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CHAPTER 15 Extreme Oncoplasty
Pre-op Post-op 1.5 years
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• Fig. 15.7 Extreme Oncoplasty: 55-year-old female with an 85-mm area of LEFT breast invasive ductal
carcinoma with ductal carcinoma in situ (DCIS) and RIGHT breast 20-mm DCIS. Surgical plan was for
LEFT and RIGHT breast wire-directed segmental resection, LEFT Split Reduction (Extreme oncoplasty)
and RIGHT Standard Reduction. (Left) Preoperative photo. (Right) 1.5 year postoperative photo after bilateral whole breast radiation therapy.
123
Extreme oncoplasty pushes the oncoplastic surgery
envelope. Patients seeking an alternative to mastectomy
are turning to a modern take on oncoplastic breast surgery. e use of standard and modied reduction excisions
and oncoplastic reconstruction dramatically increases
the probability of complete excision with an acceptable
esthetic outcome in most patients seeking breast conservation therapy. Moreover, now that the standard for an
adequate margin has been relaxed to no ink on tumor for
invasive disease,33 the probability of a successful outcome
increases.
For selected patients who need a mastectomy based on
current standards, such as patients with large multifocal or
multicentric tumors, those with small breast size relative to
tumor extent, those with locally advanced tumors, or those
with a previously irradiated breast that develops local recurrence or a new cancer, the alternative for some of them may
be extreme oncoplasty (Figs. 15.7–15.9).
Complications and Side Effects
When using plastic oncoplastic approaches, the breast
surgeon without plastic surgery training should partner
with a plastic reconstructive surgeon to become comfortable performing the basic techniques. Over time, and with
collaboration and practice, the breast surgeon can incrementally expand their armamentarium of surgical tools.
Complications when using split reductions and extreme
oncoplasty are those that are commonly associated with
cosmetic mastopexy and reductions: wound infections,
hematoma, fat necrosis, wound breakdown, delayed wound
healing, and nipple necrosis.
34
A few of the factors implicated in poor cosmetic results
after breast conservation are age >60, T2 or larger tumors,
small breast size, re-excision for inadequate margins,
improper scar orientation, breast tissue resection greater
than 100 cm3 independent of breast size, breast ptosis,
tumors located in the central, medial, or lower quadrants,
and radiation dose inhomogeneity.
22,35-38
Conclusion
e standard of care for patients with tumors >5 cm or with
locally advanced breast cancer is mastectomy due to a lack
of supportive data for breast conservation. A blinded, prospective randomized trial to conrm the validity of breast
conservation for these women is not forthcoming and likely
will never be performed. For the patient who desires to
avoid mastectomy despite this, thoughtful consideration
should be given to the concept of extreme oncoplasty.
Extreme oncoplasty oers a balanced solution that allows
aggressive tumor clearance with overlying skin but maximizes the potential for an aesthetically pleasing outcome
with minimal surgery.
124
Pre-op 6 months post-op
Pre-op Post-op 1 year
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• Fig. 15.8 Extreme Oncoplasty: 69-year-old with locally advanced left invasive ductal carcinoma at 6:00,
spanning 7 cm. She had an excellent imaging response to neoadjuvant chemotherapy, and underwent
left oncoplastic surgery (Wise pattern extreme oncoplasty) and an immediate contralateral reduction. Final
pathology showed no residual disease. She completed adjuvant radiotherapy and has an excellent cosmetic result.
• Fig. 15.9 A 56-year-old woman with a 60-mm palpable multifocal invasive ductal carcinoma of the right
lateral breast. Underwent neoadjuvant chemotherapy with a partial imaging response, followed by a right
breast segmental resection, with immediate oncoplastic reconstruction with a LICAP flap.
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16. Piper M, Peled AW, Sbitany H. Oncoplastic breast surgery: current strategies. Gland Surg. 2015;4(2):154–163.
17. Wise RJ. A preliminary report on a method of planning the
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18. Chang E, Johnson N, Webber B, Booth J, Rahhal D, Gannett
D, etal. Bilateral reduction mammoplasty in combination with
lumpectomy for treatment of breast cancer in patients with macromastia. Am J Surg. 2004;187(5):647–651.
19. Newman LA, Kuerer HM, McNeese MD, Hunt KK, Gurtner
GC, Vlastos GS, etal. Reduction mammoplasty improves breast
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20. Spear SL, Pelletiere CV, Wolfe AJ, Tsangaris TN, Pennanen MF.
Experience with reduction mammaplasty combined with breast
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21. Hudson DA. A modied excision for combined reduction mammoplasty and breast conservation therapy in the treatment of
breast cancer. Aesthetic Plast Surg. 2007;31(1):71–75.
22. Foersterling E, Golatta M, Hennigs A, Schulz S, Rauch G, Schott
S, etal. Predictors of early poor aesthetic outcome after breastconserving surgery in patients with breast cancer: initial results
of a prospective cohort study at a single institution. J Surg Oncol.
2014;110(7):801–806.
23. Silverstein MJ, Savalia NB, Khan S, Ryan J, Epstein M, DeLeon
C, etal. Oncoplastic split reduction with intraoperative radiation
therapy. Ann Surg Oncol. 2015;22(10):3405–3406.
24. Bartelink H, Fentiman I, Lerut T, Mignolet F, Olthuis G, Sylvester R, et al. Randomized clinical trial to assess the value of
breast-conserving therapy in stage I and II breast cancer, EORTC
10801 trial. J Natl Cancer Inst Monogr. 1992;(11):15–18.
25. Veronesi U, Saccozzi R, Del Vecchio M, Ban A, Clemente C,
De Lena M, etal. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with
small cancers of the breast. N Engl J Med. 1981;305(1):6–11.
26. Lichter AS, Lippman ME, Danforth Jr DN, d’Angelo T, Steinberg SM, DeMoss E, etal. Mastectomy versus breast-conserving
therapy in the treatment of stage I and II carcinoma of the breast:
a randomized trial at the national cancer institute. J Clin Oncol.
1992;10(6):976–983.
27. Fisher B, Bauer M, Margolese R, Poisson R, Pilch Y, Redmond
C, etal. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med.
1985;312(11):665–673.
28. Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M,
Fisher ER, et al. Twenty-year follow-up of a randomized trial
comparing total mastectomy, lumpectomy, and lumpectomy plus
irradiation for the treatment of invasive breast cancer. N Engl J
Med. 2002;347(16):1233–1241.
29. Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini
A, etal. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early
breast cancer. N Engl J Med. 2002;347(16):1227–1232.
30. Cochrane R, Valasiadou P, Wilson A, Al‐Ghazal S, Macmillan
R. Cosmesis and satisfaction after breast‐conserving surgery
correlates with the percentage of breast volume excised. BJS.
2003;90(12):1505–1509.
31. Al-Ghazal S, Blamey R, Stewart J, Morgan A. e cosmetic outcome in early breast cancer treated with breast conservation. Eur
J Surg Oncol. 1999;25(6):566–570.
32. Moody A, Mayles W, Bliss J, A’Hern R, Owen J, Regan J, etal.
e inuence of breast size on late radiation eects and association with radiotherapy dose inhomogeneity. Radiother Oncol.
1994;33(2):106–112.
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33. Moran MS, Schnitt SJ, Giuliano AE, Harris JR, Khan SA,
Horton J, et al. Society of Surgical Oncology–American Society for Radiation Oncology consensus guideline on margins for
breast-conserving surgery with whole-breast irradiation in stages
I and II invasive breast cancer. Int J Radiat Oncol Biol Phys.
2014;88(3):553–564.
34. Iwuagwu O. Additional considerations in the application of
oncoplastic approaches. Lancet Oncol. 2005;6(6):356.
35. Munshi A, Kakkar S, Bhutani R, Jalali R, Budrukkar A, Dinshaw
KA. Factors inuencing cosmetic outcome in breast conservation. Clin Oncol (R Coll Radiol). 2009;21(4):285–293.
36. Taylor ME, Perez CA, Halverson KJ, Kuske RR, Philpott GW,
Garcia DM, etal. Factors inuencing cosmetic results after conservation therapy for breast cancer. Int J Radiat Oncol Biol Phys.
1995;31(4):753–764.
37. Hennigs A, Hartmann B, Rauch G, Golatta M, Tabatabai P, Domschke C, et al. Long-term objective esthetic outcome after breast-conserving therapy. Breast Cancer Res Treat.
2015;153(2):345–351.
38. Waljee JF, Hu ES, Newman LA, Alderman AK. Predictors of
breast asymmetry after breast-conserving operation for breast
cancer. J Am Coll Surg. 2008;206(2):274–280.
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Oncoplastic Variations Based on Tumor
Location
ALBERT LOSKEN
Introduction
e type of reconstruction used for partial mastectomy
defects depends on (1) the size of the resection, (2) the size
of the breast, and (3) the location of the tumor. Tumor location on the breast and relative to the nipple–areolar complex
is critically important. A recent study of 350 patients demonstrated that the maximal volume of tissue resected with
lumpectomy without resulting in unacceptable aesthetic
and functional outcomes of decreased quality of life were
18–19% in the upper-outer quadrant, 14–15% in the lower
quadrant, 8–9% in the upper-inner quadrant, and 9–10%
in the lower inner quadrant.1 Tumor location not only can
predict the potential for a cosmetic deformity, but it also
can help determine the type of reconstruction required to
ll the partial mastectomy defect. Women with smaller
breasts are more often amenable to ap type volume replacement reconstructions, whereas women with larger or more
ptotic breasts are better candidates for volume displacement techniques. Adhering to strict algorithms is dicult
because every case is dierent. Being familiar with the various reconstructive tools will allow reconstruction of almost
any partial mastectomy defect. e oncoplastic reduction
and mastopexy techniques can reconstruct a tumor in any
location.
any breast defect, the type of pedicle and type of skin pattern might dier depending on the tumor location. Flaps
can also reach any tumor location; however, some aps are
better suited for certain locations than others.
Problem Areas in Oncoplastic Reconstruction
Partial reconstruction works well in lower quadrants of
the breast.5 ese areas are adjacent to suitable volumes of
breast parenchyma that can be transposed or rotated into
a nearby defect. e upper and superomedial quadrants of
the breast are relatively volume decient and are often not
close to suitable pedicles that may be used as volume llers. e supra-areolar area from the upper anterior axillary
2-4
Although principles are essentially the same for
fold laterally across to the manubriosternal junction medially is often challenging to reconstruct. is area often
requires local aps or autoaugmentation techniques to ll
the defects. Central defects can also be challenging because
they potentially interfere with blood supply to the nipple–
areolar complex and, when not lled appropriately, will lead
to nipple retraction and resultant deformity. It is important
to keep in mind that when the defect is extensive with little
remaining breast tissue, completion mastectomy and immediate reconstruction is often the more appropriate option.
1. Volume Displacement Techniques
Breast-reshaping procedures all essentially rely on advancement, rotation, or transposition of an area of the breast
to ll a small- or moderate-sized defect. is absorbs the
volume loss into a smaller breast. In its simplest form, it
entails mobilizing the breastplate from the area immediately
around the defect in a breast ap advancement technique.6
ese procedures are indicated in women with small- to
medium-sized breasts where the resection does not lead to
any signicant volume alteration that might cause breast
asymmetry. A contralateral symmetry procedure is typically
not required.
Perhaps the most popular and versatile breast-reshaping
options are the mastopexy or reduction techniques.7 e
ideal patient is one where the tumor can be excised within
the expected breast reduction specimen in medium to large
or ptotic breasts where sucient breast parenchyma remains
following resection to reshape the mound. is means
that any tumor location within the standard Wise pattern
resection tissue is ideal for this approach. Kronowitz etal
describe seven areas or zones of the breast that can be used
to determine pedicle location.3 e most dicult locations
to treat are superomedial areas, where lack of adjacent breast
volume tends to limit reconstructive options; women with
large lower poles and cleavage are easier to manage in this
area. High upper pole tumors can also be problematic unless
a ap of breast tissue can be incorporated into an inferior
pedicle as a pennant ap rotated up into the defect from
below.
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ABC
G
• Fig. 16.1 This 50-year-old female with a left lower pole breast cancer underwent a generous 120-gram
tumor resection including breast tissue and skin. Her lower pole defect is within the resection pattern for
Wise resection. A superomedial pedicle was performed with a total resection of 320 grams on the left
and 360 grams on the right. Her result is shown 5 months postoperatively and before irradiation therapy.
H I
Lower quadrant tumors in women with larger breasts are
ideally suited for the oncoplastic approach.5 Some of the
original descriptions of oncoplastic reduction techniques
were in tumors located inferiorly. Quadrantectomy type
resections are possible, removing skin and parenchyma
from this location, reshaping the breast using a superior
or superomedial pedicle (Fig. 16.4). Inferior and midline
tumors can be reconstructed using the vertical pattern
in smaller- to moderate-sized breasts. A superiorly based
pedicle can be used to reposition the nipple, and this then
results in a very familiar defect because it is the location
where tissue is resected in a vertical pattern breast reduction
or mastopexy. e medial and lateral pillars are then plicated to ll the defect and lift the breast with a similar pattern being performed on the other side. e breast surgeon
will often have the luxury of removing skin along with the
FED
tumor resection if this falls within the proposed preoperative markings (Fig. 16.1).
If the inverted T or Wise pattern reduction or mastopexy
is planned, the technique is similar. Resection is performed
either with or without skin within the Wise pattern markings. e nipple is then moved up on a superiorly based pedicle, and the remaining dermatoglandular tissue is resected
from around the lower pole, and the oncoplastic reduction
is completed. If additional tissue is resected from around the
tumor defect, it is important to mark the specimen because
this will then become the new margin. If signicant ptosis exists, and the tumor is inferior and a superiorly based
pedicle is not possible, then this becomes more challenging. Autoaugmentation techniques are often not required
for central lower pole defects because the nature of these
techniques will often have sucient remaining breast tissue
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to fall into place lling the defect without having to rearrange parenchyma.
8
Inferolateral tumors are best closed with a superomedial
pedicle incorporating an accessory ap of inferior central
tissue to rotate into the lateral defect if indicated. If a superiorly based pedicle is not possible due to signicant ptosis,
then an inferior or centrally based pedicle can be used and
shifted medially to enhance perfusion to the nipple. True
inferolateral defects often do not require autoaugmentation techniques, but when they do, extended superomedial
pedicles can be used to rotate and ll an area of volume
void when indicated. e nipple pedicle is extended and
the glandular tissue is de-epithelialized and rotated laterally.
Inferomedial tumors are also often very amenable to
superior or superomedial pedicles. e defect will often lie
in the Wise pattern markings, and completing the reduction will reshape the breast mound. If an inferior pedicle is
needed, it can also be shifted laterally and used to move the
nipple and ll the defect. Autoaugmentation techniques are
similarly not often needed but can be performed using an
extended superolateral pedicle if indicated.
Upper quadrant tumors result in defects that can be more
challenging to reconstruct. ese defects are outside the
Wise pattern markings, which makes skin and parenchyma
removal dicult. e vast majority will be lumpectomy type
defects and are often best lled with an inferior or central
pedicle (Fig. 16.2, upper). When sucient glandular tissue
remains above the nipple–areolar complex on an inferior
pedicle, this can be used to ll the central upper defects. If
not, it will be important to mobilize some upper pole tissue
to ll the defect and provide upper pole fullness. e higher
the tumor on the chest wall and the thinner the patient, the
more dicult this becomes. If there is a paucity of available
tissue, glandular “wings” of parenchyma from the lateral
and medial upper quadrants can be mobilized to help close
the defect. is is often not possible, and subsequently autoaugmentation techniques are used to ll the dead-space and
maintain shape. Extended superomedial pedicles in women
with medium-sized and ptotic breasts and upper or upperouter quadrant defects will often provide good reconstruction. A vertical reduction technique is performed creating
medial and lateral pillars. e lower pole breast tissue is kept
as an extension of the superomedial pedicle and transferred
to ll the upper or outer quadrant defect. e breast is then
shaped by closing the pillars inferiorly. A similar technique
can be performed for upper-inner quadrant defects using an
extended superolateral pedicle.
ese upper-outer quadrant defects in women with large
breasts who undergo a Wise pattern reduction can also be
lled using the secondary dermatoglandular pedicle. If a
superomedial pedicle is used to reposition the nipple, and
volume is needed to ll an upper-outer defect, then a secondary inferolateral pedicle can be created to ll the defect.
e pedicle is fashioned to t the defect and made smaller
or larger depending on the demands. is is often safer than
extending the primary pedicle as it preserves better perfused
dermatoglandular tissue with less risk of fat necrosis.
Larger quadrantectomy defects, especially above the
nipple, can be incorporated into a batwing mastopexy or
elliptical-type incision and provide preservation or improvement of shape and elevation of the ptotic breast along with
the tumor resection. A similar mirror image resection is
often performed on the opposite side for symmetry. Additional mastopexy options exist for oncoplastic breast conservation.6 e donut mastopexy allows a breast segment
to be removed through a periareolar incision and is useful
for segmentally distributed cancers in the upper or lateral
portion of the breast. e batwing mastopexy involves a full
thickness excision of lesions deep within the breast centrally
or adjacent to the nipple–areolar complex. e two similar
half-circle incisions with angled wings on either side of the
areolar allow advancement of the broglandular tissue to
close the defect. Because this removes sucient breast tissue and skin to alter the size of the breast and nipple position, a similar contralateral lift is occasionally required to
achieve symmetry. Additionally, if the patient is a candidate
for breast conservation therapy (BCT) and has multiple
areas that need to be resected, as long as sucient tissue
remains, remodeling techniques can be used in a similar
fashion.
Central tumors have in the past been considered relative contraindications to BCT; however, with the oncoplastic approach in women with macromastia, the tumor and
nipple–areolar complex can be widely excised and reconstructed using a variety of techniques.9 e mound can
be remodeled in the inverted T-closure pattern, similar to
breast amputation reduction techniques. e nipple is then
reconstructed later using the reconstruction technique of
choice (Fig. 16.3). Another option if the tumor is located
more superiorly or lateral is to perform a central elliptical excision of skin, nipple, and parenchyma, and mirror
image contralateral reduction for symmetry. A third option
includes creation of a skin island on a dermatoglandular
pedicle to rotate into the central defect to allow for shape
preservation and nipple reconstruction (Fig. 16.7). e
breast is marked preoperatively for an inverted T or a vertical approach depending on breast size, and the skin island is
brought in from inferior or medial (Fig. 16.4).
In situations where the resection is central and the
nipple–areolar complex can be spared, then parenchymal
tissue can be mobilized during the reduction technique to
provide breast tissue beneath the nipple to provide shape.
One example includes de-epithelialized inferior pedicle
with medial and lateral tissue rotated around in a similar
fashion to that described for the massive weight loss breast
(Fig. 16.5).
Medial and lateral defects are similarly treated. Medial
and upper inner quadrant defects can often be lled with
a broad inferior pedicle if sucient volume persists (Fig.
16.6). Women with smaller breasts who have small- or
medium-sized defects in the medial or lateral locations that
are not adequately lled with surrounding breast tissue are
best lled with the extended pedicle. e tissue that is typically removed when creating the medial and lateral pedicles
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A
C
B
D
E
• Fig. 16.2 This is a 65-year-old female with DCIS in the upper quadrant of her left breast. Preopera-
tive markings following guidewire placement show plan for possible superomedial reduction. Following
removal of a 100-gram partial mastectomy, the plan was changed to perform an inferior pedicle given the
extent of tumor resection. An additional 200 grams were removed around an inferior pedicle on the left,
and a similar inferior pedicle reduction (350 grams) was removed from the right breast. Her result is shown
2 years following completion of radiation therapy with good upper pole shape and symmetry.
F
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A
B
C
• Fig. 16.3 This 43-year-old woman had a tumor beneath her nipple on the left resulting in significant
nipple–areolar retraction. She had a wide resection with breast amputation on the left and a reduction on
the right. Eventual nipple reconstruction and areolar tattoo on the left results in good shape and symmetry.
A
D
• Fig. 16.4 This patient did not want to undergo skin sparing mastectomy (SSM) and reconstruction
despite having a subareolar tumor-elected breast preservation. Given proximity, she had resection of the
nipple–areolar complex with her partial mastectomy. An inferior pedicle was created leaving a skin island
appropriately located for nipple areolar replacement. She is shown after completing irradiation therapy.
B
E
C
F
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A
C
• Fig. 16.5 This 33-year-old woman with stage III breast cancer had an excellent response to preoperative
chemotherapy and desired breast conservation (A). To minimize the potential for a poor cosmetic result
with a defect in the upper pole, she underwent a right wire-guided lumpectomy (100 grams) (B, C) with
simultaneous bilateral breast reduction (total volumes, 250 grams left and 150 grams right). The nipple
was moved on an inferiorly based dermatoglandular pedicle with the central attachments intact, and used
in part to fill the upper pole volume void. Her result is shown at 1 year following completion of right breast
radiation therapy (D).
B
D
in a vertical breast reduction or mastopexy is preserved as
an extension to the superiorly based pedicle. It is rotated
with the nipple to the proposed location and used to ll the
defect (Fig. 16.7). e medial and lateral glandular pillars
are then plicated in the usual manner. is tissue can also
be used to ll superior defects or, if necessary, with a Wise
pattern. Larger, lateral, or upper-outer quadrant defects in
women with larger breasts, however, would require two
pedicles. Once the defect is examined, a superomedial
pedicle is created, and the nipple is rotated into the desired
position. An inferiorly based lateral dermatoglandular pedicle is de-epithelialized and created based on how much is
anticipated to ll the defect. e residual dermatoglandular
tissue is then resected, and the breast mound is shaped in
the usual fashion. e secondary pedicle can then independently be cut to size and placed into the defect (Fig. 16.8).
Medial defects are also amenable to a superolateral pedicle
(Fig. 16.9). is can be extended and used to ll the defect
in an autoaugmentation fashion in women without sucient local tissue to ll the defect. e medial quadrant is
aesthetically sensitive, and a lack of sucient volume ll will
result in BCT contour irregularities.
2. Volume Replacement Techniques
Partial mastectomy defects in women with small to
medium breasts are often dicult to reconstruct.10 Women
with large tumor-to-breast ratios and women with small to
moderate breasts who have insucient residual breast tissue for rearrangement require partial reconstruction using
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