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Oncoplastic Surgery of
the Breast
Second Edition
Edited by
Maurice Y. Nahabedian, MD, FACS
Professor
Department of Plastic Surgery
Virginia Commonwealth University - Inova Branch
Falls Church, VA, USA
For additional online content visit ExpertConsult.com.
© 2020, Elsevier Limited. All rights reserved.
First edition, 2009
Second edition, 2020
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s
permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the
Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).
Videos Batwing reduction, Split reduction, Split reduction with intraoperative radiation therapy (IORT), Wise pattern
copyright Nirav B. Savalia.
Notices
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. Because of rapid advances
in the medical sciences, in particular, independent verication of diagnoses and drug dosages should be
made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors, or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or
otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the
material herein.
ISBN: 978-0-7020-7680-0
eISBN: 978-0-7020-7681-7
Content Strategist: Belinda Kuhn
Content Development Specialist: Kim Benson
Project Manager: Andrew Riley
Design: Amy Buxton
Illustration Manager: Paula Catalano
Illustrator: Paul Kim
Marketing Manager: Claire McKenzie
Printed in Poland
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Preface
I am proud to introduce the second edition of Oncoplastic Surgery of the Breast. It has been 10 years since the rst
edition. As the eld of oncoplastic surgery continues to
evolve with new concepts and strategies being introduced
every year, it is important for surgeons around the world to
remain current. e safety and ecacy of oncoplastic breast
surgery has clearly been demonstrated as patient outcomes
have continued to improve and patient satisfaction has continued to soar. is second edition has made every eort to
incorporate the new ideas and innovations into a comprehensive text that is state-of-the-art and up-to-date in every
respect.
e second edition has been organized into 3 sections
and 21chapters. e three sections are focused on getting started, review of techniques, and outcomes. Most of
the authors are new and were chosen to prepare a chapter
based on their contributions to the eld and track record
for success. As with the rst edition, the second edition
includes new instructional videos that complement most of
the chapters and facilitates the readers’ ability to perform
these operations. ere are several chapters that are completely new that will introduce readers to novel approaches
to oncoplastic breast surgery. I am excited about the Breast
Augmentation Technique (Biplanar) for Oncoplasty prepared by Dr. Barnea. is has been an eective approach in
my practice that can provide excellent cosmetic outcomes.
Dr. Sivalia, Dr. Khan, and Dr. Silverstein have prepared an
excellent chapter on Extreme Oncoplasty that expands the
indication for oncoplasty in properly selected patients. ey
have contributed three wonderful videos that demonstrate
their techniques in a well-described and simplied manner.
Dr. Reiland will provide the breast surgeon’s perspective on
oncoplastic breast surgery in this ever-expanding eld.
ere are several individuals I would like to thank whose
eorts were instrumental in the preparation of this book.
First and foremost are the authors who prepared the chapters. ey are all very busy, exceptionally talented, and have
sacriced a signicant amount of their time for this project.
Second are the sta at Elsevier for their hard work and commitment toward publishing this textbook that has exceeded
all of our expectations. Finally, I would like to again thank
my family, Anissa, Danielle, and Sophia, for their support,
patience, and understanding during the many hours spent
in the preparation of this book.
Maurice Y. Nahabedian, MD, FACS
vi
List of Contributors
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e editor(s) would like to acknowledge and oer grateful
thanks for the input of all previous edition’s contributors,
without whom this new edition would not have been
possible.
Yoav Barnea, MD
Head, Plastic, and Reconstructive Breast Surgery Unit
Plastic Surgery
Tel Aviv Medical Center, aliated with the Sackler Faculty
of Medicine
Tel Aviv University
Tel Aviv, Israel
Grant W. Carlson, MD
Wadley R. Glenn Professor of Surgery
Surgery
Emory University
Atlanta, G, USA
Costanza Cocilovo, MD
Medical Director
Breast Surgery
Inova
Farifax, VA, USA
Randy De Baerdemaeker, MD, FCCP, FEBOPRAS
Member of Sta
Department of Plastic, Reconstructive, and Aesthetic
Surgery
University Hospital Brussels
Brussels, Belgium
Kirsten Edmiston, MD
Medical Director
Inova Breast Care Center
Inova Fair Oaks Hospital
Fairfax, VA, USA
Clinical Assistant Professor
Department of Surgery
VCU/Inova Fairfax Medical Center
Fairfax, VA, USA
Kenneth L. Fan, MD
Resident Physician
Department of Plastic and Reconstructive Surgery
MedStar Georgetown University Hospital
Washington, DC, USA
Jian Farhadi, MD, PD
Consultant
Plastic and Reconstructive Surgery
Guy’s and St. omas Hospital
London, UK;
Professor
University of Basel
Basel, Switzerland
Plastic Surgeon
Plastic Surgery Group
Zurich, Switzerland
Allen Gabriel, MD, FACS
Peacehealth Plastic Surgery
Peacehealth
Vancouver, WA, USA
United States
Clinical Associate Professor
Plastic Surgery
Loma Linda University Medical Center
Loma Linda, CA, USA
Moustapha Hamdi, MD, PhD
Professor
Plastic and Reconstructive Surgery
Brussels University Hospital
Brussels, Belgium
Tammy Ju, MD
Surgery Resident
Surgery
George Washington University Hospital
Washington, DC, USA
vii
viii
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List of Contributors
Sadia Khan, DO, FACS
Program Advisor - Breast Surgical Services
Breast Surgical Oncology
Hoag Memorial Hospital Presbyterian
Newport Beach, CA, USA
Assistant Clinical Professor
Department of Surgery
Keck School of Medicine USC
Los Angeles, CA, USA
Steven J. Kronowitz, MD
Owner
Kronowitz Plastic Surgery, PLLC
Houston, TX, USA
Albert Losken, MD, FACS
Emory University
Division of Plastic and Reconstructive Surgery
Emory University Hospital
Atlanta, GA, USA
Jaume Masia, MD, PhD
Chief and Professor
Plastic Surgery
Sant Pau University Hospital (Universitat Autonoma de
Barcelona)
Barcelona, Spain
Alex N. Mesbahi, MD
Assistant Clinical Professor
Plastic Surgery
Georgetown University Hospital
Washington, DC, USA
Bridget A. Oppong, MD
Reston Breast Care Specialists
Surgery
Reston Hospital Center
Reston, VA, USA
Adjunct Faculty
Lombardi Comprehensive Cancer Center
Georgetown University
Washington, DC, USA
Gemma Pons, MD, PhD
Head of the Microsurgery Unit
Plastic Surgery
Hospital de Sant Pau
Barcelona, Spain
Consultant
Plastic Surgery
Hospital de Sant Pau
Barcelona, Spain
Juliann Marie Reiland, MD
Program Director, Electron-based IORT Breast
Oncology
Avera Cancer Institute
Sioux Falls, SD, USA
Clinical Associate Professor
Surgery
Sanford School of Medicine
Sioux Falls, SD, USA
Chair: ASBrS Oncoplastic Surgery Committee
American Society of Breast Surgeons
Partner
National Center for Plastic Surgery
McLean, VA, USA
Alexandre Mendonça Munhoz, M, PhD
Plastic Surgery
Hospital Sírio-Libanês, São Paulo
São Paulo, Brazil
Professor
Plastic Surgery
Instituto do Câncer do Estado de São Paulo, São Paulo
Sao Paulo, Brazil
Maurice Y. Nahabedian, MD
Professor
Department of Plastic Surgery
Virginia Commonwealth University - Inova Branch
Falls Church, VA, USA
Jordi Riba Vílchez, MD
Plastic Reconstructive and Aesthetic Surgery Department
Hospital de Sant Pau
Barcelona, Spain
Rachel Rolph, MBBS MA(Oxon) MRCS
Clinical Research Fellow
Department of Plastic and Reconstructive Surgery
Guys and St omas’ NHS Foundation Trust
London, UK
Nirav B. Savalia, MD
Clinical Assistant Professor of Surgery
Plastic Surgery
USC/Keck School of Medicine
Los Angeles, CA, USA
Program Director for Oncoplastic and Aesthetic Breast
Surgery
Hoag Hospital Memorial Presbyterian
Newport Beach, CA, USA
List of Contributors
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ix
Hani Sbitany, MD, FACS
Associate Professor of Surgery
Plastic and Reconstructive Surgery
University of California
San Francisco, USA
Melvin J. Silverstein
Hoag Hospital Memorial Presbyterian
Newport Beach, CA, USA
Department of Surgery, Keck School of Medicine,
University of Southern California
Los Angeles, CA, USA
Toni Storm-Dickerson, BS, MD
Director
Surgical Services Compass Breast
Compass Oncology
Vancouver, WA, USA
Medical Director Surgical Services
Kearney Breast Center
PeaceHealth Vancouver
Vancouver, WA, USA
Christine Teal, MD
Director, Breast Care Center
Surgery
George Washington University
Washington, DC, USA
Peter W. Thompson, MD
Assistant Professor of Plastic Surgery
Surgery
Emory University
Atlanta, GA, USA
Mark Venturi, MD, FACS
Private Practice
Plastic Surgery
National Center for Plastic Surgery
McLean, VA, USA
Louisa Yemc, PA-C
National Center for Plastic Surgery
McLean, VA, USA
I would like to dedicate this second edition of Oncoplastic Surgery of the Breast to my long-
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time friend and associate, Scott Spear, MD. Scott was an inspiration to plastic and breast
surgeons around the world whose valuable insights and pearls of wisdom helped thousands
of surgeons who ultimately were able to help tens of thousands of patients. I was fortunate
to work with him at Georgetown University Hospital from 2005–2013, where he was the
founding Chairman of the Department of Plastic Surgery. Scott taught me to think critically,
analyze precisely, and to plan and execute accordingly. He raised the bar for all of us when it
came to surgical and aesthetic outcomes following reconstructive and aesthetic breast surgery.
I would also like to dedicate this book to the 69 plastic surgery chief residents that I have
had the privilege to work with and train while on the faculty at Johns Hopkins and Georgetown Universities from 1996–2017. eir desire to learn was my inspiration to teach both in
the operating room and in the research arena. e friendships that have been established have
stood the test of time, and I am so proud of each and every one of them. Special thanks to
Mark Venturi, MD, and Alex Mesbahi, MD, who were two of my plastic surgery residents. It
has been a privilege to become a partner in their practice where we continue to provide state
of the art reconstructive and aesthetic breast surgery for our patients.
Finally I would like to thank my wife, Anissa, and my two daughters, Danielle and
Sophia. eir endless support and encouragement have made it possible to continue to educate
and teach surgeons around the world and to provide patients with the highest quality care
possible.
Maurice Y. Nahabedian, MD, FACS
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1
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Introduction to Oncoplastic
Breast Surgery
MAURICE Y. NAHABEDIAN
Oncoplastic breast surgery has become a common option
for women with breast cancer. Oncoplastic surgery is
dened as tumor excision with a wide margin of resection
followed by immediate or staged immediate reconstruction
of the partial mastectomy defect. It diers from traditional
breast conservation in that the margin of excision is signicantly wider ranging from 1–2 cm rather than 1–2 mm.
Oncoplastic breast surgery has been demonstrated to be
safe and eective and results in high patient satisfaction.
is introductory chapter will review the evolution and
many of the milestones associated with ablative breast cancer surgery and how oncoplastic breast surgery has evolved
as a primary option for women diagnosed with breast cancer.
History of Mastectomy
e management of breast cancer has been subject to
several paradigm shifts over the past century. Before the
era of William Stewart Halstead, the diagnosis of breast
cancer was often associated with few options for management and poor patient survival. With the introduction of
the radical mastectomy, the morbidity and mortality of
breast cancer was markedly improved; however, the disgurement following this operation was signicant.1 e
modied radical mastectomy (MRM), in which the pectoral major muscle was preserved and the axillary lymph
node basin was dissected, maintained similar survival
statistics with slightly less physical disgurement.
simple mastectomy in conjunction with radiation therapy
was introduced at the same time and continued to provide
less aggressive surgical techniques.5 Further renements in
mastectomy techniques allowed for skin-sparing patterns
that were demonstrated to equivalent local recurrence and
survival rates.
node biopsy (SLNB) for breast cancer, the need to perform an axillary dissection was signicantly reduced, and
the simple mastectomy with SLNB has become a common
mastectomy strategy.
6-8
With the introduction of sentinel lymph
9,10
e most recent innovation has
2-4
e
been the widespread acceptance of nipple-sparing mastectomy for malignant disease that has been applied to women
in select situations.
e common feature of the early mastectomy techniques was that the breast was removed, and the likelihood of disgurement was high. is ultimately led to the
need for reconstructive techniques that could minimize
this disgurement. e advancements in breast reconstruction paralleled the advancements in mastectomy so
these disgurements could be eliminated. Reconstructive
options have included prosthetic devices, musculocutaneous aps, and perforator aps.
techniques has made a signicant impact when it came
to mastectomy and outcome; however, the breast conservation therapy (BCT) movement had been initiated and
represented a new frontier in the management of breast
cancer.
11-15
16-23
e evolution of these
History of Breast Conservation
e breast conservation movement began to move forward
as our understanding of the pathophysiology of breast cancer improved and optimal utilization of radiation therapy
became standardized. e notion that total mastectomy
was not an absolute requirement and that lumpectomy
could be performed with equivalent safety and ecacy was
a signicant breakthrough.
tion of the nipple–areolar complex in many cases as well
as maintaining breast shape in the majority of women.26
Common to all patients having BCT is the need for postoperative radiation to eradicate microscopic disease that may
be present.
Outcomes following BCT have been generally favorable with survival statistics that have remained essentially
equal to that of MRM.27 However, local recurrence rates
are slightly increased. Although the aesthetic outcomes following BCT have been good to excellent in the majority
of women, some have required secondary procedures to
improve the appearance and achieve symmetry.28
24,25
Benets included preserva-
2
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