting factor is the amount of tissue removed, not only in absolute volume, but also in relation to tumour location and relative size of breast. If either of these two goals is not achievable, mastectomy is often chosen as an alternative to BCS. The failure of classical BCS techniques to offer solutions for challenging scenarios has stimulated the growth and advancement of new techniques in breast surgery during the past decade. The dichotomy between extent of excision and cosmetic outcome has made it evident that new surgical techniques need to be developed to address the problems and shortfalls of BCS, and accommodate the expanding indications for BCS.

Oncoplastic surgery (OPS) has emerged as a new approach to allow wide excisions for BCS without compromising the natural shape of the breast. It is based upon integrating plastic surgery techniques with immediate reshaping of the breast together with oncological surgery to excise the breast cancer. The conceptual idea of OPS is not new and its oncological efficacy in terms of margin status and recurrence compares favourably to traditional BCS.¹^,²

The difference in the level of difficulty in performing various oncoplastic procedures has created a dichotomy in oncoplastic surgery. Oncoplastic techniques range from simple reshaping and mobilisation of breast tissue to more advanced mammaplasty techniques that allow resection of up to 50% of the breast volume. Variations in difficulty and the need for advanced training for some OPS techniques require a clear classification system of oncoplastic techniques, which provides a systematic approach that all breast surgeons can follow when undertaking BCS.

Oncoplastic considerations

Selection criteria for oncoplasty

There are three elements that are important in the identification of patients who would benefit from an oncoplastic approach. The two factors already recognised as major indications for OPS are excision volume and tumour location.³ The third additional element is glandular density, a recently recognised factor in the determination of the safety of major breast reshaping. When considered together, these three major elements provide a sound basis for determining when and what type of OPS to perform and, more importantly, in reducing the guesswork when performing BCS.

Volume

The first element is excision volume, which is the single most predictive factor for cosmetic surgical outcome and potential for breast deformity. Studies have suggested that once 10–20% of the breast volume is excised there is a clear risk of deformity ⁴ (see Chapter 4).

Excision volume compared to the total breast volume is estimated preoperatively. Through systematic correlation of specimen weights compared with tumour size, an accurate preoperative estimation of excision volume can be achieved, once the tumour size is known from preoperative imaging. The average specimen from BCS should weigh between 20 and 40 g, and as a general rule 80 g of breast tissue is the maximum weight that can be removed from a medium-sized breast without resulting in deformity (see Chapter 4).

OPS techniques allow for significantly greater excision volumes while preserving the natural breast shape. Reshaping of the breast is based upon rearrangement of the breast parenchyma to create a homogeneous redistribution of volume loss. This redistribution can be achieved easily though either the advancement or rotation of breast tissue into excision defects. Another option is to harvest a latissimus dorsi ‘miniflap’ to fill in the lumpectomy cavity (see Part 1 of this chapter).³

Tumour location

High-risk zones in the breast are more likely to be followed by deformity after BCS when compared to more forgiving locations.

The upper outer quadrant of the breast is a favourable location for large-volume excisions. In this location, defects can readily be corrected by the mobilisation of adjacent tissue. Excision from less favourable locations such as the lower pole or upper inner quadrants of the breast often results in breast deformity.

One example is the ‘bird’s beak’ deformity that is classically seen during excision of tumours from the lower pole of the breast (Fig. 6.5a). Other examples of difficult areas include excision of a central tumour (Fig. 6.5b) and removal of cancers from the upper inner quadrant (Fig. 6.5c). Therefore, it is important when planning the appropriate surgical approach to determine the tumour location and the likely level of associated deformity. An oncoplastic atlas of surgical techniques based on tumour location has been developed. The atlas provides a specific surgical technique for each possible tumour location in the breast.

Figure 6.5 Deformities after breast-conserving surgery. (a) Lower pole: bird’s beak deformity. (b) Central tumour. (c) Upper inner quadrant.

Glandular characteristics and breast density

Glandular density is evaluated both clinically and radiographically. Although clinical examination provides reliable information on density, mammographic evaluation is a more reproducible approach for breast density determination. Breast density predicts the amount of fat in the breast and determines the ability to perform extensive breast undermining and reshaping without complications. Breast density can be classified into four categories based on the Breast Imaging Reporting and Data System (BI-RADS). The four categories comprise: (1) fatty; (2) scattered fibroglandular; (3) heterogeneously dense; or (4) extremely dense breast tissue.⁵

A dense glandular breast (BI-RADS 3/4) can be mobilised easily with undermining and advancement of breast tissue into the excision cavity without risk of necrosis. Low-density breast tissue with a major fatty component (BI-RADS 1/2) has a much higher risk of fat necrosis if extensive undermining is performed. Undermining the breast from both the skin and pectoralis fascia is a major requirement to perform level I OPS. A low breast density means that either the amount of undermining from the breast and skin during level I OPS should be limited, or a decision made to proceed with a level II option that requires limited skin undermining. Level II procedures that require extensive skin undermining such as the round-block technique are likewise not suitable for the patient with a predominantly fatty breast.

Classification system

Complexity of surgical procedure: a bi-level system

A new classification of OPS techniques has been proposed based upon the relative level of surgical difficulty. Level I techniques should be able to be performed by all breast surgeons without specific training in OPS. A level I approach includes skin and glandular undermining, including the nipple–areola complex (NAC), and NAC recentralisation if nipple deviation is anticipated. Level II techniques encompass more complex procedures that involve skin excision and glandular mobilisation to allow major volume resection. Level II techniques are derived from breast reduction techniques and require additional training.

The bi-level classification system lends itself to the creation of a practical guide to OPS and provides the necessary framework during surgical planning to correctly select the most appropriate surgical procedure for the patient (Table 6.3).

Table 6.3

Oncoplastic decision guide

Criteria	Level I	Level II
Maximum excision volume ratio	20%	20–50%
Requirement of skin excision for reshaping	No	Yes
Specific training in reduction and mam- maplasty techniques	No	Yes
Glandular characteristics	Dense	Dense or fatty

If less than 20% of the breast volume is excised then a level II approach is not usually required and a level I procedure is usually adequate. Anticipation that 20–50% of breast volume is to be excised or the cancer is in a specific location will require a level II procedure to produce a satisfactory cosmetic outcome. Large-volume excisions require concurrent skin excision to adequately reshape the skin envelope. If the breast parenchyma is fatty in composition, it may be risky to employ a level I technique if excising more than 10% of the breast volume. A superior outcome is likely to be obtained in such patients by selecting an appropriate level II procedure.

General considerations for all OPS techniques

The approach to OPS includes careful patient selection and starts with patient counselling. It is important to stress to the patient that although oncoplastic procedures can provide greater satisfaction with a better final breast shape and in some situations will avoid the need for mastectomy, outcomes do vary. During the consultation period patients need to be informed that OPS may result in longer and multiple scars. The position of each incision should be described in detail. The patient should also be made aware of the possible asymmetry that will follow from a level II OPS. Asymmetry in volume is expected, but necessary to limit breast distortion and deformity. The patient must be informed that, in such circumstances, to achieve symmetry an immediate reduction of the contralateral side can be performed either at the same time or later as a second-stage procedure.

All oncoplastic procedures begin with preoperative marking of the patient sitting upright or standing prior to the induction of anaesthesia. Once marked, the patient is carefully centred on the operating room table and secured so that she can be moved from the supine to the upright position during the operation. The arms can be extended if any axillary surgery is planned, or secured by the side if no axillary surgery is required. Movement between these positions allows optimisation of contralateral breast symmetry and allows for optimal reshaping.

Level I oncoplastic techniques

The step-by-step approach for level I OPS

The driving force behind level I OPS is the ability of all surgeons to adopt the following steps into their surgical practice. There are six general steps for level I OPS that begin with the skin incision (1) followed by undermining of the skin (2) and NAC (3). After completion of undermining, a full-thickness glandular excision incorporating the cancer and a surrounding rim of normal breast tissue is performed from subcutaneous fat down to pectoralis fascia (4). The glandular defect is subsequently closed, following specimen X-ray to demonstrate complete radiological excision, with tissue re-approximation (5). If required, an area in the shape of a crescent bordering the areola is de-epithelialised to reposition the NAC (6). If this is not performed the NAC displaces towards the site of excision and is no longer positioned in the centre of the breast mound.

Incisions

The concepts of oncoplastic surgery are not based on minimising incision length. Short incision lengths limit mobilisation of the gland and do not allow creation of adequate glandular flaps to fill excision defects.

Effective mobilisation of the gland is a key component in achieving a natural breast shape.

In our experience, OPS is not minimally invasive surgery. The location of the incision is at the discretion of the operating surgeon. In general, incisions should allow for both en bloc excision of the cancer, without causing fragmentation of the specimen, and also allow undermining of the surrounding breast tissue to facilitate reshaping. The general principle for placing incisions is to follow Kraissl’s lines of maximum resting skin tension to limit visible scarring ⁶ (see Chapter 4). However, in many cases an incision away from the cancer is possible, such as along the areola border with radial extension towards the tumour in the axilla for upper outer quadrant lesions, or in the inframammary fold for cancers in the lower half of the breast.

Skin undermining

Extensive subcutaneous undermining ranging from one-half to two-thirds of the breast envelope may be required to facilitate glandular redistribution after removal of the tumour (Fig. 6.6a). Aggressive undermining can free an entire quadrant from the overlying skin envelope. In terms of technique, it is easier to undermine a large area of skin before excising the lesion. Skin undermining should be performed in the plane between the breast tissue and subcutaneous fat and definition of this plan is enhanced by the use of hydrodissection using saline containing 1 in 500,000 to 1 in a million adrenaline (see Chapter 5).

Figure 6.6 Level I oncoplastic techniques: skin and NAC undermining. (a) Extensive skin undermining. (b) Wide excision from subcutaneous fat to muscle, then NAC undermining. (c) Glandular flap re-approximation.

Risk factors for vascular compromise should be evaluated prior to performing extensive undermining. Smoking, diabetes mellitus and connective tissue disease are recognised as risk factors to be taken into consideration prior to planning the surgery to be performed.

Although smoking does not prevent the completion of a safe level I oncoplasty, it decreases the total area of skin that can be undermined safely. Patients who smoke should be warned of the greater risk of complications and advised to reduce or stop smoking for as long as possible before and immediately after surgery (see Chapter 5).

The area of undermining should be inversely proportional to the number of risk factors present, but the final factor in determining the amount of undermining that is safe is the fat composition of the breast. Division of the chest wall perforating blood vessels in a fatty breast is much more of a problem, and to maintain tissue vascularity and reduce the risk of postoperative necrosis, a level II procedure, which involves direct glandular excision and less skin undermining, should be considered if extensive undermining is considered necessary to close the defect.

Avoiding NAC displacement is a key element for both level I and II OPS. The NAC is repositioned to adjust for both the anticipated deviation of the nipple and the new shape of the breast. A crescentic area of periareolar skin opposite the excision defect is de-epithelialised (Fig. 6.7a–c). De-epithelialisation can be achieved using a scalpel blade or fine scissors. This technique is simple and safe and used systematically in aesthetic surgery of the breast. The vascular supply of the NAC after its separation from the gland and de-epithelialisation is based on the vasculature from the dermal plexus and this is not compromised by careful de-epithelialisation.⁸

Figure 6.7 Level I oncoplastic techniques: NAC recentralisation. (a) De-epithelialisation opposite the tumour bed. (b) NAC recentralisation. (c) Intraoperative result (upper outer quadrant resection).

Level II oncoplastic surgery

Introduction

The major consideration when choosing the oncoplastic technique to be used is the extent of excision volume. A level I approach is suitable for excision volumes less than 20% of the entire gland. The resulting glandular defect can usually be filled by advancement of adjacent tissue. Immediate lipofilling in addition to tissue advancement adds extra flexibility to the level I approach. Level II techniques are generally reserved for situations that require major volume excisions of between 20% and 50%.

To simplify the selection of a level II OPS technique, an atlas has been devised based on tumour location. This atlas does not contain an exhaustive list of options, but provides one or two options for each tumour location.

Atlas principles

The concept of the oncoplastic atlas is based primarily on tumour location. Initially used only for lower pole tumours, OPS has evolved to allow resection of breast lesions located almost anywhere in the breast. Different mammaplasty techniques have been adapted for specific locations in the breast.⁹

The superior pedicle reduction mammaplasty is a model for the description of all mammaplasty techniques. Schematically rotating the NAC on a pedicle based directly opposite the site of tumour excision allows the application of this technique for a variety of tumour locations. These procedures are listed in an anticlockwise direction and described for the left breast.

Level II OPS will generally result in a smaller breast that is rounder and higher on the chest wall than the contralateral breast, thus there is a need for a contralateral symmetrisation and the necessity to discuss this with the patient prior to the excision. Either immediate or delayed symmetrisation can be performed, depending on the amount of tissue resected and the desire of the patient. In a recent series of 175 women having an oncoplastic breast-conserving procedure, a contralateral breast reduction was performed in 25% of patients (19% during the initial operation and 6% as a secondary procedure). A higher rate of contralateral surgery was performed in patients who had an inverted-T mammaplasty (50% vs. 14% with other techniques; P < 0.001).¹⁰

Lower pole location (4–7 o’clock)

General principles

The lower pole of the breast was the first location recognised to be at high risk of deformity following BCS.¹ Removal of tissue from the 6 o’clock position results in retraction of the skin and downward deviation of the NAC, producing what is known as the ‘bird’s beak’ deformity, which results in a low level of patient satisfaction. A superior pedicle mammaplasty can permit large-volume excision of the lower pole without causing NAC deviation and has the added benefit of breast reshaping and elevation.

Techniques

‘Standard’ superior pedicle mammaplasty with inverted-T scar (Fig. 6.8a–e): The superior pedicle mammaplasty technique that is in routine use involves using the inverted-T and periareolar scars as utilised in most breast reductions.¹¹ The procedure begins with the de-epithelialisation of the area surrounding the NAC. Once completed, the NAC is dissected away from the underlying breast tissue. A superior pedicle of dermoglandular tissue is preserved to provide the NAC with a blood supply.

Figure 6.8 Level II oncoplastic techniques for lower pole breast cancers: superior pedicle mammaplasty. (a) Treatment planning: superior pedicle mammaplasty and contralateral symmetrisation. (b) Superior pedicle de-epithelialised. Submammary fold incision. (c) Superior pedicle elevated. Wide excision of tumour and surrounding tissues. (d) Breast reshaping. (e) Result.

The inframammary incision is then completed, followed by wide undermining of the breast tissue from the pectoral fascia, which can be preserved. The undermining starts inferiorly and proceeds superiorly beneath the tumour while encompassing the medial and lateral aspects of the breast as well as the NAC. The tumour is removed en bloc with a wide margin of normal breast tissue and overlying skin as determined by the preoperative marking.

As for all BCS, the goal of the excision is to obtain at least a 1-cm macroscopic margin of normal tissue in order to ensure free microscopic margins. Mobilisation of the breast tissue from the pectoralis fascia allows for palpation of both the deep and superficial surfaces of the tumour, which improves the ability of the surgeon to obtain clear margins. The breast tissue is remodelled after the resection is completed. Remodelling incorporates the re-approximation of the medial and lateral glandular columns towards the midline to fill in the defect, followed by NAC recentralisation. All tissues excised should be weighed, as this provides a guide to the amount of tissue to be excised in any contralateral reduction procedure. As a general rule the resection of the cancer-bearing breast should be 10–20% less than excised from the opposite breast to allow for shrinkage of the treated breast following whole-breast radiotherapy. Results from excision of ductal carcinoma in situ at the lower pole of the left breast are shown in Fig. 6.9a and b. The result 2 years after operation is shown in Fig. 6.9c.

Figure 6.9 Level II technique for a 6-cm ductal carcinoma in situ of the lower pole of the left breast. Wide excision and postoperative radiotherapy. (a,b) Preoperative. (c) Two years postoperation.

Vertical mammaplasty (Lejour/Lassus): One modification to the technique to excise lower quadrant tumours is to use the vertical-scar mammaplasty described by Lejour ¹² and Lassus.¹³ The site and volume of excision are identical to the inverted-T scar, but this approach avoids the submammary scar. In general, T-shaped reductions work best in the largest breasts and vertical scar reductions in smaller breasts.

Lower inner quadrant (7–9 o’clock)

General principles

Standard superior pedicle mammaplasty described for tumours located at the 6 o’clock position can be extended to 7 o’clock. However, adaptation for tumours located more medially, between 7 and 8 o’clock, is more difficult and requires a novel level II technique.

Technique

V mammaplasty: This procedure involves excising a pyramidal section of skin and underlying breast tissue with the base located in the submammary fold and the apex at the border of the areola. This skin and underlying breast tissue are removed en bloc down to the pectoral fascia. An incision is then made along the inframammary fold and developed starting at the medial aspect of the base of resection moving towards the anterior axillary line and taken as far as necessary to perform adequate mobilisation of the breast tissue laterally. The lower pole of the breast is then mobilised off the pectoralis fascia medially and laterally for use as an advancement flap to fill the defect. Volume replacement is thus achieved through the advancement of the gland from the remaining lower medial and lateral aspects of the breast. The NAC is then recentralised on a de-epithelialised superior lateral pedicle.¹⁴

Upper inner quadrant (10–11 o’clock)

General principles

Special caution is needed when considering BCS for lesions in the upper inner aspect of the breast. A wide excision in this location can have a significant impact on the overall quality of the breast shape by distorting the visible breast line known as the ‘décolleté’. This represents the visible area of the breast.

For moderate resections, level I techniques can be utilised safely and combined with immediate lipofilling to achieve a very smooth final contour. For more extensive excisions, the ability and likelihood of being able to preserve the natural breast shape should be discussed with the patient. Standard level II oncoplastic procedures that reliably address the specific limitations of BCS at this troublesome location are limited. Silverstein and colleagues have described an effective OPS procedure to address the upper inner quadrant. Their approach utilises a batwing excision pattern.¹⁵ Silverstein et al.’s OPS solution is innovative but excises tissue in excess of that which is required, leaves a large scar and, as described, removes pectoral fascia as well as skin. Immediate lipofilling may offer the best solution at present to this difficult area, combined with mobilisation and closure of the defect.

Upper pole (11–1 o’clock)

General principles

Lesions located at the 12 o’clock position can be excised widely followed by volume redistribution of tissue from a central location. Access to lesions in this location of the breast is accomplished either using an inferior pedicle or round-block mammaplasty approach. The inferior pedicle mammaplasty is commonly performed in the USA as a breast reduction technique and utilises an inverted-T scar pattern.¹⁶ A round-block approach, on the other hand, is more technically challenging when trying to achieve the desired breast shape. These two techniques are used extensively for breast reduction, with low complication rates and durable results. They can be applied for wide excision of upper pole tumours while preserving a patient’s natural breast shape. There are dangers with this technique when trying to preserve breast tissue superior to the nipple to advance into the defect. So-called ‘bottoming out’ is a problem with inferior mammaplasty techniques.

Techniques

Inferior pedicle mammaplasty: The skin markings are identical to those described for the superior pedicle reduction. The resection, however, is located in the upper pole, hence the vascular supply of the NAC is based on its inferior and posterior glandular attachments. The excision of the cancer is performed through an incision placed within the skin to be removed. Once the cancer has been excised and the specimen X-ray shows complete radiological excision, the inferior pedicle is de-epithelialised and advanced upwards towards the excision defect to achieve volume redistribution. Resection of the breast tissue is performed in the inner and outer lower quadrants to optimise the breast shape.

Round-block mammaplasty: The round-block mammaplasty utilises a periareolar incision and was originally described by Benelli.¹⁷^,¹⁸ The procedure starts by making two concentric periareolar incisions, followed by de-epithelialisation of the intervening skin. The outer edge of de-epithelialised skin is incised and the entire skin envelope can then be undermined to allow access to the tumour. The NAC remains vascularised through its posterior glandular base. Resection of the lesion from the subcutaneous tissue down to the pectoralis fascia is performed and this results in the formation of an external and internal glandular flap. The flaps are then mobilised off the pectoralis fascia and advanced towards each other to eliminate the excision defect. The two incisions are then approximated, resulting in a periareolar scar.

Although the round-block mammaplasty has been used mainly for upper pole tumours, it is a versatile technique that can be easily adapted for tumours in any location of the breast. The round-block technique is not a method of breast reduction favoured by most breast surgeons because it has limitations. In general, there are alternative options to the round-block technique so, although some surgeons use it widely, others use it rarely, if ever. Given its lack of universal favour, this suggests the technique has its limitations.

Upper outer quadrant (1–3 o’clock; Fig. 6.10a–c)

General principles

In the upper outer quadrant, large lesions can usually be excised with standard BCS without causing deformity. However, resection of greater than 20% of the breast volume will result in retraction of the overlying skin with NAC displacement towards the excision site. A result of a patient with a T3 cancer treated by neoadjuvant chemotherapy and wide excision with mammaplasty is shown in Fig. 6.11a–d. Level II OPS can be utilised to increase resection possibilities while limiting deformity risk in this forgiving region of the breast.

Figure 6.10 Level II oncoplastic techniques for upper outer quadrant breast cancers. (a) Treatment planning: wide resection and NAC de-epithelialisation. (b) Resection. (c) Breast reshaping and contralateral symmetrisation.

Figure 6.11 Level II technique for a T3N0 cancer of the upper outer quadrant of the right breast. Preoperative chemotherapy: partial response. Wide excision and mammaplasty. (a,b) Preoperative. (c) Resection weight 215 g. (d) Result prior to contralateral symmetrisation.

Techniques

Fusiform mammaplasty: A large portion of the upper outer quadrant can be excised utilising a fusiform skin excision pattern oriented in a radial direction from the NAC towards the axilla, similar to a quadrantectomy.¹⁹^,²⁰ After wide excision, the reshaping is performed by mobilising the lateral and central gland into the cavity and suturing it together. Central gland advancement is accomplished easily following NAC undermining. Complete detachment of the retroareolar gland from the NAC enables the central part of the gland to be available for volume redistribution without compromise of NAC vascularity. Once the defect is eliminated, the NAC is placed in its optimal position, at the centre of the new breast mound. The area of glandular excision directly follows the skin excision. Additional glandular excision can be accomplished to remove almost the entire quadrant, depending on tumour size and the amount of tissue required to be removed to obtain clear margins.

Superior pedicled therapeutic mammaplasty: Given the increasing use of superomedial pedicles in breast reduction surgery, tissue that is normally removed from the lower breast can be kept alive on a superomedial pedicle and rotated into the upper outer quadrant. To be successful, care is needed to maintain a wide base to the pedicle and thus maintain a good blood supply to the whole of the tissue to be rotated.

Lower outer quadrant (4–5 o’clock)

General principles

A large-volume resection of the lower outer quadrant leaves a deformity similar to a bird’s beak. As for lower inner pole lesions, the inverted-T mammaplasty does not always ‘fit’ well for excisions within this quadrant. One option is a J-type mammaplasty described by Gasperoni et al.²¹

Techniques

J mammaplasty (Gasperoni): The first incision begins at the medial edge of the de-epithelialised periareolar area and then gently curves upwards with a concavity to the inframammary crease. The second incision starts at the lateral border of the de-epithelialised zone and follows a similar pattern. The parenchymal excision then follows the skin pattern in the shape of the letter J. The NAC remains vascularised on a de-epithelialised superior pedicle and is detached from the retroareolar gland. Lateral and central breast tissue can then be recruited into the excision defect to achieve an equitable redistribution of remaining breast volume.

Secondary pedicles: An alternative is to excise the cancer, leaving the skin intact through the incision selected for reducing the breast – be that a T-shaped or vertical scar. The skin that would normally be removed, is de-epithelialised and using primary pedicles attached to the nipple–areola complex or secondary pedicles attached to the inframammary fold, the defect is closed.

Retroareolar location

General principles

Subareolar breast cancers are candidates for BCS. However, superficial subareolar tumours are associated with a risk of NAC involvement approaching 50%.²² Such cases require en bloc removal of the NAC with the tumour. This results in a ‘flattened breast’ or ‘shark-bite’ deformity and poor cosmetic outcome unless techniques are used to avoid this. If the patient has a glandular breast that allows wide undermining for reshaping, a level I OPS is a reasonable option.

Level II mammaplasty techniques are reserved for patients with ptosis or fatty breasts or for patients for whom excision of more than 20% of the breast volume is required. There are a number of mammaplasty approaches that can be chosen for the centrally located lesion. They include the inverted-T mammaplasty with resection of the NAC, a modified Lejour or J pattern with NAC excision or a Grisotti flap (see Chapter 4). The latter offers the advantage of allowing for immediate NAC reconstruction through preservation of a skin island on an advancement flap.²³

Technique

Modified inverted-T mammaplasty: Oncoplastic techniques for centrally located tumours have recently been outlined by Huemer et al.²⁴ An inverted-T incision is preferred, similar to that used in a superior pedicle mammaplasty. The only modification is that the two vertical incisions encompass the NAC, which is removed together with the tumour. The breast shape is reconstructed as already demonstrated for the superior pedicle approach. The NAC is usually reconstructed at a later stage, after completion of radiotherapy, although it can be reconstructed during the same procedure. A modification of this technique is to leave a circular island of skin or an inferior dermoglandular flap, which is relocated in the position of the new NAC and produces symmetry with the opposite NAC (see Chapter 4).

Discussion

General

Until recently, the breast surgeon has been able to provide only two options for patients with breast cancer: either a modified radical mastectomy or a wide local excision followed by radiation. BCS indications have expanded, but only moderate surgical advancements have been made since its introduction.

The integration of plastic surgery techniques at the time of tumour excision has delivered new alternatives, enabling surgeons to perform major resections involving more than 20% of breast volume without causing breast deformity. This new combination of oncological and reconstructive surgery is commonly referred to as oncoplastic surgery. This has allowed surgeons to extend the indications for BCS without compromising oncological goals or aesthetic outcomes. It is a logical extension of the quadrantectomy technique described by Veronesi et al.¹⁹ The innovation of the quadrantectomy provided women with a safe oncological option for conserving their breasts.

The recurrence rates of quadrantectomy compared favourably with those of lumpectomy, but cosmetic outcomes were unpredictable and were worse than a wide excision alone, so are no longer advocated.25–27

With immediate reshaping employing OPS, resections of larger cancers can now be achieved with satisfactory cosmetic outcomes.

A major advantage of OPS is avoiding the need for secondary reconstruction by preventing major breast deformities.²⁸ Prior to the development of OPS, patients with major deformities were referred subsequently to plastic surgeons.²⁹ A classification system of these deformities has been described and reconstructive techniques for breast deformity after BCS have been developed³⁰^,³¹ (see Part 1 of this chapter). Despite continued efforts to treat these deformities, the results of postoperative repair of BCS defects in irradiated tissue are poor, regardless of the surgical procedure or team.³²^,³³ Immediate reshaping of the breast will eliminate some of the need for these complex procedures.

Advances in OPS have been restricted by the diversity of techniques used, the lack of uniformity in classifying oncoplastic techniques and the limited guidelines of the optimum OPS procedures in the surgical literature. This has generated confusion and difficulty in patient and technique selection. The foundation of OPS starts with simple techniques that are easily incorporated into everyday practice (level I techniques), followed by acquiring the experience to perform the various mammaplasty techniques utilised for more extensive resections (level II techniques).

Indications for oncoplastic surgery

The main indication for OPS is the need to excise large lesions or a significant percentage of the breast, so permitting BCS for large lesions for which a standard excision with safe margins would be either impossible or lead to major deformity. Extensive ductal carcinoma in situ, invasive lobular carcinoma, multifocality, and partial or poor responses to neoadjuvant therapy are areas where there may be benefits for OPS intervention. Standard BCS with positive margins where re-excision is being considered is an additional category of patients for whom OPS is appropriate.³⁴

Oncoplastic and oncological safety

Large randomised prospective clinical trials have not validated the efficacy and safety of oncoplastic techniques, but there is growing evidence, through prospective series, that the techniques offer patients safe and effective surgical treatment. Our prospective analysis of over 100 patients undergoing OPS at our institution demonstrated 5-year overall and disease-free survival rates of 95.7% and 82.8%, respectively.¹¹ Delay in adjuvant treatment was related to slow wound healing in only four patients, but all patients were able to receive appropriate postoperative radiotherapy and chemotherapy during the study. The cosmetic results at a median of 49 months in our most recent series of 175 pateints were favourable in 85% of patients.¹⁰ Final cosmetic outcomes and complication rates are not altered in patients undergoing neoadjuvant chemotherapy. A more recent retrospective review of 298 patients treated with OPS demonstrated a 5-year recurrence-free rate of 93.7% and 94.6% overall survival. This larger review confirms the equivalent outcomes of OPS and standard BCS.³⁵ Rietjens et al. have reported long-term results from the European Institute of Oncology indicating no local relapse in the pT1 cohort. The pT2 and pT3 combined group had a 5-year local recurrence rate of 8% and a mortality rate of 15%. The overall local recurrence rate was determined to be 3%.³⁶