ONCOPLASTIC BREAST SURGERY

INTRODUCTION

Oncoplastic surgery of the breast is an innovative approach to the treatment of breast cancer.

The word ‘oncoplastic’ is derived from the Greek words ‘onco’ (tumour) and ‘plastic’ (to mould). The concept encompasses plastic surgical techniques in order to reshape the remaining breast or reconstruct the breast after appropriate excision of breast cancer. It also includes the correction of imbalance relative to the natural unaffected breast. It is a welcome concept to women with breast cancer who not only have to deal with the diagnosis and life changing implications of breast cancer, but also the effect of possible disfiguring surgery to their breast. Surgery still remains the mainstay of treatment for breast cancer today with the addition of adjuvant treatments such as chemotherapy, radiotherapy and hormonal therapy.

The principles of oncoplastic surgery of the breast are based on minimal scarring and producing optimal breast shape and size. It includes careful preoperative planning as part of a multidisciplinary approach and a surgical plan that will result in optimal cancer management and the best possible aesthetic outcome. Neoadjuvant chemotherapy or endocrine therapy may, in appropriate cases, be used to shrink the tumour before surgery.

ONCOPLASTIC TECHNIQUES FOR BREAST CONSERVING SURGERY

Breast conserving surgery has become increasingly used for the treatment of breast cancer. Although it may be preferable to mastectomy, studies have shown that up to 40% of patients are left with a residual deformity that may require a surgical correction by a plastic surgeon. It is accepted that these deformities are best treated at the time of original surgery for breast cancer excision. This is because it is more difficult to correct a deformity, especially after radiotherapy to the breast, and because results of secondary corrective surgery are often not as good.

With breast conserving surgery for breast cancer, the aim is to remove the whole tumour with a clear margin of healthy tissue around it. When a wider margin of normal tissue is removed with the tumour, there is a smaller risk of local recurrence of the cancer. There is however, a higher risk of visible deformity in the breast and a poorer cosmetic result with the greater amount of tissue removed. A conflict exists between a wide enough resection in order to have optimal oncologic control and not removing so much breast tissue as to leave a deformed breast or a large size difference as compared with the other breast. The size of the tumour in relation to the breast is one of the single most important factors when attempting to obtain a good cosmetic result.

Another factor that may lead to a poor cosmetic outcome is the location of tumour within the breast. When the tumour is located in the centre, inferior (lower) or medial (inner) parts of the breast, as many as 50% of patients have a cosmetically unacceptable result with breast conserving surgery. This may be a result of a concave deformity, skin puckering, poor scars, nipple-areolar displacement, a misshapen breast and poor symmetry.

Studies have shown that one of the reasons for inferior cosmesis after wide local excision is the insufficient remodelling performed at the time of surgery. While the remaining cavity may fill with haematoma or seroma and produce an initially acceptable cosmetic result in the short term, major deformities are seen on long term follow-up. The results become worse with post-operative radiotherapy that is routinely given after wide local excision of an invasive breast cancer.

Oncoplastic techniques can be used to reduce these resection deformities and include:

• the displacement of nearby breast tissue into the defect (simple volume displacement)
• the use of plastic surgical breast reduction techniques in order to refashion the whole breast after tumour excision (mammaplasty volume displacement)
• the replacement of tissue into the defect by importing tissue from elsewhere, for example the Latissimus Dorsi (LD) flap.

VOLUME DISPLACEMENT ONCOPLASTIC TECHNIQUES

Simple Volume Displacement

The best cosmetic results are obtained when reshaping of the breast is done immediately after wide local excision during the same operative procedure. Simple reshaping is done with displacement of adjacent remaining breast tissue, by widely undermining nearby skin and the breast gland off the chest wall. If there is a risk of nipple displacement, which is frequent, undermining is carried out beneath the nipple-areolar complex. Other methods are sometimes necessary to adjust the position of the nipple-areolar complex so that it is not pulled towards the scar.

Mammaplasty Volume Displacement

When simple volume displacement methods are not sufficient, it is possible in larger breasts, to perform a remodelling mammaplasty based on plastic surgical breast reduction techniques to reshape the breast immediately following excision of the tumour. This results in a smaller breast that appears normal in shape. When this is done, surgery to the opposite breast is often required to achieve a balanced result.

These volume displacement procedures are only suitable if there is enough remaining healthy breast tissue to allow reconstruction of the breast and the patient is amenable to having an operation to the other breast.

VOLUME REPLACEMENT ONCOPLASTIC TECHNIQUES

If the amount of remaining tissue is insufficient to reshape the breast after excision of the breast cancer, another option would be to import tissue into the defect. This can be in the form of a flap, either of local tissue (local flap) or from more a distant donor site, for example the Latissimus Dorsi (LD) muscle or perforator flap.

The LD flap can contain muscle, fat and skin in various combinations depending on the defect to be reconstructed. It can be used to fill in partial breast defects left after wide local excision or the whole breast after mastectomy.

Volume replacement techniques are most suited to women who do not wish to have surgery to the opposite breast. They should however, be made aware of the donor site scar and the fact that should they subsequently require a full mastectomy, the option of a fully autologous (patient’s own natural body tissue) LD flap breast reconstruction will not be possible.

An experienced oncoplastic surgeon will be able to advise on whether or not the type of cancer, size and location of the tumour within the breast or the use of primary chemotherapy or endocrine therapy will allow breast conservation and still result in acceptable cosmesis.

ONCOPLASTIC TECHNIQUES FOR MASTECTOMY

Mastectomy is advised when disease is widespread, multifocal (more than one tumour), the tumour is large in relation to breast size or there is residual disease after attempted wide local excision. Some women opt for mastectomy in the first instance in order to have the least chance of residual disease or to avoid radiotherapy to the remaining breast tissue.

If mastectomy is necessary, the whole range of appropriate techniques for breast reconstruction should be offered either immediately if appropriate, or after all adjuvant therapy has been given. Studies have shown that as many as 50% of patients having a mastectomy would like a breast reconstruction if possible.

Immediate breast reconstruction often allows less breast skin to be removed (skin sparing mastectomy), less sensory nerve division and can produce shorter scars.

Women choose immediate breast reconstruction because it helps them face the physical and emotional impact of the loss of a breast. With immediate breast reconstruction, a second operation and general anaesthetic can be avoided.

An oncoplastic breast surgeon can often perform both the cancer excision surgery and breast reconstruction, as well as discuss any necessary procedures to the opposite breast in order to give the best overall cosmetic result. These may include breast reduction, augmentation (enlargement), mastopexy (breast uplift) or a combination of these.