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CHAPTER 2 Safety of Oncoplastic Breast Reconstruction
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documented and to a certain extent may be extrapolated
to predict changes following oncoplastic reconstruction.
In a small case-control study, Roberts et al compared the
mammographic ndings of 87 patients who had undergone
breast reduction to those of 30 patients with macromastia
who did not undergo breast reduction. e authors found
that mammographic ndings following breast reduction
did not increase the rate of obtaining additional imaging
studies or diagnostic interventions and suggested that this
nding was likely generalizable to oncoplastic breast reconstruction.19 In contrast, two small series comparing postoperative cancer surveillance between patients undergoing
oncoplastic reconstruction or standard breast conservation
suggested a higher rate of need for additional imaging and
tissue sampling in the oncoplastic group.
20,21
Although the
expected mammographic changes following breast reduction (oil cysts, fat necrosis, calcications) are distinct from
those found in patients with breast cancer, it is possible that
the increased pretest suspicion in a patient with a history
of breast cancer leads to an increased request for additional
imaging and biopsies.
Conclusions
Oncoplastic reconstruction techniques hold great appeal for
their ability to extend the indications for breast conservation to patients with larger tumors in whom standard breast
conservation would not provide acceptable cosmesis. e
widespread applicability of these techniques depends on an
oncologic safety prole comparable to standard BCT. Available data suggest that rates of positive margins, local recurrence, distant recurrence, disease-free survival, and overall
survival following oncoplastic breast reconstruction compare favorably with outcomes following both breast conservation and mastectomy. Oncoplastic breast reconstruction
can be accomplished with a reasonable complication rate,
and when complications do occur there is likely a minimal
impact on the timing of adjuvant therapy administration.
Appropriate patient selection and preoperative discussion
are essential to optimize patient decision making and surgical outcomes following oncoplastic breast reconstruction.
References
1. Jacobson JA, Danforth DN, Cowan KH, etal. Ten-year results of
a comparison of conservation with mastectomy in the treatment of
stage I and II breast cancer. N Engl J Med. 1995;332(14):907–911.
2. Haloua MH, Krekel NM, Winters HA, etal. A systematic review
of oncoplastic breast-conserving surgery: current weaknesses and
future prospects. Ann Surg. 2013;257(4):609–620.
3. Carter SA, Lyons GR, Kuerer HM, etal. Operative and onco-
logic outcomes in 9861 patients with operable breast cancer:
single-institution analysis of breast conservation with oncoplastic
reconstruction. Ann Surg Oncol. 2016;23(10):3190–3198.
4. Losken A, Hart AM, Broecker JS, Styblo TM, Carlson GW.
Oncoplastic breast reduction technique and outcomes: an evolution over 20 years. Plast Reconstr Surg. 2017;139(4):824e–833e.
5. Moran MS, Schnitt SJ, Giuliano AE, et al. Society of Surgical
Oncology-American Society for Radiation Oncology consensus
guideline on margins for breast-conserving surgery with wholebreast irradiation in stages I and II invasive breast cancer. Ann Surg
Oncol. 2014;21(3):704–716.
6. Losken A, Dugal CS, Styblo TM, Carlson GW. A meta-analysis
comparing breast conservation therapy alone to the oncoplastic
technique. Ann Plast Surg. 2014;72(2):145–149.
7. Piper ML, Esserman LJ, Sbitany H, Peled AW. Outcomes following oncoplastic reduction mammoplasty: a systematic review.
Ann Plast Surg. 2016;76(suppl 3):S222–S226.
8. Losken A, Pinell-White X, Hart AM, et al. e oncoplastic
reduction approach to breast conservation therapy: benets for
margin control. Aesthet Surg J. 2014;34(8):1185–1191.
9. Wijgman DJ, Ten Wolde B, van Groesen NR, et al. Short term
safety of oncoplastic breast conserving surgery for larger tumors.
Eur J Surg Oncol. 2017;43(4):665–671.
10. Clough KB, Gouveia PF, Benyahi D, et al. Positive margins
after oncoplastic surgery for breast cancer. Ann Surg Oncol.
2015;22(13):4247–4253.
11. Amabile MI, Mazouni C, Guimond C, etal. Factors predictive of
re-excision after oncoplastic breast-conserving surgery. Anticancer
Res. 2015;35(7):4229–4234.
12. De La Cruz L, Blankenship SA, Chatterjee A, et al. Outcomes after oncoplastic breast-conserving surgery in breast
cancer patients: a systematic literature review. Ann Surg Oncol.
2016;23(10):3247–3258.
13. Fitoussi AD, Berry MG, Fama F, etal. Oncoplastic breast surgery
for cancer: analysis of 540 consecutive cases [outcomes article].
Plast Reconstr Surg. 2010;125(2):454–462.
14. Cil TD, Cordeiro E. Complications of oncoplastic breast surgery involving soft tissue transfer versus breast-conserving
surgery: an analysis of the NSQIP database. Ann Surg Oncol.
2016;23(10):3266–3271.
15. Losken A, Pinell XA, Eskenazi B. e benets of partial versus
total breast reconstruction for women with macromastia. Plast
Reconstr Surg. 2010;125(4):1051–1056.
16. Gulcelik MA, Dogan L, Camlibel M, et al. Early complications of a reduction mammoplasty technique in the treatment of
macromastia with or without breast cancer. Clin Breast Cancer.
2011;11(6):395–399.
17. Hillberg NS, Meesters-Caberg MAJ, Beugels J, et al. Delay
of adjuvant radiotherapy due to postoperative complications
after oncoplastic breast conserving surgery. Breast. 2018;39:
110–116.
18. Khan J, Barrett S, Forte C, etal. Oncoplastic breast conservation does not lead to a delay in the commencement of adjuvant chemotherapy in breast cancer patients. Eur J Surg Oncol.
2013;39(8):887–891.
19. Roberts JM, Clark CJ, Campbell MJ, Paige KT. Incidence
of abnormal mammograms after reduction mammoplasty:
implications for oncoplastic closure. Am J Surg. 2011;201(5):
611–614.
20. Dolan R, Patel M, Weiler-Mitho E, et al. Imaging results following oncoplastic and standard breast conserving surgery. Breast
Care (Basel). 2015;10(5):325–329.
21. Losken A, Schaefer TG, Newell M, Styblo TM. e impact of
partial breast reconstruction using reduction techniques on postoperative cancer surveillance. Plast Reconstr Surg. 2009;124(1):
9–17.
3
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Indications and Patient Selection for
Oncoplastic Breast Surgery
KIRSTEN EDMISTON
Introduction
e newly diagnosed breast cancer patient and her interdisciplinary treatment team must address both the local control
(breast) and systemic control (body) issues to minimize the risk
of recurrence. From a surgical perspective, the fundamental
goals are to remove the tumor with an adequate margin of normal tissue while optimizing the long-term aesthetic outcomes
for the patient. e technical decision then becomes whether
to proceed with breast conservation therapy (lumpectomy and
radiation) or a mastectomy with or without reconstruction.
With the pioneering work of the National Surgical Adjuvant
Breast and Bowel Project (NSABP), Umberto Veronesi, MD,
and others in the 1970s, breast conservation therapy (BCT) has
been well established as oncologically safe, oering similar local
control rates and equivalent long-term survival rates compared
with non-nipple-sparing mastectomy.
sparing mastectomy (NSM) has been demonstrated to be a
third alternative for patients requiring or requesting removal of
the breast parenchyma while preserving the skin envelope and
nipple–areolar complex (NAC). Breast-conserving lumpectomy
and radiation therapy must then be evaluated as an alternative
to both nipple-sparing and non-NSM with reconstruction.
e benets of breast conservation over mastectomy
are well established. Clinical outcome studies with 20-year
follow-up have demonstrated that breast conservation is
equivalent to mastectomy in terms of overall survival.3 In
addition, preservation of the natural breast confers a signicant psychological advantage for many women diagnosed
with breast cancer. In most cases, preservation of the NAC
is possible; therefore, the natural breast elements remain,
and the majority of women are happy with the nal breast
appearance. With the advent of oncoplastic techniques,
breast conservation can be expanded to include wider margins of resection and achieve local recurrence rates that are
similar to mastectomy.4 As the reconstructive options have
expanded, so has the prevalence of oncoplastic surgery.
ere are several dierences between traditional breast
conservation and oncoplastic surgery. With traditional
1,2
More recently, nipple-
lumpectomy, the skin is opened directly over the localized
lesion. e tumor is then removed, oriented, and sent for
pathological evaluation. e skin is closed without attempts
to close the internal cavity. For small tumors (either ductal carcinoma in situ [DCIS] or invasive breast cancer),
this approach is adequate. Unfortunately, up to 40–45% of
patients can be found to have positive margins requiring
re-operation to achieve negative margins.
30% of patients undergoing lumpectomy and subsequent
radiation therapy surveyed were found to be dissatised
with their cosmetic outcome.7 Cosmetic defects included
deformity of the overall shape of the breast, volume loss,
changes in the shape and location of the nipple, and Snoopy
deformities of the NAC after a transverse incision in the
lower central breast. e challenge thus becomes extending
the indications for lumpectomy while minimizing the risk
of positive margins to optimize the cosmetic results after not
only the surgical lumpectomy but also radiation therapy.
In the 1990s, Werner Audretsch, Christian Gabka, and
Heinz Bohmert applied reduction mammoplasty and mastopexy concepts to expand the number of patients who are
candidates for breast conservation as “oncoplastic surgery.”8
e term oncoplastic breast surgery is a Greek-derived word
that literally means “molding of tumor”; however, in its
present context it refers to excision of the tumor (onco)
and reconstruction and shaping of the breast (plastic). is
often requires a team approach between the oncologic and
reconstructive surgeon. Today, the spectrum of oncoplastic
surgery includes four basic techniques including:
1. Local tissue mobilization and rearrangement
2. Reduction pattern mammoplasty
3. Skin and nipple rearrangement
4. Volume replacement
is chapter will discuss the aspects of the tumor characteristics, patient’s anatomy, medical comorbidities,
treatment-related issues, psychosexual concerns, and possible complications that aect the indications and patient
selection for oncoplastic breast surgery over NSM and
non-NSM.
4-6
Historically,
14
CHAPTER 3 Indications and Patient Selection for Oncoplastic Breast Surgery
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Indications
Oncoplasty enables the breast surgery team to excise more
breast tissue, widening the margin of clearance between the
tumor and the normal parenchyma. In addition, natural
breast appearance is more likely to be achieved, although
the volume will be less. ese benets have expanded the
number of patients eligible for breast conservation. Many
women who are treated with oncoplastic breast conservation surgery would otherwise have needed a mastectomy
and/or have had a poor aesthetic result. Fundamentally,
the indications for oncoplastic breast surgery are the
same as those for breast conservation surgery. Patients
should be considered for BCT if they have an adequate
tumor-to-breast volume ratio to establish negative
margins and are candidates for radiation therapy. All
patients undergoing breast-conserving surgery (lumpectomy, partial segmental mastectomy, quadrantectomy, and
tylectomy) should be assessed for their oncoplastic needs.
e most common indications for oncoplastic breast surgery are tumor size (37%), poor tumor location (22%),
oncocosmetic (1%), multifocality (10%), skin retraction
(9%), positive margins after previous surgery (5%), and
other reasons (5%).
It is also important to identify patients who are not
candidates for breast conservation. Historically, absolute
contraindications to BCT include (1) patients with a high
probability of recurrence due to multicentric disease or the
inability to obtain clear margins; (2) patients who are currently pregnant; (3) those with active collagen vascular disease, such as active lupus and scleroderma10; and (4) those
with a history of prior breast irradiation either related to
prior breast cancer or Hodgkin’s disease. Soft contraindications include (1) patients with a high probability of
subsequent breast cancers including those with BRCA1/2
mutations, PTEN, etc.; (2) tumors that directly involve the
NAC; and (3) patients with high tumor-to-breast ratios.
e increasing use of neoadjuvant chemotherapy has in creased the number of patients eligible for breast- conserving
surgery and oncoplastic tissue rearrangement. is is, in
part, predicated on the invasive tumor molecular subtype.
Neoadjuvant dual HER2 blockade with trastuzumab and
pertuzumab in combination with cytotoxic chemotherapy
for patients with HER2+ amplication results in a high
pathology complete response (pCR) (16.8–66.2%)11.
Patients with ER+/HER2- cancers have lower pCR rates
(7.0–16%), and those with triple negative tumors have
33–35% chances of achieving a pCR12; 40–70% overall will
achieve a partial response.
9
Patient Selection
Comprehensive preoperative evaluation is necessary to determine patients appropriate for oncoplasty and the necessary
type of reconstruction. e surgical team should obtain the
patient’s history of any prior breast surgery, chest radiation,
and infections. Risks factors for wound complications such
as diabetes mellitus, active smoking, cardiovascular conditions, history of Ehlers-Danlos, coagulopathies, poor nutrition, and obesity should be noted. Patients with a history of
chronic pain, bromyalgia, and opioid dependence should
also be assessed to coordinate optimal care with their primary care provider.
It is also important to understand the patient’s psychosexual concerns and feelings about her breast. Loss of nipple–
areolar and breast sensation may be important to patients
undergoing breast surgery in terms of quality of life and satisfaction. Patients undergoing skin-sparing mastectomy and
NSM can have considerable loss in skin and nipple sensation. Many patients complain of loss of sexual arousal with
breast or nipple stimulation after mastectomy. As such, fear
of loss of nipple sensation may be an important consideration for oncoplastic tissue rearrangement. Very little data
are currently available about the risks of nipple sensation
loss after oncoplastic breast surgery and radiation. Concerns
about nipple viability, postoperative nipple positioning,
fears about the risk of recurrence, and risks of needing additional surgery should be ascertained along with the patient’s
history of anxiety. Lastly, patients’ concerns about foreign
body implantation and complications, including the remote
risk of implant-associated anaplastic large-cell lymphoma,
should be addressed.
On physical exam, the surgeon should clinically evaluate the patient’s breast and chest anatomy for breast symmetry, prior scars, bra size, and degrees of ptosis. Enlarged
lymph nodes should be assessed for possible regional disease. Patients who have had prior breast conservation and
radiation therapy are generally not good candidates for
oncoplastic surgery. Diagnostic mammogram, ultrasound,
and breast magnetic resonance imaging (MRI) should be
strongly considered to precisely identify the location and
extent of the breast tumor. Patients undergoing neoadjuvant chemotherapy should undergo another preoperative
MRI to assess the extent of the residual tumor and rule out
the possibility of disease progression. is will conrm that
breast conservation and oncoplastic tissue rearrangement is
still possible.
Tumor Characteristics
Invasive Breast Carcinoma
Oncoplastic surgery has been shown to have no adverse
eects related to local recurrence, disease-free, or overall
survival for all stages of breast cancer.
For patients with invasive lobular carcinoma, extensive
microcalcications, or multifocal breast cancer, the possibility or risk of positive margins is an important consideration
for oncoplastic planning.
Ductal Carcinoma In-Situ (DCIS)
e management of DCIS remains controversial to minimize
overtreatment and undertreatment. Despite this, margin
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status is one of the most important determinants in local recurrence and clinical outcomes. e Society of Surgical Oncology (SSO)/ American Society Radiation Oncology (ASRO)/
American Society of Clinical Oncology (ASCO) Consensus
Guidelines on margins for DCIS, published in 2016, recommend at least 2-mm margins to reduce the risk of in-breast
recurrence relative to narrower negative margins.13 Parenthetically, the multidisciplinary panel also noted that clinical
judgment was necessary to determine whether patients with
smaller negative margin widths (≥ 1 mm) require re-excision.
ey identied additional factors important to consider
before additional surgery, including an assessment of residual
calcications on postexcision mammogram, extent of DCIS
in proximity to margin, and which margin is close (anteriorly
just under the skin and posteriorly excised to the pectoral fascia) versus margins associated with residual breast tissue. e
routine practice of obtaining negative margin widths wider
than 2 mm is not supported by the evidence.
In a recent case-control study, De Lorenzi etal at the European Institute of Oncology (IEO) compared oncoplastic breast
surgery followed by radiation (44 patients) and conservative
breast surgery alone followed by radiation (375 patients).14
e primary endpoints were disease-free survival (DFS)
and ipsilateral breast tumor recurrence (IBTR). e tumor
size was larger in the oncoplastic group. is was expected
as oncoplasty can manage the resection of larger volumes of
breast tissue. e average annual rates of invasive IBTR were
1.6% and 1.0% for the oncoplastic and conservative patients,
respectively. e authors also found no dierence in the rates
of contralateral breast cancer distant metastasis and contralateral breast cancer. ey observed similar rates of focally
involved margins (focally ink on DCIS) in 4.5% and 3.5%,
respectively, for the oncoplastic and conservative patients.
Close margins (<1 mm) were observed in 22.8% and 17.9%,
respectively. None of their patients underwent further surgery.
ey conclude that oncoplastic breast surgery is a safe and
valid treatment component for patients with DCIS.
In a recent review of DCIS, Song etal reviewed their
experience at Emory Healthcare System.15 Twenty-eight
patients were included in the study. erapeutic mammoplasty was the denitive procedure in 64%. ere were
10 patients (36%) who required re-operation: 9 for positive margins and 1 for residual microcalcications. Positive
margin rates were independent of tumor location. All 10
patients requiring completion mastectomy or re-excision
had intermediate or high-grade disease. In addition, the
women requiring re-operation were younger (mean 45.6;
median 43) compared with those who did not require reoperation (mean 57; median 57). e authors concluded
that oncoplastic reduction techniques are appropriate for
DCIS taking into account patient selection and improved
conrmation of negative margins. One strategy to minimize
the incidence of positive margins is to obtain a preoperative
breast MRI, which is useful in determining the extent of
DCIS and establishing the boundaries for resection. Intraoperative margin assessment can also reduce the risk of positive margins.
• Fig. 3.1 Preoperative photograph of a patient with A cup breasts and
not a candidate for oncoplasty.
• Fig. 3.2 Postoperative photograph following nipple-sparing mastec-
tomy and two-stage reconstruction at 2-year follow-up.
The Impact of the Tumor-to-Breast Size Ratio
on Oncoplastic Breast Surgery
In general, women with an A or B cup breast are poor candidates for oncoplastic tissue rearrangement or reduction.
ey simply do not have enough breast tissue. In this population, small tumors can be excised with local tissue mobilization for adequate closure. Alternatively, the patient may
be a candidate for neoadjuvant chemotherapy to shrink the
tumor, allowing her to be converted from a mastectomy to
breast conservation. If not, the patient may be best suited
for mastectomy and immediate implant reconstruction.
Figs. 3.1 and 3.2 illustrate a patient with an A cup who
completed NSM and two-stage prosthetic reconstruction.
Patients with a C cup breast may be candidates for an
oncoplastic reduction. e decisions will be based on the
tumor-to-breast ratio, degree of ptosis, and sucient volume to adequately rearrange the tissue. ese are usually
well suited for tissue rearrangement, particularly if they
CHAPTER 3 Indications and Patient Selection for Oncoplastic Breast Surgery
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• Fig. 3.3 Preoperative photograph of a woman with C cup breasts and
left breast cancer who is a good candidate for oncoplasty with tissue
rearrangement.
17
• Fig. 3.5 Postoperative photograph following ipsilateral oncoplastic
tissue rearrangement and contralateral reduction mammaplasty for
symmetry at 2-year follow-up.
• Fig. 3.4 Preoperative markings demonstrating wire localization in the
lower outer quadrant.
have signicant ptosis and can tolerate a modication of
the NAC position. Lack of ptosis may be problematic due
to the xed nipple–areolar position. Figs. 3.3–3.5 illustrate
a patient with a C cup breast following oncoplastic tissue
rearrangement.
Larger breasted women with a D or larger cup breast
often have some degree of ptosis. e additional breast tissue and mobility of the NAC lend well to reconstruction
using reduction mammoplasty techniques. Figs. 3.6 and 3.7
illustrate a woman with DD breasts following oncoplastic
reduction mammaplasty.
Women who have had prior breast augmentation with
implants present a special challenge. Up front, it is important to recognize that the presence of a breast implant does
not have an adverse eect on the ecacy of treatment to
• Fig. 3.6 Preoperative photograph and markings of a patient with DD
breasts and a left breast cancer who is a good candidate for oncoplastic reduction mammaplasty.
minimize the risk of recurrence. Although they often present with D cup or larger, the pre-augmentation breast is
often an A or B cup with reduced breast tissue for recruitment. is is complicated by the fact that women with
breast augmentation implants have an increased risk of
developing capsular contracture and brosis slowly over
time after breast radiation. is progressive contracture
may begin 6–9 months after radiation completion and
continue for 2–10 years. e patient may notice that the
implant becomes xed, rm, and uncomfortable leading to
decreased patient satisfaction. Patients with breast implants
are also at increased risk for infection after radiation therapy.
Given these problems, the question remains how to
optimally treat these patients. One option for women
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• Fig. 3.7 Postoperative photograph following bilateral oncoplastic
reduction mammaplasty at 2-year follow-up.
• Fig. 3.9 Postoperative photograph following breast conservation
demonstrating severe capsular contracture and distortion of the left
breast.
augmentation following biopsy (see Fig. 3.8) and oncoplasty with radiation (see Fig. 3.9).
It is important to recognize that it is not just the tumor
size that denes the type of oncoplastic tissue reconstruction
procedure but rather the interplay between the tumor size,
breast size (volume and bra size), and estimated percentage
of breast volume that would be removed (see Fig. 3.10).
• Fig. 3.8 Preoperative photograph of a woman status postbilateral
breast augmentation following a biopsy for left breast cancer.
with early stage disease would be a nipple-sparing or skinsparing mastectomy and replacement with a same size or
larger implant. is approach can achieve excellent cosmetic results with the potential NAC preservation, albeit
often insensate. is can avoid the need for radiation. For
early stage patients who decline a mastectomy, the options
become either treat with the implant in place or remove
the implant and plan for a tissue ap reconstruction in the
future after radiation. e majority of women are reluctant to have the implants removed, which results in a much
smaller breast volume. For these reasons, oncoplastic surgery is not usually recommended for women with breast
implants to avoid the long-term aesthetic issues related to
capsular contracture and infection. Figs. 3.8 and 3.9 illustrate a patient with breast cancer in the setting of breast
Extent and Location of the Anticipated
Breast/Skin Excision
Tumor location is a critical factor in determining the type of
reconstruction and pedicle design. In a recent study of 980
patients, Rummel etal identied approximately 51% of tumors
were located in the upper outer quadrant (UOQ) compared
with 15.6% in the upper inner quadrant (UIQ), 14.2% in
the lower outer quadrant (LOQ), 10.6% in the central breast,
and 8.1% in the lower inner quadrant (LIQ).16 A thorough
preoperative discussion and review of the mammogram and
MRI images by both the breast surgeon and the reconstructive
surgeon is essential to understand the extent and location of
the planned resection and reconstructive needs. Both need to
have a shared mental model. e presence of tumor within or
extremely close to the skin is an indication to consider neoadjuvant chemotherapy for tumor shrinkage except for patients
with ER/PR+/HER2 neu(-) tumors or DCIS. As such, the
need to remove breast skin as part of a partial segmental mastectomy is now rare. Skin involvement of the LIQ and LOQ
quadrant can frequently be excised within the boundaries of
the inverted T pattern. For skin involvement of the UOQ and
UIQ outside the boundaries of a traditional inverted T pattern, consideration can be given to rotate, split, or otherwise
modify the inverted T skin pattern.
For central/NAC skin involvement, a vertically oriented
elliptical incision can be made for a central resection with preservation of the anterior projection and native shape. Tumors
close to but not directly involving the NAC may be managed
CHAPTER 3 Indications and Patient Selection for Oncoplastic Breast Surgery
% Breast excised
Volume of breast (cm3)
38F 40F
r
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19
25
20
15
10
32A
5
Bra size
32D
32C
34B
36A
34C
36B
32B
34A
Volume
Replacement
Simple
Wide Local Excision
34D
36C
38B
34DD
36D
38C
40B
Therapeutic
36DD
38D
40C
Mastopexy
36E
38DD
40D
38E
40DD
Therapeutic
Reduction
Mammaplasty
40E
5
4
3
2
1
Tumour
diamete
(cm)
0
200
with a batwing resection or a central resection to assure negative
margins. Radiation therapy will still be needed in this situation.
Alternatively, the patient may be considered for a skin-sparing
mastectomy with immediate volume reconstruction using
either a tissue expander/implant or tissue transfer. is would
potentially eliminate the need for radiation therapy and the
potential complications of capsular contracture and brosis.
e challenge occurs when a large amount of skin needs to
be resected, particularly in the UOQ or UIQ. e team will
need to consider the overall breast volume and the patient’s
aesthetic goals. e patient may be best served with a mastectomy and immediate reconstruction. A latissimus ap can
be considered for a large UOQ skin defect. e potential
problems with a latissimus ap in this context include skin
color and texture mismatches. In addition, the latissimus ap
is then no longer available for future reconstructive needs if
the patient develops a recurrence after radiation therapy or
needs a ap reconstruction and is not a candidate for a deep
inferior epigastric perforator (DIEP) ap, transversus rectus
abdominus myocutaneous (TRAM) ap, or other ap.
Immediate versus Delayed Reconstruction
Kronowitz etal reviewed their experience with 69 patients
at e University of Texas MD Anderson Cancer Center.17
300
400
500
600
700
800
900
1000
1100
1200
1300
1400
• Fig. 3.10 An algorithmic chart listing oncoplastic treatment options. (From Macmillan RD, McCulley SJ.
Oncoplastic breast surgery: what, when and for whom? Curr Breast Cancer Rep 2016; 8:112–117.)
Fifty patients underwent immediate repair of partial mastectomy defects before external beam radiation therapy, which
included local tissue rearrangement in 28%, breast reduction in 66%, and aps in 6%. Nineteen patients underwent
delayed reconstruction after external beam radiation therapy
of which 32% had local tissue rearrangements, 42% had
breast reductions, and 26% had aps. Results included a
complication rate of 26% for immediate reconstruction and
42% for delayed reconstruction. Autologous aps were associated with increased complications when performed immediately compared with local tissue rearrangement; however,
aps were associated with a lower complication rate when
performed on a delayed basis. e authors concluded that the
immediate repair of partial mastectomy defects with volume
displacement techniques (reduction mammaplasty, tissue
rearrangement) resulted in fewer complications and better
aesthetic outcomes. Spear etal demonstrated that reduction
mammaplasty or mastopexy performed following radiation
therapy resulted in a complication rate of 28%.18 Figs. 3.11
and 3.12 illustrate a patient following breast conservation
without oncoplasty followed several years later with ipsilateral autologous fat grafting and contralateral reduction
mammaplasty for symmetry. Figs. 3.13–3.15 illustrate a
patient following breast conservation followed several years
later by performing a bilateral reduction mammaplasty.
1500
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• Fig. 3.11 Preoperative photograph following right breast conservation
demonstrating a mild contour abnormality.
• Fig. 3.13 Preoperative photograph of a woman with severe mammary
hypertrophy following left breast conservation therapy.
• Fig. 3.12 Postoperative photograph following autologous fat grafting
of the lumpectomy defect as well as a contralateral reduction mammaplasty for symmetry.
Impact of Intraoperative Radiation Therapy
Intraoperative radiation therapy (IORT) has become an
alternative to whole breast radiation therapy. IORT delivers
a single intraoperative dose of radiation to the tumor bed
at the time of surgical excision. e Targeted Intraoperative
Radiotherapy Versus Whole Breast Radiotherapy for Breast
Cancer (TARGIT-A) demonstrated similar breast cancer
mortality in patient undergoing IORT and whole breast
radiation after lumpectomy (WBRT) (2.6% [1.5–4.3%] for
TARGIT vs 1.9% [1.1.–3.2] for WBRT; p = 0.56). Woundrelated complications were similar for both groups, but
grade 3 or 4 skin complications were signicantly reduced
with TARGIT (4 of 1720 vs 13 of 1731, p = 0.029).19 e
main advantage of IORT is that a single dose of 20 Gy can
safely be delivered directly to the tumor bed while sparing
the healthy surrounding tissue.
• Fig. 3.14 Postoperative anterior view following bilateral reduction mam-
maplasty demonstrating mild asymmetry and distortion of the left breast.
• Fig. 3.15 Postoperative oblique view demonstrating distortion along
the inframammary region due to delayed healing at the trifurcation point.
CHAPTER 3 Indications and Patient Selection for Oncoplastic Breast Surgery
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IORT in patients undergoing oncoplastic tissue rearrangement raises the possibility of wound-healing complications. Cracco et al studied the surgical outcomes, early
complication rates, and esthetic results after oncoplastic
breast surgery of 83 patients undergoing IORT and 109
patients treated with WBRT with a mean follow-up time of
17 months.20 e early postoperative complication rate after
IORT was 26.6%. e majority were liponecrosis (12%),
seroma formation (7.4%), and infection/dehiscence (2.4%).
In contrast, the early postoperative complication rate after
WBRT was 14.7%. e most common complications were
hematomas (7.6%), liponecrosis (1.9%), and seroma formation (1.9%). e complication rates after IORT were
statistically higher (p < 0.0001). Despite this increase in
early complications, the late cosmetic results were good in
both IORT and WBRT groups (84.3% and 88%, respectively). ey concluded that IORT did not appear to negatively inuence the cosmetic outcomes after conservative
breast surgery and oncoplastic reconstruction.20 Crown and
Grumley analyzed their experience with oncoplasty patients
undergoing either IORT or WBRT at Virginia Mason Medical Center.21 Minor surgical site complications occurred in
29 patients (17.9%) in the IORT group, compared with 20
patients (6.9%) in the WBRT group (p = 0.001). Obesity,
smoking, diabetes, chemotherapy, advanced age, tumor size,
and need for re-excision were not associated with increased
rates of complications.8 Overall, oncoplastic breast surgery
is a safe reasonable reconstructive option for patients undergoing IORT.
Indications for Nipple-Sparing Mastectomy
An increasing proportion of women with newly diagnosed
unilateral breast cancer are choosing mastectomy (either
unilateral or bilateral) for treatment with immediate breast
reconstruction. Expanded genetic testing has also identied
women at high risk for developing breast cancer for whom
bilateral prophylactic mastectomy is recommended. NSM is
generally indicated in women with small to moderate breast
volume (A, B, and C cup) based on vascular perfusions factors following mastectomy. Traditional indications included
tumors that were less than 3 cm in diameter, greater than
2 cm from the NAC, and with clinically negative axillary
lymph nodes.22 Current guidelines however suggest that
NSM can be safely performed so long as margin status is
appropriate.23 e topic of mastectomy versus oncoplasty
will be further discussed in a separate chapter.
Conclusion
Collaboration between the breast surgeon and plastic surgeon is recommended to develop a shared mental model of
the patient’s tumor and anatomy, treatment plan (including the need for radiation therapy), and the patient’s aesthetic goals both in the short term as well as in the long
term. Together the team must answer the questions: Is the
patient a candidate for breast conservative surgery and
oncoplasty? If so, what type of oncoplastic surgery would
best suit the patient’s needs and its timing? Alternatively,
would the patient be best served with an NSM or nonNSM with reconstruction? As oncoplastic techniques continue to evolve and expand and the evidence mounts that
this technique is safe and eective with excellent surgical
and aesthetic outcomes, the indications and prevalence of
this technique will certainly increase.
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