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Type 1 Oncoplasty inBreast

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Cancer

DiptendraKumar Sarkar andSrijaBasu

Breast conservation surgery is becoming the standard of care [1, 2]. Evolving evidences suggest superiority of BCS over mastectomy-based treatments [3, 4, 5]. The hindrance to BCT has been large lumps, inappropriate tumour–breast ratio, multifocal and multicentric tumours. Successful neoadjuvant therapy has increased the conservation rate [6, 7]. In small lumps asymmetry after resection is minimum. However larger resection or inappropriate tumour–breast ratio needs complex techniques to attain acceptable aesthetic outcome without compromising oncological safety [8, 9]. This has led to evolution of new subspeciality in breast surgery known as oncoplasty.

Goal of Oncoplasty: Optimising the cosmetic outcome while maintaining the oncological safety.

D. Kumar Sarkar (*) Clinical and Research Lead, Comprehensive Breast Services, Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, India

S. Basu Senior Resident, Comprehensive Breast Services, Institute of Post Graduate Medical Education and Research, Kolkata, India

13.1 Types ofOncoplasty

1. Type 1 OPS: When the volume loss after resection is less than 20% of the total breast volume, primary apposition with mobilisation of surrounding breast volume is sufcient.

2. Type 2 OPS: When the volume of resection exceeds 20%, the remaining glands require volume displacement to achieve acceptable aesthetic outcome.

3. Reconstruction: When more than 50% of the volume is respected, the breast needs reconstruction (also known as volume replacement therapy).

13.2 Factors Determining

theType ofSurgery

1. Volume of the breast in cup size along with HRUSG aided volume assessment. The authors presently are undertaking a validation study in breast volume assessment by HRUSG.

2. Resection Volume in Percentage: Clinical assessment is usually subjective. Preoperative HRUSG aided volume assessment can aid in planning. There are centres which use 3D reconstruction techniques in planning the type of OPS.

3. The Distance of the Tumour from the NAC: It helps in planning the type of OPS.

https://doi.org/10.1007/978-981-99-5536-7_13

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D. Kumar Sarkar and S. Basu

4. Quadratic Location of the Tumour: It helps in planning the incision.

5. Depth: The distance of the tumour from the overlying skin.

6. Density of the Breast: Dense breast is associated with improved aesthetic outcome compared to less dense breast [10]. It is categorised mammographically as:

(a) fatty breast (b) scattered broglandular (c) heterogeneously dense (d) extremely dense breast tissue

13.3 Principles ofType 1 OPS:

TheRule of‘Ten’

1. Planning of OPS: It is done preoperatively

with the patient in standing position.

2. Incision: planned according to the location

of the tumour (Fig. 13.1). It is generally placed directly over the tumour conforming to the Kraissl’s line.

3. Skin is usually not excised. However, very

small biopsy point can be excised en bloc with the lesion.

4. Full thickness resection of breast tissue with at least 1cm macroscopic margin.

Fig. 13.2 Undermining of skin ap

Fig. 13.1 Incision marking in skin. (a) Dotted line

divides the breast into two halves for upper ½ lesions, curvilinear incision along skin crease is preferred. In lower ½

lesions, radial incision along skin crease is preferred. (b) Showing incision in peri-NAC swelling

13 Type 1 Oncoplasty inBreast Cancer

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Fig. 13.3 Undermining of base of the breast

5. The wall of the cavity is clipped for postoperative localisation for tumour cavity boosting.

6. Dual plane mobilisation: It involves

(a) mobilisation of surrounding breast tissue

with pectoral fascia over the underlying pectoralis muscle and (Fig.13.2)

(b) undermining overlying skin (Fig.13.3).

In ladies with less dense /fatty breast, the rate of necrosis is higher. Thus in low density breast extensive mobilisation of overlying skin may be avoided. In such cases type 1 OPS may need conversion to type 2 to reduce skin ap necrosis.

7. Dealing with Peri-NAC Lesion: In case of peri-NAC lesion, the NAC skin ap is mobilised before excision of the lesion. Subsequently the NAC is re-centralised to achieve symmetry. Classically a width of

0.5 cm to 1 cm is recommended to ensure NAC ap viability (Fig.13.4).

8. Closure of Defect: The apposition of the wall is done by layered closure. Usually it is done in 3 layers, viz. base, mid, and subcutaneous planes to achieve perfect shape (Fig.13.5).

9. In some cases where the lesion is situated laterally, a circumareolar incision with a lateral radial extension may be made. When NAC lateralisation is anticipated, medial deepithelization up to 5 cm may be done to achieve symmetrization.

Fig. 13.4 Approximation of breast pillars

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Fig. 13.5 Cosmetic outcome

10. Drains: It depends on the volume loss and density of the breast. In larger volume loss or in fatty breast draining the cavity is preferred to avoid seroma.

13.4 Complications

1. NAC Displacement: In case of unplanned sur-

gery, NAC displacement can be a major issue. Though symmetrization procedures can be done as a second procedure, such interventions can delay the initiation of adjuvant therapy. Appropriate preoperative planning in standing position is the key way to achieve symmetry.

2. Skin Necrosis: Over enthusiastic undermining

can lead to skin ap necrosis. Extreme care should be taken in patients with low density breasts.

3. Seroma: In low density and obese patients

seroma can be a major issue which can lead to poor long term cosmetic outcome. Optimum draining (drain removal is recommended only when the amount is less than 30–50 ml in 24hours) can reduce the problem.

4. Poor Skin Scar: Inappropriate skin incisions

can lead to poor cosmetic outcome and various deformities (e.g. bird beak deformity).

D. Kumar Sarkar and S. Basu

References

1. 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 Oct 17;347(16):1233–41.

2. Fisher B, Anderson S, Redmond CK, Wolmark N, Wickerham DL, Cronin WM. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med. 1995 Nov 30;333(22):1456–61.

3. Breast-conserving therapy and modied radical mastectomy for primary breast carcinoma: a matched comparative study - Chinese Journal of Cancer Research [Internet]. [cited 2021 Aug 20]. Available from: http://www.cjcrcn.org/article/html_8450.html

4. Yoo GS, Park W, Yu JI, Choi DH, Kim Y-J, Shin KH, et al. Comparison of breast conserving surgery followed by radiation therapy with mastectomy alone for pathologic N1 breast cancer patients in the era of anthracycline plus Taxane-based chemotherapy: a multicenter retrospective study (KROG 1418). Cancer Res Treat. 2019 Jul;51(3):1041–51.

5. Wrubel E, Natwick R, Wright GP.Breast-conserving therapy is associated with improved survival compared with mastectomy for early-stage breast cancer: a propensity score matched comparison using the National Cancer Database. Ann Surg Oncol. 2021 Feb;28(2):914–9.

6. Woeste MR, Bhutiani N, Donaldson M, McMasters KM, Ajkay N. Evaluating the effect of neoadjuvant chemotherapy on surgical outcomes after breast conserving surgery. J Surg Oncol. 2021 Feb;123(2):439–45.

7. Spronk PER, Volders JH, van den Tol P, Smorenburg CH, Vrancken Peeters M-JTFD. Breast conserving therapy after neoadjuvant chemotherapy; data from the Dutch breast cancer audit. Eur J Surg Oncol. 2019 Feb;45(2):110–7.

8. Menke-Plugmers MBE, Wai RTJ, van Geel AN, Eggermont AMM.Oncoplastic surgery of the breast: a combination of oncological and plastic surgery. Ned Tijdschr Geneeskd. 2007 Jul 21;151(29):1623–7.

9. Rainsbury RM. Surgery Insight: oncoplastic breastconserving reconstruction—indications, benets, choices and outcomes. Nat Clin Pract Oncol [Internet]. 2007 Nov [cited 2021 Aug 20];4(11):657–

664. Available from: http://www.nature.com/articles/

ncponc0957

10. Shiina N, Sakakibara M, Fujisaki K, Iwase T, Nagashima T, Sangai T, etal. Volumetric breast density is essential for predicting cosmetic outcome at the late stage after breast-conserving surgery. Eur J Surg Oncol. 2016 Apr;42(4):481–8.

Round Block Breast Oncoplasty

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GeetaKadayaprath

14.1 Introduction

It has been proven beyond doubt that breast conservative treatment is as effective as modied radical mastectomy for breast cancer, in terms of local control as well as distant metastases. With advances in surgical techniques, it is not enough to just conserve the breast. It has become important to not only aim for adequate margins but also to have an aesthetically pleasing breast. While volume displacement and replacement are methods which are often used to restore shape to the breast, simple techniques, which can get the fear of oncoplasty out of a surgeon, would be very appealing. Round block oncoplasty is one such technique employed to restore shape in small to moderate sized breast with tumors which would require less than 20% of breast to be sacriced while excising it with margins [1].

The round block mammoplasty was initially performed by a periareolar incision along the entire circumference of the areola and subsequently modied to the better known circumareolar mastopexy technique, also known as donut mastopexy [2]. The round block technique was rst described by Benelli etal. almost 30years ago as a mastopexy technique [3]. While it works best for tumors in the upper half of the breast, it may be used elsewhere

G. Kadayaprath (*) Breast Surgical Oncology and Oncoplastic Surgery, Max Institute of Cancer Care, Delhi, India

also except for tumors close to the inframammary crease and in the periphery of large breasts with signicant ptosis [4]. These areas pose a challenge in that the ability to reach these areas and remove the tumor with adequate margins may be affected by the limited exposure through the outer incision. A modication to the conventional technique by dissecting the entire breast in the subcutaneous plane can allow access to all quadrants [5]. To perform a classical round block oncoplasty, it is mandatory that the tumor is neither abutting the skin or involving it and a clear anterior margin is achievable. While this technique is preferred in women with small- or medium-sized breasts and mild ptosis, it is feasible in young women with large brous breasts also [6]. Round block should be avoided in fatty breasts wherein extensive undermining in the dual plane would lead to fat necrosis and poor cosmetic outcome [7].

14.2 Eligibility forRound Block Oncoplasty

1. Small- to medium-sized breasts. Best avoided

in large, ptotic, and fatty breasts.

2. Preoperative mammographic density assess-

ment: ACR category C and D is safe; however, it may be used judiciously in ACR category B.

3. Upper quadrant is preferred but all quadrants

can be addressed by round block technique especially if the tumor is periareolar.

https://doi.org/10.1007/978-981-99-5536-7_14

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G. Kadayaprath

14.3 The Technique

1. Skin is incised up to the dermis around the areola if the areola is small or within the areola if the areola is large. A concentric circle about 1–4 cm away is marked around this circle, depending on the size of the breast and the amount of ptosis correction desired. Increasing the distance between the inner and outer circle will lead to attening of the breast as there is little scope to reshape the breast and restore projection (Fig.14.1).

2. The skin between the two circles is deepithelialized (Fig.14.2).

3. The incision around the outer circle is deepened for about half the circle in relation to the tumor to be excised. Flaps are raised in the mastectomy plane (Fig.14.1). If need be, the entire circle may be incised to facilitate access and excision. By raising the ap using the outer circle allows for wider access to the tumor. You have more control over how much you want to raise so that you can perform an oncologically safe resection and have enough well mobilized gland to approximate. Compromising on the mobilization can lead to deformities away from the incision where the approximation of the two pillars after tumor excision was hampered by lack of mobility of the two pillars.

4. Undermining should be between skin and glandular tissue but in younger women with dense glandular tissue, dual plane undermining between skin-gland and gland-muscle is acceptable, provided two of the three major blood supply to the breast is preserved.

5. The tumor is excised with margins, right up to the pectoralis fascia to include it. Excising the tumor as an ellipse or triangle would facilitate optimal glandular approximation (Fig.14.3).

6. Glandular reapproximation is achieved with absorbable sutures. Well mobilized pillars will allow for ease of reapproximation and

Fig. 14.1 Raising the aps in the mastectomy plane after incising the outer circle

Fig. 14.2 Deepithelialization between two circles Fig. 14.3 Tumor excised with margins

14 Round Block Breast Oncoplasty

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sutures should hold the pillars in place without tightening the knots excessively. This could lead to fat necrosis (Figs. 14.4 and

14.5).

7. Periareolar purse-string suture is applied. This may be done using nonabsorbable suture to prevent spreading of the areola later.

8. After applying the purse-string to the outer circle, there may be pleating of the skin around the areola, initially, which settles down over time (Fig.14.6).

Fig. 14.5 Pillars held together with absorbable sutures

Fig. 14.4 Glandular reapproximation

Fig. 14.6 Purse-string suture applied on the outer circle

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G. Kadayaprath

14.4 For Tumors Close totheSkin

Tennis Raquet Oncoplasty or Lateral Mammaplasty [8]

from the areolar margin, a combination of round block technique with an outward exten-

Image 14.1 Tennis Raquet oncoplasty

For tumors close to the skin and those away

sion in the form of an ellipse over the tumor to include the skin over the tumor is preferred. By deepthelializing the skin around the areola, it is possible to reposition the nipple areola complex, while the lateral extension allows for the pillars to be approximated easily after resection of the tumor.

Image 14.2 Right breast—round block oncoplasty for an UOQ tumor-post-op day 1

14 Round Block Breast Oncoplasty

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Image 14.3 (a) Left breast—round block oncoplasty for an UIQ tumor, post NACT-post-op day 7. (b) Left breast— round block oncoplasty for an UIQ tumor, post NACT 6months

a b

Image 14.4 (a) Left breast—round block oncoplasty for 3 o’clock tumor, 6months—arms by side. (b) Left breast— round block oncoplasty for 3 o’clock tumor, 6months—arms raised

14.5 Complications ofRound

References

Block Technique

1. Clough KB, Kaufman GJ, Nos C, Buccimazza I, Safati

1. Excessive undermining under the nipple can lead to partial nipple loss.

2. Seroma formation and occasional hematoma formation are known.

3. Fat necrosis and brosis may happen with further aggravation after radiotherapy especially in women who are older with fatty breasts, where the vascularity of the gland may be compromised.

4. Areolar widening

IM.Improving breast cancer surgery: a classication and quadrant per quadrant atlas for oncoplastic surgery. Ann Surg Oncol. 2010;17:1375–91.

2. Gruber RP, Jones HW Jr. The ‘donut’ mastopexy: indications and complications. Plast Reconstr Surg. 1980;65:34e38.

3. Benelli L.A new periareolar mammaplasty: the ‘round block’ technique. Aesthet Plast Surg. 1990;14:93–100.

4. Yang JD, Lee JW, Cho YK, etal. Surgical techniques for personalized oncoplastic surgery in breast cancer patients with small- to moderate-sized breasts (part 2): volume replacement. J Breast Cancer. 2012;15:7–14.

100

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G. Kadayaprath

5. Refaat M, Abouelnagah G, Awad AT, etal. Modied round block technique for peripherally located early cancer breast, a technique that ts for all quadrants. Breast J. 2020;26:414–9.

6. Zaha H, Onomura M, Unesoko M. A new scarless oncoplastic breast-conserving surgery: modied round block technique. Breast. 2013;22:1184.

7. Zaha H, Motonari T, Abe N, Unesoko M. Fat necrosis in level I oncoplastic breast conserving surgery focusing on a modied round block technique. Breast Cancer. 2020 Jul;27(4):567–72.

8. Gainer SM, Lucci A. Oncoplastic techniques for reconstruction of partial breast defects based on tumor location. J Surg Oncol. 2011;103:341–7.

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