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• Fig. 14.6 (Clinical Case 1): (A, B) Preoperative frontal view, left oblique view of a 43-year-old patient
with previous superior left quadrantectomy and immediate reconstruction with submuscular implant and
breast advancement flaps through periareolar approach. (C) Preoperative markings showing the mastopexy planning, the area of AFG and contralateral procedure. (D–F) The patient underwent to delayed
BCS reconstruction with bilateral mastopexy, implant change and AFG on the upper pole of the left
breast. (E, F) Postoperative (1 year) frontal view, left oblique view following BCS reconstruction with AFG
associated with bilateral mastopexy, showing a very good outcome.
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TABLE
Conducted Clinical Studies Concerning Breast Conservative Surgery Reconstruction with Autogenous Fat
14.2
Grafting
Author Year No. pts Mean Age (ys) Timing of Reconstruction Follow-up (months) LR (%)
Petit etal.
Petit etal.
Rietjens etal.
Delay etal.
Semprini etal.
Brenelli etal.42 2014 59 50 Delayed 34 3
Gale etal.
Kronowitz etal.482016 69 NR Delayed 60 1
Garcia etal.
Mestak etal.51 2015 32 53 Delayed 19 2
Biazus etal.
Turnhout etal.
Khan etal.9 2017 35 49 Immediate 36 0
Mirzabeigi etal.332017 20 53 Delayed/Brava 25 0
Munhoz etal. 2018 53 49 Delayed 56 0.5
LR, local recurrence; No. pts, number of patients; NR, not reported; ys, years; Personnal communication.
14
48
10
49
15
13
2011 143 NR Delayed/Immediate 18 13
2013 12 NR Delayed/Immediate 63 2
46
2011 62 NR Delayed 19 1
2007 42 51 Delayed 19 2
50
2014 151 NR Delayed 45 0
2015 35 NR Delayed 34 2
2016 37 55 Immediate 12 0
2015 20 55 Delayed/Immediate 18 0
24
2017 109 55 Delayed 26 0.7
approximately 3–4 weeks, edema in 2–4 months, and the
nal result can be observed after 4 months. Local infection
may be noted but is infrequent. Infections in the donor area
and breast can normally be managed using systemic or local
antibiotics with satisfactory outcome. In our clinical experience, no cases of moderate to severe hematoma, pneumothorax, and fat embolism were observed.
Long-term complications include microcalcications,
fat necrosis, cysts, and contour irregularities in the donor
areas. ese complications are more frequently observed
when a large volume of AFG is injected and are more
common during the learning curve period or when large
cannulas are used. Microcalcications are usually easy to
identify, and in our experience these image alterations are
less frequent in this procedure than in reduction mammoplasty, which can produce up to 85% of postoperative
radiological features.
42,54,55
Microcalcications tend to
have a round, regular appearance with a light center and
are completely dierent from calcications associated with
local relapse and classied as ACR 2 (American College
of Radiology). Most breast images associated with AFG
are easily recognized as benign lesions by an experienced
radiologist.
42,50,54
Donor area complications such as depressions, nodules,
and irregularities can be produced by aggressive AFG harvesting. To avoid these unsatisfactory results, it is important
to harvest fat the same way that conventional aesthetic liposuction/liposculpture would be performed.20
Postoperative Care
All patients received intravenous antibiotics, and oral antibiotics were continued for 48 hours. Immobilization with
an occlusive dressing should be used for 3 days to improve
scarring. Elastic bands or straps over the grafting areas of
the breasts should not be used, to avoid pressure and fat
reabsorption. In terms of postoperative care, early massaging or mobilization of the breasts should also be avoided
for at least three weeks. It is essential for patients to avoid
physical activities for a period of time following surgery
to minimize the risk of fat necrosis and other complications. As breast edema diminishes, bra tension will require
adjustment, and patients are seen at appropriate intervals
to evaluate the outcome. e nal result can be observed
3–4 months after AFG procedure, and in case of inadequate
correction, supplementary surgeries can be indicated, each
3 or 4 months apart.
Conclusions
Advances in AFG techniques have led to an important
improvement in aesthetic outcomes for BCS. is technique is most frequently used in delayed reconstructions
and to repair partial breast defects, where thin tissue and
irregularities provide inadequate volume/coverage. Most
of the complications in our series were minor and did not
impact aesthetic outcomes or normal follow-up. e ideal
CHAPTER 14 Lipolling and Oncoplasty
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aesthetic result must provide a natural contour and achieve
adequate symmetry and shape. To achieve these results, surgeons have increasingly relied on associated maneuvers such
as the Coleman technique, closed systems for AFG ltration, and recipient site pre-expansion in selected cases. is
chapter presents an overview of the oncoplastic approach
to primary and secondary BCS reconstruction with AFG.
Ultimate success will depend on proper patient selection
and careful intraoperative and postoperative management.
References
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24. Van Turnhout AA, Fuchs S, Lisabeth-Broné K, Vriens-Nieuwenhuis
EJC, van der Sluis WB. Surgical outcome and cosmetic results
of autologous fat grafting after breast conserving surgery and
radiotherapy for breast cancer: a retrospective cohort study of
222 fat grafting sessions in 109 patients. Aesthetic Plast Surg.
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25. Khouri RK, Rigotti G, Khouri Jr RK, Cardoso E, Marchi A,
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26. Munhoz AM, Montag E, Arruda E, Aldrighi C, Gemperli R, Aldrighi JM, etal. e role of the lateral thoracodorsal fasciocutaneous ap in immediate conservative breast surgery reconstruction.
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27. Munhoz AM, Montag E, Arruda E, Arruda EG, Sturtz GP, Aldrighi C, etal. Outcome analysis of breast-conservation surgery
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28. Zhu L, Mohan AT, Vijayasekaran A, Hou C, Sur YJ, Morsy M,
etal. Maximizing the volume of latissimus dorsi ap in autologous breast reconstruction with simultaneous multisite fat grafting. Aesthet Surg J. 2016;36(2):169–178.
29. Largo RD, Tchang LA, Mele V, Scherberich A, Harder Y,
Wettstein R, etal. Ecacy, safety and complications of autologous fat grafting to healthy breast tissue: a systematic review. J
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30. Gir P, Brown SA, Oni G, Kashe N, Mojallal A, Rohrich R.
Fat grafting: evidence-based review on autologous fat harvesting, processing, reinjection, and storage. Plast Reconstr Surg.
2012;130:249–260.
31. Saint-Cyr M, Rojas K, Colohan S, Brown S. e role of fat grafting in reconstructive and cosmetic breast surgery: a review of the
literature. J Reconstr Microsurg. 2012;28(2):98–107.
32. Rosing JH, Wong G, Wong MS, Sahar D, Stevenson TR, Pu LL.
Autologous fat grafting for primary breast augmentation: A systematic review. Aesth Plast Surg. 2011;35:882–890.
33. Mirzabeigi MN, Lanni M, Chang CS, Stark RY, Kovach SJ, Wu
LC, etal. Treating breast conservation therapy defects with brava
and fat grafting: technique, outcomes, and safety prole. Plast
Reconstr Surg. 2017;140(3):372–381.
34. Coleman SR, Saboeiro A. Fat grafting to the breast revisited:
safety and ecacy. Plast Reconstr Surg. 2007;119:775–785.
35. Khater R, Atanassova P, Anastassov Y, Pellerin P, MartinotDuquennoy V, etal. Clinical and experimental study of autologous fat grafting after processing by centrifugation and serum
lavage. Aesthetic Plast Surg. 2009;33:37–43.
36. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat
transfer viability: a quantitative analysis of the role of centrifugation and harvest site. Plast Reconstr Surg. 2004;113:391–395.
37. Mestak O, Sukop A, Hsueh YS, Molitor M, Mestak J, Matejovska J, etal. Centrifugation versus PureGraft for fat grafting to
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38. Zhu M, Cohen SR, Hicok KC, Shanahan RK, Strem BM, Yu
JC, et al. Comparison of three dierent fat graft preparation
methods: gravity separation, centrifugation, and simultaneous
washing with ltration in a closed system. Plast Reconstr Surg.
2013;131(4):873–880.
39. ASPRS Ad-Hoc Committee on New Procedures. Report on
autologous fat transplantation. Plast Surg Nurs. 1987;7:140–141.
40. Gutowski KA, ASPS Fat Graft Task Force. Current applications
and safety of autologous fat grafts: a report of the ASPS fat graft
task force. Plast Reconstr Surg. 2009;124:272–278.
41. Gennari R, Griguolo G, Dieci MV, Guarneri V, Tavaniello B,
Sibilio A, etal. Fat grafting for breast cancer patients from basic
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42. Brenelli F, Rietjens M, De Lorenzi F, Pinto-Neto A, Rossetto
F, Martella S, etal. Oncological safety of autologous fat grafting after breast conservative treatment: a prospective evaluation.
Breast J. 2014;20(2):159–165.
43. Schaer A, Scholmerich J, Buechler C. Mechanisms of disease:
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45. Delay E, Garson S, Tousson G, Sinna R. Fat injection to the
breast: technique, results, and indications based on 880 procedures over 10 years. Aesthet Surg J. 2009;29:360–376.
46. Rietjens M, De Lorenzi F, Rossetto F, Brenelli F, Manconi A,
Martella S, etal. Safety of fat grafting in secondary breast reconstruction after cancer. J Plast Reconstr Aesthet Surg. 2011;64:477–
483.
47. Petit JY, Rietjens M, Botteri E, Rotmensz N, Bertolini F, Curigliano G, etal. Evaluation of fat grafting safety in patients with
intraepithelial neoplasia: a matched-cohort study. Ann Oncol.
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48. Kronowitz SJ, Mandujano CC, Liu J, Kuerer HM, Smith B, Garvey P, etal. Lipolling of the breast does not increase the risk
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Reconstr Surg. 2016;137:385–393.
49. Gale KL, Rakha EA, Ball G, Tan VK, McCulley SJ, Macmillan
RD, etal. A case-controlled study of the oncologic safety of fat
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50. Semprini G, Cattin F, Zanin C, Lazzaro L, Cedolini C, Vaienti L,
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15
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Extreme Oncoplasty
NIRAV B. SAVALIA, SADIA KHAN, AND MELVIN J. SILVERSTEIN
Introduction
e surgical management of breast cancer has seen a paradigm shift from radical ablation to maximum conservation.
e Halstedian radical mastectomy of the late 1800s gradually evolved by 1975 to spare muscle, lymph nodes, skin,
and ultimately manifested in the modern-day nipple–areola
sparing mastectomy. e 1970s and 1980s brought forth
prospective randomized trials supporting breast conserving
therapy for tumors ≤5 cm as a viable alternative to mastectomy. Breast conserving therapy was widely adopted and
evolved from quadrantectomies requiring wide margins to
localized wire-directed excisions requiring merely no ink
on tumor. ese advances in breast conservation allowed
a cosmetic benet to the patient without sacricing oncologic care. Unfortunately, many patients were left with postlumpectomy deformities that compromised the aesthetic
goal of the operation. e advent of oncoplastic surgery was
led by the awareness of these post-lumpectomy deformities
and gradual acceptance of the concept that optimal oncologic care and breast cosmesis are not mutually exclusive. As
a result, post-lumpectomy deformities were not deemed an
inevitable or unavoidable outcome and proactive measures
to reduce their incidence were encouraged. Oncoplastic surgery further advanced breast conservation to allow larger
and larger resections, while still maintaining the aesthetic
appearance of the breast.
Modern medical therapies, with improved hormonal and
chemotherapy, new techniques and protocols in radiation
oncology, and a better understanding of the biology of breast
cancer, have improved overall and breast cancer specic survival. Naturally, local recurrence rates have improved after
both mastectomy and breast conservation. Recent prospective randomized trials have demonstrated local recurrence
rates less than 1.5% at 5 years for patients randomized to
excision plus whole breast radiotherapy.
spective randomized trials studying breast conservation
were only conducted for tumors ≤5 cm. Consequently,
women with tumors >5 cm, or those with multicentric or
multifocal disease, are often denied breast conservation and
are relegated to mastectomy with adjuvant radiotherapy.
1,2
However, pro-
Oncoplastic surgery presents an opportunity to reexamine this paradigm. A successful aesthetic result after
oncoplastic surgery largely depends on a favorable tumorto-breast volume ratio and the application of appropriate
tissue rearranging maneuvers.
narios is a small tumor in the lower pole of a large breast
that is easily addressed with a standard Wise pattern or
vertical pattern mammaplasty. However, when tumors are
in unfavorable locations, are close to the overlying skin, or
involve the skin, these standard techniques can be modied to still allow an oncoplastic reconstruction, albeit with
nontraditional scar patterns. Gradually, we have evolved
to push the limits of these techniques and apply to them
to patients with less favorable tumor:breast volume ratios.
With experience, it becomes apparent that even patients
with >5 cm tumors, or those with multifocal or multicentric disease, can potentially have breast conservation while
still achieving excellent cosmetic outcomes. It is particularly
tempting when comparing this reconstructive approach to
a post-mastectomy reconstruction. Patients with large or
locally advanced tumors typically require post-mastectomy
radiotherapy. Implant-based reconstruction with radiotherapy is fraught with poor results and higher complication
rates. Autologous reconstruction avoids this issue but often
requires multiple procedures and long recovery periods.
With current data reporting low local recurrence rates, the
impetus for defaulting to mastectomy is fading. Although
it is unlikely that randomized prospective data will be gathered to support breast conservation for >5 cm tumors, there
is clear interest in this concept, as evidenced by a growing
body of literature dedicated to this topic.
At our institution, oncoplastic reconstruction is oered
to all patients whenever technically feasible. Extreme onco-
plasty is the term applied to a specialized concept for a
breast conserving operation, using oncoplastic techniques,
in a patient who, in most physicians’ opinions, requires a
mastectomy. Extreme oncoplasty applies to breast conservation using a reduction mammaplasty technique in
patients with larger lesions, with the goal of clear surgical
margins, while maintaining or improving the cosmetic outcome. ese lesions are generally large, >5 cm, multifocal,
3,4
One of the simplest sce-
5-10
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or multicentric tumors. ey may be locally advanced, and
many will have positive lymph nodes. Most of these patients
will require radiation therapy, even if they are treated with
mastectomy.
10,11
Oncoplastic reconstruction generally yields a cosmetic
result superior to a mastectomy with immediate reconstruction and radiation therapy. ere is less operative and postoperative morbidity with extreme oncoplasty, fewer surgeries
required, and nally, radiation therapy is far kinder to breast
conservation than to mastectomy with reconstruction.
10,11
Patient Selection
e ideal patient for extreme oncoplasty is a woman with a
large breast, who desires a smaller breast, who desires breast
conservation, and has disease limited to a single quadrant,
with limited comorbidities. Naturally, not all patients meet
every one of the criteria, and many decisions are made on
a case-by-case basis. Neoadjuvant chemotherapy is often
utilized to downstage a patient and convert from obligatory mastectomy to potential breast conservation. e overriding theme is that if a method of reconstruction with a
volume-displacing technique is possible, regardless of the
aforementioned criteria, then the patient is a candidate. e
value of extreme oncoplasty is in its ability to condense surgical therapy. e patient will undergo the ablative surgery,
immediate reconstruction, and immediate contralateral
breast surgery within a 3-hour outpatient operation. e
recovery is usually rapid, similar to the recovery process of a
reduction mammaplasty, and there are no additional reconstructive procedures necessary. Although most patients are
treated with volume displacement oncoplasty, occasionally
a volume replacement technique involving local fasciocutaneous aps (e.g., LICAP) may be utilized. Regional or
distant tissue transfer techniques for oncoplastic reconstruction are usually not utilized, given the uncertainty of margin
status at the time of reconstruction. Delayed partial breast
reconstruction with autologous methods is another option;
however, these patients may be better suited for mastectomy if they are considering this signicant investment in
reconstruction.
Preoperative History and Consideration
Oncoplastic surgery requires a multidisciplinary approach
and thorough preoperative planning. Multidisciplinary
planning requires discussion, at minimum, with the oncologic surgeon, radiologist, and plastic surgeon; however,
other team members should be included as well. Oncoplastic surgery requires a philosophy that the appearance
of the breast after tumor excision is important. All preoperative imaging tests must be carefully evaluated and integrated with information about the pathological subtype,
tumor size, location in relation to the nipple, skin quality,
and patient preferences. Other concerns include invasive
lobular cancers that may be larger on the microscopic level
than expected based on initial imaging, extensive in situ
components with similar risk for understaging on imaging.
Also, radiation eects on the size and shape of the ipsilateral
breast compared with the contralateral side undergoing a
symmetry procedure must be considered.
A common misconception is that the goal of breast
reconstruction is to create the “perfect breast.” e goal
should be to achieve an outcome that best suits the patient’s
goals for reconstruction and desires for nal breast appearance, while still considering the primary goal of treating the
cancer. e reconstructive plan can be formulated only after
analysis of the tumor size and location; the preoperative
breast shape, size, and degree of ptosis; and understanding
the patient’s oncologic and reconstructive desires. e ideal
is to minimize the amount of surgery, recovery period, risk
of complications, and surgical failure rates, while maximizing the desired aesthetic and oncologic outcome.
12
At our institution, the oncologic breast surgeon assumes
the role of “leader” to guide the team and ensure excellent
communication among all team members. During the rst
visit we generate a surgical plan, called the “Flight Plan,” that
summarizes the diagnosis, includes photos of the patient’s
chest and relevant imaging, and lists the plan of action leading up to and including the planned operation (Fig. 15.1).
e surgical plan is given to the patient, as well as distributed to all team members, and updated as the patient moves
through the consultation process.
Preoperative work-up should include a full history and
physical, paying close attention to prior breast surgery and
location of prior surgical incisions. Breast imaging should
include a combination of mammogram, ultrasound, and
breast magnetic resonance imaging (MRI). MRI can often
better determine extent of disease in mammographically
subtle ndings and has improved sensitivity for invasive
lobular carcinoma.13
Indications and Contraindications
Historically, women were commonly left feeling maimed
after breast cancer surgery when a lumpectomy cavity was
left to form a seroma that later resorbs, leading to deformation after radiation therapy (Fig. 15.2). In a typical lumpectomy, an incision is made over the tumor, the tumor is
removed, and no specic eort is made to ll the defect left
with remaining breast tissue. Even when surrounding breast
tissue is used to ll with a small local tissue ap advancement, this can still lead to puckering or dimpling when the
patient is out of the supine position and sitting or standing
upright. Unfortunately, as many as 36% of simple excisions
fail to achieve adequate margins in a single operation, leading to re-excision, worsening cosmesis, and conversions to
mastectomy.14 Oncoplastic surgery, using a reduction mammaplasty, allows removal of the tumor but also prevents
undue distortion of the breast by allowing the defect to be
lled with remaining breast tissue.
Oncoplastic surgery can be performed in tandem with
a lumpectomy in most cases where the tumor is ≤5 cm.
Extreme oncoplasty can be considered when women with
SURGEON NAME
DATE
PATIENT NAME
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Diagnosis: 61F presents with LEFT BREAST mass spanning 30x34x20mm
on MRI at 2:00 6cm from Nipple - Invasive Ductal Carcinoma Grade 3,
SBR 8/9 ER+ 100% PR+100% HER2 NEG Ki67 10%. FH: Sister and
Maternal Aunt with Breast CA.
CHAPTER 15 Extreme Oncoplasty
PATIENT MRN
119
LEFT Breast Invasive Ductal CA - Clinical Stage cT2N0, Stage IIA
PLAN:
1. Genetic Testing - PENDING
2. Medical Oncology Consultation
3. Radiation Oncology Consultation
4. Plastic Surgery Consultation for LEFT breast oncoplastic Split
Reduction with contralateral mastopexy for symmetry
5. SURGICAL PLAN: LEFT BREAST wire directed segmental resection,
LEFT axillary sentinel lymph node biopsy with possible axillary lymph
node dissection
• Fig. 15.1 Surgical plan sheet that includes summary of pathology and imaging findings, involved con-
sultants, and proposed surgical plan. This plan goes with the patient through their journey and can be
adjusted as needed when the treatment plan changes.
tumors >5 cm are seeking an alternative to mastectomy,
when oncologically feasible. In either case, oncoplastic surgery allows for breast conserving therapy with a better cosmetic result.
15,16
Oncoplastic surgery should be considered
in all patients who are candidates for surgical treatment of
breast cancer.
Operative Approach
e workhorse of oncoplastic surgery at our institution is
performed with the inverted T or Wise pattern as the preferred incisional approach for the mammaplasty.17 is
versatile technique is the ideal option for women with
preoperative macromastia.
skin pattern and nipple–areolar complex (NAC) pedicle are
designed preoperatively to allow for resection of the tumor
18-20
Based on tumor location, a
and lling of the tumor cavity defect with the remaining
breast tissue. is technique can also be applied to tumors
that fall outside the Wise pattern by shifting tissue and
rotating the reduction pattern.21 e wide amount of skin
excised allows for correction of ptosis, exposure to the entire
breast, the ability to widely resect tissue from any quadrant, and signicantly reduce overall breast volume to aid
radiation dose homogeneity. Once the amount of required
tissue resection is determined on the ipsilateral side, the
contralateral breast is reduced to match as a symmetrizing
procedure.
22
e need to be certain of the anterior tumor margin led
our group to develop the Split Reduction. e main strength
of the Wise pattern is the independence of the skin resection
and the parenchymal resection. e parenchymal reduction
does not need to follow the skin reduction pattern; the end
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• Fig. 15.2 A 60-year-old female who presented with concerns about
the appearance of her right breast subsequent to lumpectomy and
radiotherapy 5 years prior.
goal is creation of a breast mound over which the skin can
be re-draped. For an aesthetic breast reduction, it is desirable to place the scars in the least visible areas. us, the
Wise pattern is designed to limit the scars to the circumareolar border, the vertical midline of the breast, and the inframammary crease. For oncoplastic breast surgery, we do not
need to limit ourselves to this ideal skin pattern. Because
the need for tumor clearance trumps this aesthetic ideal,
we may modify the traditional Wise pattern to displace a
hidden scar from the medial or lateral infra mammary fold
onto the visible breast, directly over the tumor, in favor of
clearing the anterior margin in lesions close to the skin. is
modication, that we term a Split Reduction, allows denitive clearance of the anterior (skin) margin or access to a
lesion that falls out of the standard Wise pattern. e end
result is resection of a comparable amount of skin as a traditional Wise pattern with maintenance of a similar, coneshaped skin envelope but higher visibility of the scar. In our
opinion, this trade-o is acceptable, because the alternative
of a close or involved anterior margin leading to mastectomy is avoided (Fig. 15.3).
• Fig. 15.3 A 48-year-old female with a 30-mm LEFT breast invasive ductal carcinoma close to the lateral
skin on preoperative imaging. Surgical plan was for LEFT breast wire-directed segmental resection and
LEFT axillary sentinel lymph node biopsy through a LEFT Split Reduction and contralateral mastopexy for
symmetry. (Left) Preoperative photos. (Right) 1 week postoperative photos showing in the LEFT breast—
radial incision in the upper outer quadrant that represents the “split” or “Z” pattern incision. In the RIGHT
breast, the standard Wise pattern inverted T scar is seen.
Pre-op Post-op 1 week
CHAPTER 15 Extreme Oncoplasty
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Post-op 2 years
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e Wise pattern mammaplasty requires the creation
of three triangles: vertical, medial, and lateral. e inferior
borders of all three triangles are incorporated into the inframammary fold incision, limiting the scars to the circumareolar border, the vertical midline of the breast, and the
inframammary fold (Fig. 15.4). e pedicle for the NAC is
chosen based on the tumor location: superior, medial, lateral, inferior, or central. Tumors located in the inferior pole
can be easily incorporated in this pattern, with the overlying
skin, through a standard Wise pattern. e vertical pillars
are then plicated and the NAC inset into the keyhole. If the
NAC cannot be saved, a nipple can be reconstructed immediately or as a delayed procedure. is technique allows the
lower pole and central tumors to be easily excised along
with the overlying skin to avoid a close or positive anterior
margin. When the tumors are located in areas that do not
naturally fall within a standard Wise pattern, two options
exist. e rst is to perform a standard Wise pattern technique and elevate skin aps to reach the distant tumor. is
is acceptable if the tumor is deep and the anterior margin
is not felt to be of concern. However, for most cases when
the tumor is located outside the Wise pattern, our preferred
alternative is to excise the tumor with the anterior skin margin to decrease the need for re-excision or mastectomy with
close or positive margins. For tumors located in the upper
outer or upper inner quadrants, the Wise pattern may be
recongured to include the tumor with the overlying skin
in a split reduction.
When the tumor is in the upper central breast, the split
occurs at the apex of the keyhole rather than along the vertical limbs of the pattern (Fig. 15.5). If the NAC is involved
by tumor, the central excision of breast tissue is incorporated
into an inverted T mammaplasty that allows for reshaping
and immediate NAC reconstruction. In a split reduction, the
lateral or medial triangle of the Wise pattern is not positioned
at the base of the breast but advanced cephalad to a position
directly overlying the tumor (Fig. 15.6). e medial or lateral
vertical limb of the inverted T is split on the side of the tumor
excision to accommodate the higher position of the medial
or lateral triangle.
10,11,23
During the reconstruction, secondary and tertiary pedicles may also be employed to allow for
maximal preservation of volume and to reconstruct excisional
defects. Videos 15.1–15.4 demonstrate the authors’ various
approaches to standard and extreme oncoplasty.
• Fig. 15.4 Photo representing the typical incisions for a standard Wise
pattern reduction. Surgical scars outlined in inframammary crease,
periareolar border, and vertical midline of the breast.
• Fig. 15.5 A 56-year-old female with an 18-mm LEFT breast ductal carcinoma in situ (DCIS) close to skin
on preoperative imaging. Surgical plan was for LEFT breast wire-directed segmental resection and intraoperative radiation therapy, LEFT Split Reduction (Split from the keyhole) and contralateral mastopexy for
symmetry. (Left) Preoperative photo with approximate tumor location marked. (Middle) and (Right) 2 year
postoperative photo outlining split reduction scar oriented radially from the keyhole to remove skin over
the lesion.
Outcome
e rationale for breast conserving therapy comes from a
group of prospective randomized trials performed in the
24-27
1970s.
was 5 cm. When breast preservation is performed in
In these trials, the maximum tumor size allowed
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• Fig. 15.6 Split Reduction: 58-year-old female with a 36-mm LEFT breast invasive ductal carcinoma. Sur-
gical plan was for LEFT breast wire-directed segmental resection, LEFT Split Reduction and contralateral
mastopexy for symmetry. (Left) Preoperative photo with approximate tumor location marked. (Middle) and
(Right) 5 year postoperative photo, after whole breast radiation therapy, outlining split reduction scar in
upper outer quadrant to remove skin over the lesion.
patients with tumors larger than 5 cm, there are no prospective randomized data to support it. Nevertheless, in clinical
practice, it is commonly done. When breast conservation
was rst adopted, the recurrence rates were higher for those
randomized to breast conservation therapy compared with
mastectomy. Despite higher local recurrence rates, survival
at 20 years was similar.
28,29
Surgeons and patients have long
accepted a higher local recurrence rate in exchange for a
better aesthetic and sensory outcome and a happier patient
with no decrease in survival.
Our institution’s experience with extreme oncoplasty
and standard oncoplastic surgery is outlined in Table 15.1.
In the extreme series, 88% of tumors with a mean size of 74
mm were excised with no ink on tumor. Only six patients
of 200 (3%) patients who attempted to save their breast
after being advised to have a mastectomy were converted
to mastectomy after nal pathology was reviewed. All six
had multiple positive or close margins. An additional 16
patients (8%) underwent re-excision and then continued
on with breast conservation and radiation therapy. Eight
patients (4%) have developed a local recurrence.
Breast conservation can generally be done in one operation
erative pain, and it is less expensive for the patient as multiple
operations and procedures are avoided. ere is no foreign
body and no donor site. It is more functional when compared
with mastectomy and allows patients to keep their natural
breast shape and sensation. e patient often has a better perceived body image.
30,31
Additionally, breast cancer patients
with macromastia present a challenge for radiation oncologists planning for whole breast radiation therapy. A larger
more pendulous breast often requires higher energy photos
to ensure delivery to a deeper depth of tissue. is leads to
hot spots of radiation and can lead to signicant toxicity to
the skin and tissue.32 For these reasons, if it is technically possible and oncologically reasonable, we should consider breast
conservation as the rst option for our patients.
TABLE
Comparison of Wise Pattern Reduction
Mammoplasty (Standard Oncoplasty),
15.1
Including Patients with Split Reductions,
Versus Extreme Oncoplasty
Standard
Variable
N 500 200
Mean Sample
Weight
Mean Tumor Span 22 mm 74 mm
No Ink on Tumor 97% 88%
Margin ≥ 1 mm 90% 70%
Re-excision 3% 8%
Mastectomy 1% 3%
Median Follow-up 28 months 20 months
Any Local
Recurrence
Oncoplasty
141 grams 201 grams
3% 4.1%
Extreme
Oncoplasty
Whether for standard or extreme cases, it is important
to maintain a multidisciplinary approach. ere are many
patients who are relegated to mastectomy as the only
option, simply due to an erroneous judgment that a deformity would inevitably result with breast conservation. ese
patients are referred for plastic surgical consultation with a
plan for mastectomy already in place. e plastic surgeon
will then counsel the patient regarding post-mastectomy
reconstruction, and an oncoplastic approach may never be
discussed. Improved communication and a mindset that
breast conservation should not be ruled out before plastic
surgery consultation may allow many women to escape the
default mastectomy.
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