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6
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Plastic Surgeon’s Approach to
Oncoplastic Breast Surgery
MAURICE Y. NAHABEDIAN
Introduction
Oncoplastic breast surgery has become a common option for
women with breast cancer and is currently being performed
throughout the world on a regular basis. is operation has
provided women with the best of oncologic and reconstructive options in that they can achieve oncologic safety and
ecacy, retain the majority of their breast, and retain a natural breast appearance. In many parts of the world, breast
surgeons and plastic surgeons perform oncoplastic breast
surgery as a team and work together to optimize surgical
outcomes. Breast and plastic surgeons each have a unique
perspective on oncoplastic surgery and how to perform it.
Many breast surgeons have expanded their scope of practice
and now perform simple reconstructive procedures in addition to ablative procedures.1 Plastic surgeons continue to
be an integral component of the oncoplastic team in that
they can provide expertise in both simple and complex situations. is chapter will provide a plastic surgeon’s perspective on oncoplastic breast surgery.
Role of Plastic Surgery
Plastic surgeons have a long-standing interest in reconstructive breast surgery and have been at the forefront of reconstructive innovation. e role of the plastic surgeon is to
provide expertise in the management of complex defects of
the breast following partial mastectomy and not just to close
a defect. Plastic surgeons are able to incorporate principles
and concepts to reshape and contour the breast in a predictable and reproducible manner. Oftentimes, this is relatively
straightforward and may not require complex maneuvers;
however, there are times when a defect may be larger than
usual relative to the volume of the breast or it may be in a
location that will be dicult to reconstruct.
ere are many surgeons who feel that plastic surgery
comprises a collection of techniques that can be performed
by anyone.2 Being able to perform a particular procedure can
be learned, but understanding the principles and concepts
that dictate the optimal operation requires training and specialization. Fellowship programs now exist that combine
the oncologic and plastic surgical principles to optimally
care for these patients.3 Plastic surgeons have an intricate
understanding of blood supply and tissue perfusion and are
able to use local parenchymal aps and, in more complex
cases, remote adipocutaneous aps. Inherent to this is an
understanding of tissue tension, perfusion analysis, appropriate suturing techniques, the use of drains, and a working
knowledge of breast aesthetics and how to achieve them.
It is clearly appreciated that not every partial mastectomy
defect will require the assistance of a trained plastic surgeon.
Defects that are relatively small may be easy to close without the assistance of a trained plastic surgeon and result in
minimal to no breast distortion. ere are a number of techniques and approaches that have been described to facilitate these reconstructive maneuvers, and if breast surgeons
can perform them safely and eectively, then they should
do so.4 One of the principles that plastic surgeons adhere
to is that the performance of a particular operation should
be based on the ability to take care of any complications
that may arise following that operation. In the case of oncoplastic surgery, this includes, but is not limited to, delayed
healing, fat necrosis, skin necrosis, nipple–areolar necrosis,
infection, bleeding, seroma, asymmetry, and complex scarring. e role of the plastic surgeon should not solely be to
manage complications but rather to perform operations that
will minimize the risk of complications.
In the specialized eld of oncoplastic breast surgery, there
are currently three pathways for plastic and breast surgeons
to collaborate.5 e rst and traditional pathway is for plastic and breast surgeons to work together on all cases. It can
be argued that this option will provide patients with optimal outcomes based on the combined expertise with the
oncologic and reconstructive management of the patient.
e second pathway also involves both the breast and plastic surgeons with specic involvement based on the complexity of the reconstruction. is is the model that exists
throughout much of Europe in which the breast surgeon
33
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34
will perform certain reconstructive procedures such as an
implant, latissimus dorsi aps, and reduction mammaplasty,
and the plastic surgeon will perform the more complex procedures such as pedicled abdominal aps or free tissue transfers. e third pathway is the least common in which a sole
surgeon provides the oncologic and reconstructive options
in all cases. e specialist may be a breast surgeon trained
in reconstructive techniques or a plastic surgeon trained in
oncologic management.
Breast reconstruction and oncoplastic surgery have
evolved over the years to the point that they are regarded as
oncologically safe and aesthetically advantageous.6 Surgeons
now practice in an era of high patient expectations where
many patients will desire to have their appearance enhanced
following surgery. is is why the role of trained plastic surgeons is so important when it comes to oncoplastic procedures of the breast. Studies have conrmed the ability
of plastic surgeons to create ideal breast proportions based
on case complexity and the optimization of operative techniques. In a recent survey of membership from the American Society of Plastic Surgeons and the American Society
of Breast Surgeons, 70% of breast surgeons felt that partial
breast reconstruction following lumpectomy compromised
a good portion of their practice, whereas 50% of plastic surgeons felt that their ability to perform oncoplastic surgery
was limited due to a lack of referrals.7 Interestingly, both
societies opined that complex partial breast reconstruction
was best performed using the team approach. Benets of the
team approach included being able to take wider margins
and enhanced aesthetics.
Based on this survey, it is important for plastic surgeons
who have an interest in oncoplastic breast surgery to make
their referring breast surgeons aware of their interest and
desire to collaborate. Many breast surgeons become frustrated with their plastic surgery colleagues because they are
often not available or are busy doing other operations. Coordinating the two schedules can sometimes be a challenge,
but plastic surgeons should make every eort to facilitate a
good relationship with breast surgeons and have designated
blocks for these operations. Failure to do so will result in a
reduction in referrals and the gradual erosion of our ability
to stay active in breast reconstruction. Plastic surgeons have
advanced the eld of breast reconstruction and have been
performing high-level aesthetic and reconstructive breast
surgery for decades. It would be a shame for the specialty of
plastic surgery to become obsolete in the oncoplastic care of
breast cancer patients.
Vascular Anatomy
When considering oncoplastic surgery, a thorough understanding of the vascular anatomy of the breast is critical.8
e primary blood supply to the breast is derived from
the perforating branches of the internal mammary and
lateral thoracic vascular systems. ese perforators will
traverse through the breast to form an anastomotic cluster around the periareolar region and provide vascularity
to the nipple–areolar complex (NAC). It is important to
realize that the vascularity to the parenchyma and the skin
are distinct and can be compartmentalized. Another dominant source of blood supply is via the intercostal perforators. Studies have demonstrated that the second, third, and
fourth perforating branches of the intercostal system course
within the horizontal ligament of the breast toward the
nipple.9 e remainder of the vascular supply to the breast
is derived from the thoracoacromial and supercial thoracic arteries. is knowledge is important when designing
parenchymal aps and in maintaining the perfusion to the
skin and NAC.
Patient Selection
When a patient with breast cancer is referred for reconstructive options, more often than not, the breast surgeon has
reviewed the oncologic options with the patient and mentioned some of the reconstructive options. During the initial
consultation, a thorough history and physical examination
is performed. An assessment of comorbidities is completed
with an emphasis on cardiac disease, pulmonary disease,
tobacco use, and diabetes mellitus. Poorly controlled diabetes and active tobacco use are indicative of poor wound
healing following oncoplastic surgery. Cardiac and pulmonary disease are also important given that these procedures
are usually performed under general anesthesia, and good
health will promote safe surgery.
Understanding patient expectations is a critical component of all breast surgery and especially oncoplastic breast
surgery. It is important to appreciate how a patient feels about
her breasts before the diagnosis of breast cancer and what
she would like modied. is may pertain to breast volume,
shape, symmetry, contour, nipple position, or diameter of
the NAC. It is important to explain that oncoplastic breast
surgery is performed more often on women with mammary
hypertrophy; however, women with normal or small volume breasts can also have oncoplastic procedures. Studies
evaluating complications, recurrence, and patient satisfaction following breast conservation, oncoplastic reduction
mammaplasty, and oncoplastic ap reconstruction have
demonstrated increased satisfaction and fewer recurrences
and complications with oncoplastic procedures compared
with breast conservation alone.10
Technique Consideration
When considering the options for oncoplastic surgery, it is
important to recognize that there are two fundamental strategies that include volume displacement and volume replace-
11,12
ment.
can be performed together. Volume displacement techniques
include reduction mammaplasty, mastopexy, and adjacent
tissue rearrangement. Volume replacement includes the use
of remote aps such as a thoracodorsal artery perforator
or a latissimus dorsi ap as well as the use of implants in
select cases. Volume replacement techniques are the most
ese are typically performed independently but
CHAPTER 6 Plastic Surgeon’s Approach to Oncoplastic Breast Surgery
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common form of oncoplastic reconstruction with reduction
mammaplasty being the workhorse. ese operations can be
performed immediately following the partial mastectomy or
on a staged bases following conrmation of clear pathological margins.
e classic candidate for oncoplastic breast surgery is
the patient with mammary hypertrophy because the breast
cancer and adjacent parenchyma can be removed and easily reconstructed without resulting in a complex deformity.
ese patients are usually reconstructed using techniques
of adjacent tissue rearrangement that includes reduction
mammaplasty, mastopexy, or parenchymal undermining
and advancement. Performance of these operations requires
a thorough understanding of the vascular anatomy of the
breast.
35
Reduction Mammaplasty with Parenchymal
Flaps
In women with mammary hypertrophy, reduction mammaplasty coupled with parenchymal aps to ll the
partial mastectomy defect is the most common variant
of oncoplastic reconstruction.13 It is important to recognize that an oncoplastic reduction mammaplasty is
very dierent from a standard reduction mammaplasty.
With a standard reduction mammaplasty, the skin and
parenchyma are usually excised in a symmetric and balanced method, and the NAC is transposed on a vascularized pedicle. With an oncoplastic reduction, a partial
mastectomy defect is created that will need to be lled
with a parenchymal ap that is sometimes dierent from
the parenchymal ap used to transpose the NAC. Many
patients will choose to have the oncoplastic procedure
coupled with a contralateral reduction mammaplasty. In
these situations, it is common to perform a completely
dierent operation on the cancerous and noncancerous
breast; however, the goal is to achieve nal volume and
contour symmetry.
Creation of parenchymal aps can be challenging and
requires an understanding of the anatomy and tissue perfusion. It is especially important to recognize that the vascularity to the parenchyma and skin are distinctly dierent and
that multiple variations are possible. e location and size of
the defect will dictate the location and size of the parenchymal ap. e orientation of the parenchymal ap typically
depends upon the location of the defect. In general, parenchymal aps are oriented opposite to the defect such that a
superior breast defect would be typically reconstructed with
an inferiorly based ap. Detaching the distal segment of the
parenchymal ap from the chest wall to adequately rotate
it and ll the defect without tension facilitates mobilization. It is important to constantly assess the perfusion to
the parenchymal ap to maintain its vascularity; thus, it is
critical to minimize the extent of detachment. Perfusion can
be assessed clinically by noting arterial and venous bleeding
from the distal edges and, if questionable, by using uorescent angiography.
• Fig. 6.1 Preoperative markings of a woman with right breast can-
cer scheduled for right oncoplasty and left reduction mammaplasty
for symmetry.
Once the ap has been adequately mobilized, it is inset
into the breast defect and sutured in place. e perimeter of
the chest wall defect is tagged with surgical clips or staples
to facilitate identication of the tumor bed for the radiation oncologist. Once complete, the next step is to decide
how much additional breast skin and parenchyma needs
to be excised to create a natural breast contour. is will
depend upon the skin pattern utilized. It is advised to keep
the cancer side approximately 10% larger than the contralateral because of radiation-related shrinkage of the breast
over time. Closed suction drains are routinely placed in
these cases because of the ap mobilization and to maintain
negative pressure in the space to promote ap adherence.
Figs. 6.1–6.5 illustrate a patient having a right oncoplas-
tic reduction mammaplasty and an immediate contralateral
reduction mammaplasty for symmetry.
Oncoplasty in Patients with Small Breast
Volume
In patients with small volume breasts, proper assessment
and counseling is necessary. ese patients are informed
about the risks and benets of total and partial mastectomy.
With total mastectomy, standard reconstructive techniques
are employed and include prosthetic devices or autologous
aps. However, in patients who desire lumpectomy or partial mastectomy, contour abnormalities without reconstruction are likely and breast asymmetry may be problematic.
Because these patients are not candidates for reduction
mammaplasty variations, alternative strategies must be considered to ensure that the likelihood of acceptable contour
and breast symmetry is achieved. For the ipsilateral breast,
these include mastopexy, parenchymal rearrangement, and
placement of a small implant or a remote ap. Contralateral
procedures can also be considered and include mastopexy,
minimal reduction, or augmentation in some cases.
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• Fig. 6.2 Intraoperative image demonstrating a full thickness upper
pole parenchymal defect extending to the pectoralis major muscle.
Note the surgical clips placed along the periphery of the defect.
• Fig. 6.3 A medial-based pedicle with a lateral extension is created.
Autologous Flaps
In women with smaller breast volume who desire breast conservation that are not candidates for reduction techniques,
the use of regional aps such as the latissimus dorsi musculocutaneous ap, latissimus dorsi fasciocutaneous ap, or
the thoracodorsal artery perforator ap are considered.
Consideration for these operations is based on the desire to
avoid mastectomy and reconstruct the partial mastectomy
defect with similar tissue resulting in breast contour that is
nearly identical to the preablative appearance. e preferred
donor site for reconstruction is the posterolateral chest
14-16
• Fig. 6.4 The pedicle is rotated into the upper pole defect and sutured.
• Fig. 6.5 An early postoperative image demonstrating nice volume
and contour symmetry.
because the amount of harvested tissue will approximate the
defect and is ideally suited for partial mastectomy reconstruction. Although the abdominal donor can be used, this
usually is reserved for total breast reconstruction because
there is a greater quantity of tissue available.
When considering the design or template of the ap, it
is important to know exactly where the partial mastectomy
defect will be. ese posterolateral-based aps are ideally
suited for lateral, inferior, and central breast defects, and
are less suitable for medial breast defects due to limitations
in the arc of rotation. ese aps can all be transferred on a
pedicle and do not usually require free tissue transfer utilizing an operative microscope. Because these defects require
replacement of skin and parenchyma, it is important to
design the cutaneous territory of the ap so that the arc of
CHAPTER 6 Plastic Surgeon’s Approach to Oncoplastic Breast Surgery
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• Fig. 6.6 A preoperative image of a right breast defect involving the
inferolateral quadrant following breast conservation.
• Fig. 6.7 A latissimus dorsi flap is elevated for reconstruction.
rotation will easily reach and the ap skin matches the specimen skin. e technical details of these operations will be
described in subsequent chapters. Figs. 6.6–6.10 illustrate
a patient with a partial breast deformity following partial
mastectomy who was reconstructed with a latissimus dorsi
musculocutaneous ap.
Biplanar Oncoplasty
An alternative approach for women with localized breast
cancer who have smaller breasts that preclude them from
oncoplastic reduction mammaplasty and who desire breast
conservation is the biplanar technique.
this technique involves volume displacement and replacement simultaneously and includes prepectoral parenchymal rearrangement to reestablish adequate breast contour
and subpectoral placement of a small breast implant to
reestablish breast volume. With these cases, it is highly
17-19
Simply stated,
37
• Fig. 6.8 The latissimus dorsi flap is tunneled and inset. The skin terri-
tory of the flap is de-epithelized to fit the skin defect.
recommended that the breast and plastic surgeon operate
together because the technical aspects are more complex and
require a thorough understanding of breast vascularity and
the principles and concepts related to parenchymal advancement aps. e performance of this technique requires a
moderate degree of detachment between the breast parenchyma and the skin envelope, and a mild to moderate degree
of detachment between the parenchyma and the pectoralis
major muscle. Assessment of tissue perfusion is critical in
these cases as it can be compromised if the operation is not
performed correctly. In some patients, a small implant can
be placed under the pectoral major muscle to restore the
volume.
Preoperative assessment includes determining the degree
of ptosis and if volume replacement will be necessary. If there
is no ptosis, the nipple position does not need to change;
however, if present, the NAC may be elevated as needed,
and a small amount of infraareolar skin can be excised. If
the tumor is small and the expected volume of resection
is less than 25% of the breast perimeter, this procedure is
considered. If, however, the volume of excision exceeds this
or a multifocal tumor is present, this technique may not be
ideal or indicated due to vascular considerations. A thorough discussion about radiation therapy will be necessary as
this can result in breast distortion and capsular contracture
over time.
e salient aspects of the operation will be reviewed. A
circumvertical incisional pattern is always utilized because
this will facilitate exposure of the breast parenchyma, the
ablative portion, the parenchymal rearrangement, and the
placement of a small implant. e typical weight of the
excised specimen in these patients is small and typically
ranges from 40–100 grams. e parenchymal rearrangement typically involves advancement of the medial and lateral aspects of the parenchymal defect followed by suture
closure. If an implant is used, it is usually a low prole
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38
• Fig. 6.9 Postoperative anterior view demonstrating restoration of volume and contour.
• Fig. 6.10 Postoperative lateral view demonstrating a natural breast
slope and contour.
device ranging in volume from 80–120mL. e use of an
acellular dermal matrix can be considered. Some patients
may desire a contralateral implant or a mastopexy to achieve
symmetry. Figs. 6.11–6.15 illustrate a patient who had partial mastectomy with the biplanar oncoplastic reconstruction and a contralateral breast augmentation for symmetry.
Immediate versus Delayed Oncoplastic
Surgery
e decision regarding immediate versus staged-immediate
(delayed) oncoplasty is typically based on margin assessment
made at the time of the partial mastectomy.
20,21
Immediate
• Fig. 6.11 Preoperative view of a patient with an upper lateral quadrant
tumor scheduled for oncoplastic biplanar oncoplastic reconstruction.
oncoplastic reduction mammaplasty is performed in conjunction with lumpectomy in the majority of cases because
it will minimize the psychological eect of breast distortions. A caveat with this approach includes an increased
risk of a positive tumor margin that may compromise the
ecacy of this immediate approach and possibly result in
total mastectomy. erefore, in some patients in whom
there is uncertainty about margin status, the decision to
close the defect without oncoplasty may have merit. In the
staged immediate reconstruction, oncoplasty is performed
following pathological conrmation of a negative margin
and before radiation therapy. is is typically performed
1–2 weeks following the initial ablation and has the benet
of retaining breast conservation and obviates the need for
mastectomy.
CHAPTER 6 Plastic Surgeon’s Approach to Oncoplastic Breast Surgery
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• Fig. 6.12 The upper lateral defect extends to the pectoralis major
muscle.
39
• Fig. 6.14 Postoperative image following radiation therapy demon-
strating good symmetry. A small implant was placed under the left
breast for symmetry.
• Fig. 6.13 Intraoperative view demonstrating parenchymal rotation
above the pectoralis major muscle and placement of a small silicone
gel implant under the pectoralis major muscle.
Management of Complications
Plastic surgeons are optimally positioned for management
of complications following oncoplastic procedures. Complications include, but are not limited to, infection, seroma,
delayed healing, device failure, capsular contracture, skin
necrosis, nipple–areolar necrosis, fat necrosis, asymmetry,
sensory changes, and breast distortion.22 It is much simpler
to manage complications before radiation therapy. Radiation in and of itself can result in adverse events such as fat
atrophy, breast shrinkage, and soft tissue brosis.
e management of adverse events will be briey
reviewed. Infection is typically managed with antibiotics;
however, surgical drainage or debridement may sometimes
be required. Seroma is usually managed with observation; however, serial aspiration or surgical evacuation may
be needed. Skin and nipple necrosis may be managed
• Fig. 6.15 A postoperative complication of superficial nipple–areolar
necrosis following oncoplastic reduction mammaplasty.
conservatively with local wound care; however, debridement
and possible closure may be necessary when it occurs before
radiation therapy. Fat necrosis may be observed if small and
excised if bothersome and problematic. A biopsy may be
indicated to rule out recurrence or malignancy. e longterm sequela of fat necrosis is liquefaction necrosis. Sensory
changes to the skin or nipple are often transient but may be
permanent in 10% of patients.
References
1. Challoner T, Skillman J, Wallis K, Vourvachis M, Whisker L,
Hardwicke J. Oncoplastic techniques: attitudes and changing
practice amongst breast and plastic surgeons in Great Britain.
Breast. 2017;34:58–64.
2. Nahabedian MY. Plastic surgery: technique or discipline? Plast
Reconstr Surg. 2006;118:1653–1655.
3. Maxwell J, Arnaout A, Hanrahan R, Blackstone M. Training oncoplastic surgeons: the Canadian fellowship experience.
24(5):394–402.
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4. Honart JF, Reguesse AS, Struk S, etal. Indications and contro-
versies in partial mastectomy defect reconstruction. Clin Plast
Surg. 2018;45(1):33–45.
5. Losken AB, Nahabedian MY. Oncoplastic breast surgery: past,
present, and future directions in the United States. Plast Reconstr
Surg. 2009;124:969–972.
6. Van Paridon MW, Kamali P, Paul MA, etal. Oncoplastic breast
surgery: achieving oncological and aesthetic outcomes. J Surg
Oncol. 2017;116(2):195–202.
7. Losken A, Kapadia S, Egro FM, Baecher KM, Styblo TM, Carlson GW. Current opinion on the oncoplastic approach in the
USA. Breast J. 2016;22(4):437–441.
8. Van Deventer PV, Graewe FR. e blood supply of the breast
revisited. Plast Reconstr Surg. 2016;137:1388.
9. Wuringer E, Tschabitscher M. New aspects of the topographical anatomy of the mammary gland regarding its neurovascular
supply along a regular ligamentous suspension. Eur J Morphol.
2002;40:181–189.
10. Losken A, Dugal CS, Styblo TM, Carlson GW. A meta-analysis
comparing breast conservation therapy alone to the oncoplastic
technique. Ann Plast Surg. 2014;72:145–149.
11. Kronowitz SJ, Kuerer HM, Buchholz TA, Valera V, Hunt KK. A
management algorithm and practical oncoplastic surgical techniques for repairing partial mastectomy defects. Plast Reconstr
Surg. 2008;122(6):1631–1647.
12. Munhoz AM, Montag E, Gemperli R. Oncoplastic breast surgery: indications, techniques and perspectives. Gland Surg.
2013;2(3):143–157.
13. Losken A, Hart AM, Chatterjee A. Updated evidence on the
oncoplastic approach to breast conservation therapy. Plast Recon-
str Surg. 2017;140:14S–22S (5S Advances in Breast Reconstruction).
14. Hamdi M, Van Landuyt K, Hijawi JB, Roche N, Blondeel P,
Monstrey S. Surgical technique in pedicled thoracodorsal artery
perforator aps: a clinical experience with 99 patients. Plast
Reconstr Surg. 2008;121:1632.
15. Munhoz AM, Montag E, Arruda EG, etal. e role of the lateral thoracodorsal fasciocutaneous ap in immediate conservative breast surgery reconstruction. Plast Reconstr Surg. 2006;117:
1699.
16. Smith ML, Molina BJ, Dayan E, et al. Dening the role of
free aps in partial breast reconstruction. J Reconstr Microsurg.
2018;34(3):185–192.
17. Nahabedian MY, Patel K, Kaminsky AJ, Cocilovo C, Miraliakbari R. Biplanar oncoplastic surgery: a novel approach to breast
conservation for small/medium sized breasts. Plast Reconstr Surg.
2013;132:1081–1084.
18. Miraliakbari R, Kaminsky AJ, Patel KM, Cocilovo C, Nahabedian MY. e biplanar oncoplastic technique: a 2-year review.
Gland Surg. 2015;4(3):257–262.
19. Barnea Y, Friedman O, Arad E, etal. An oncoplastic breast
augmentation technique for immediate partial breast reconstruction following breast conservation. Plast Reconstr Surg.
2017;139:348e.
20. Patel KM, Hannan C, Gatti M, Nahabedian MY. A head to head
comparison of quality of life and aesthetic outcomes following
immediate, staged-immediate, and delayed oncoplastic reduction
mammaplasty. Plast Reconstr Surg. 2011;127(6):2167–2175.
21. Egro FM, Pinell-White X, Hart AM, Losken A. e use of reduction mammaplasty with breast conservation therapy: an analysis
of timing and outcomes. Plast Reconstr Surg. 2015;135:963e.
22. Mattingly AE, Ma Z, Smith PD, et al. Early postoperative complications after oncoplastic reduction. South Med J.
2017;110(10):660–666.
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Volume Displacement and Volume
Replacement Techniques
ALEX N. MESBAHI AND LOUISA YEMC
Introduction
Breast conservation therapy, or partial mastectomy, continues to be a popular treatment option for breast cancer
patients. As a result, the demand for suitable oncoplastic
reconstructive options is imperative.
supported by the increased use of neoadjuvant chemotherapy, rise of mammographic screening leading to earlier
detection of breast cancers, and proliferation of breast cancer reconstruction awareness.
breast radiation therapy and intraoperative radiation technique support breast conservation therapy displaying eective local control with potentially less soft tissue damage and
long-term soft tissue sequelae.
Most defects created from breast conservation therapy
can be closed primarily; however, the aesthetic outcomes are
often unpredictable.8 Adjuvant radiation therapy may distort
the breast, and the ensuing scarring and brosis can make it
dicult to correct. Some of the clinical changes to the breast
seen with breast conservation therapy include asymmetry,
skin dimpling, contour irregularity, and nipple retraction.
ese obstacles were considered by Werner Audretsch who
provided the German experience of repairing lumpectomy
defects before radiation to American plastic surgeons in the
late 1990s.9 is was considered a revolutionary concept
at the time. Although breast conservation and mastectomy
therapies result in equivalent long-term survival, oncoplastic
reconstruction following breast conservation was historically
slow to catch on in the United States.10 Although advancements in technology and surgical technique have emerged
with time, the primary consideration in breast conservation
reconstruction has always remained consistent: tumor-tobreast size ratio. A large tumor in a small breast presents
reconstructive challenges due to minimal remaining breast
parenchyma following excision. Conversely, small to moderate tumors in a large breast allow for many reconstructive
approaches. ese fundamental considerations create the
basis for the volume displacement and replacement techniques to be discussed in this chapter.
1,2
is trend has been
3-5
Advancements in partial
6-7
Volume loss is conceivably the most important change
with breast conservation therapy. With oncoplastic reconstruction, volume loss can be corrected. Small to moderate
losses of volume allow for the use of volume displacement
techniques including parenchymal remodeling and plication practices, local tissue rearrangement, and mastopexy or
reduction (Table 7.1). Larger losses of breast volume call for
volume replacement techniques like adjacent or distant tissue
transfers, fat transfers, and even implant placement.11 When
anticipated volume loss exceeds 50% and the reconstructive
plan entails using a distant tissue transfer, the option of mastectomy should be given strong consideration. In this setting, the potential advantages of breast conservation therapy
including preservation of breast tissue and sensation, less
surgical invasiveness, and shorter recovery are lost.
Timing of Repair
e timing of oncoplastic reconstruction can be at the time of
the lumpectomy or partial mastectomy (immediate), after the
tumor excision but before radiation (staged immediate), or at
an unspecied time after radiation therapy (delayed). Whenever possible, immediate reconstruction should be favored by
TABLE
Partial Mastectomy Reconstruction
7.1
Techniques
Volume Displacement
Techniques
• Primary closure
• Breast parenchyma
plication
• Breast flap advancements
• Nipple–areolar centralization
• Small volume fat injection
• Mastopexy techniques
• Reduction techniques
Volume Replacement
Techniques
• Adjacent tissue transfer
• Local fasciocutaneous flaps
• Local perforator flaps
• Pedicled latissimus myocutaneous flap
• Pedicled TRAM myocutaneous flap
• Free flaps
• Large volume fat transfer
• Implant placement
42
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