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General Principles ofOncoplastic
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Breast Surgery
S.V.S.Deo, ManojGowda, JyouthismanSaikia,
andSelviRadhakrishnan
6
6.1 Introduction
Breast is the symbol of femineity, attractiveness,
and motherhood. Mastectomy is associated with
loss of feminine attractiveness, altered body
image perception, psychosexual problems, painful reminder of cancer, and depression. Based on
many landmark clinical trials comparing mastectomy with breast conserving surgery (BCS), the
latter has become the standard of care for the
treatment of early breast cancer [1–3]. However,
some patients with unfavourable tumour and
breast factors may not be suitable to undergo
BCS and among the patients who undergo conservation, about 25–50% are not satised with
the aesthetic outcome [4, 5]. The eld of oncoplastic breast surgery (OBS) was developed to
address these issues and it integrates techniques
of plastic surgery into breast cancer surgery to
improve cosmesis without compromising oncologic goals. The oncologic safety of OBS in terms
of margin status and recurrence is comparable
with traditional BCS [6, 7].
The most frequent cosmetic deformities after
BCS are: deciency of glandular tissue and overlying skin retractions resulting from wide resections and late side effects after radiotherapy;
deformity and retraction of the nipple and areola
complex (NAC); reduction of mammary ptosis
and asymmetry of the infra-mammary crease as a
consequence of brosis and breast retraction
after radiotherapy (Fig.6.1). The severity of these
deformities is related to the tumour location and
its proximity with the NAC and skin and the radiation boost. Hence, the optimal technique of OBS
should be planned by considering these factors
and the patient’s expectations. All attempts
should be made to minimize the risk of positive
margins, which are difcult and sometimes
impossible to reassess in the second surgery, and
to reduce and prevent complications that may
delay adjuvant treatments.
S. V. S. Deo (*)
Department of Surgical Oncology, AIIMS and NCI,
New Delhi, India
M. Gowda · J. Saikia
Department of Surgical Oncology, AIIMS,
New Delhi, India
S. Radhakrishnan
Chennai Breast Centre, Chennai, Tamil Nadu, India
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
S. V. S. Deo (ed.), Breast Oncoplasty and Reconstruction,
https://doi.org/10.1007/978-981-99-5536-7_6
41
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Fig. 6.1 Classic deformities seen after conventional BCS+RT
6.2 Principles ofOncoplasty
There are six basic principles which should be
followed during any OBS:
1. Oncological safety
2. Surgical expertise
3. Patient selection and counselling
4. Documentation and photography
5. Surgical principles
6. Adjuvant therapy and follow-up
S. V. S. Deo et al.
1. Oncological safety: Preoperative planning
with multidisciplinary oncology team is mandatory to decide an optimal surgical plan. The
ne balance between an over-resection with
the fear of positive margin and under- resection
with the fear of poor cosmesis needs to be
ne-tuned by the surgical team and is one of
the key determinants of successful OBS.
2. Surgical expertise: Surgical experience and
skills are extremely important for executing
successful OBS procedure. Training in a highvolume centre and mentorship by experienced
surgeon is essential prerequisite before
embarking into the eld of OBS.
3. Patient selection and counselling:
(a) Main indications for OBS are:
i. Loss of >20% of breast volume
ii. Poor tumour vs breast ratio (Fig.6.2)
iii. Loss of skin
iv. Tumours in central/upper medial
quadrants
Fig. 6.2 Indications for OPS
v. Patients with large pendulous breasts
keen for reduction
vi. Prior breast surgery/scars/deformities
(Fig.6.1)
(b) Elements of selection: Three elements
are important in selecting any patient for
OBS (Fig.6.3):
i. Excision volume: It is the single
most important predictive factor of
surgical outcome and potential for
breast deformity. Studies have
suggested that, once 20% of the
breast volume is excised, there is a
clear risk of deformity [8]. Excision
Favorable location of tumour Unfavorable location of tumour
6 General Principles ofOncoplastic Breast Surgery
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volume compared to the total breast
volume should be estimated preoperatively to plan OBS.
ii. Tumour location: The location of the
tumour is the second factor in planning OBS.There are zones that are at
high risk of deformity during BCS
when compared with more forgiving
locations. The upper outer quadrant
of the breast is a favourable location
for large-volume excisions. In this
location, defects can readily be corrected by mobilization of adjacent tissue (Fig. 6.4). Excision from less
favourable locations, such as the
lower pole or upper inner quadrants
of the breast, often creates a major
risk for deformity. For example, a
“bird’s beak” deformity is classically
Fig. 6.3 Elements for selection of patient for OBS
seen in excision of tumours from the
lower pole of the breast. Therefore, a
key tool used in planning the appropriate surgical approach is evaluating
the tumour location and the associated risk of deformity.
iii. Glandular density: Breast density
predicts the fatty composition of the
breast and determines the ability to
perform extensive breast undermining and reshaping without complications. Breast density can be classied
into four categories based on the
Breast Imaging Reporting and Data
System (BIRADS): fatty (1), scattered broglandular (2), heterogeneously dense (3), or extremely dense
breast tissue (4). Undermining the
breast from both the skin and pectoralis muscle (dual-plane undermining)
is a major requirement to perform
level I OPS.A dense glandular breast
(BIRADS 3/4) can easily be mobilized by dual-plane undermining
without risk of necrosis. Low-density
breast tissue with a major fatty composition (BIRADS 1/2) has a higher
risk of fat necrosis after extensive
undermining.
4. Documentation and photography: Preop
marking of the tumour and planned incisions
Fig. 6.4 Location of
tumour and cosmetic
outcome
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S. V. S. Deo et al.
both in sitting and standing positions is very
important. The surgical plan should be explained
and documented in the patient’s le. After discussing the plan with the patient, obtaining the
informed consent is very important. If allowed
in your institution, preop photographs in front
view and lateral view should be obtained. The
photographic documentation should continue in
the postoperative period as well. This will help
in following the long-term outcomes of OBS.
5. Surgical principles: The main principles
which should be followed during surgery are:
(a) Tissue respect to maintain vascularity
(b) Sharp dissection—cautery/knife
(c) Margins—gross intraoperative 1 cm
(OBS—more margins)
(d) Layered closure
(e) No drains
(f) Clip—cavity walls before tissue
rearrangement
(g) Prophylactic antibiotics
(h) Avoid tight dressings
(i) Postoperative breast support (sports bra)
6. Adjuvant therapy and follow-up:
(a) Timely adjuvant therapies are extremely
important. Delay in initiation of these
treatments due to complexity of proce-
dure or complications may sometimes
lead to adverse oncological outcomes.
(b) Follow-up: All cases of OBS should be
followed by the primary surgical team for
locoregional disease assessment and cos-
metic scoring.
6.3 Types ofOBS
OBS can be classied into two major groups:
(i) Volume displacement oncoplasty and
(ii) Volume replacement oncoplasty
1. Volume displacement OBS: Volume displace-
ment techniques are generally used in larger
ptotic breasts. These techniques include a
wide variety of surgical techniques like:
Simple parenchymal advancement, round
block mammoplasty, racket mammoplasty,
therapeutic mastopexy, and mammoplasty.
Based on the amount of tissue excised and
level of surgical expertise required, Krishna B
Clough classied volume displacement into
two levels [9]:
(a) Level I (Simple): If less than 20% of the
breast volume is excised, a level I procedure is often adequate. These procedures
can be performed by all breast surgeons
without specic training in plastic surgery. There are six steps in level I oncoplasty (Table6.1 and Fig.6.5).
(b) Level II (Complex): Anticipation of
20–50% breast volume excision will
require a level II procedure with excision
of excess skin to reshape the breast. They
are based upon mammoplasty techniques
and require specic training in
OBS.Various types of level II oncoplasty
are briey shown in Fig.6.6. These techniques are described in detail in other
chapters of this book.
2. Volume replacement OBS: In volume
replacement OBS tissue from sites away from
breast is used for reconstruction. These techniques are suitable in small breasts with minimal or no ptosis. Volume replacement
techniques are classied as follows and are
described in detail in other chapters of this
book (Fig.6.7):
(a) Local perforator aps:
i. Lateral intercostal artery perforator
ap (LICAP)
ii. Anterior intercostal artery perforator
ap (AICAP)
iii. Medial intercostal artery perforator
ap (MICAP)
iv. Thoracodorsal artery perforator ap
(b) Mini-latissimus dorsi (mini-LD) ap
(c) Free ap
ab
cd
ef
6 General Principles ofOncoplastic Breast Surgery
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Table 6.1 Steps of level I oncoplasty
Procedure Result
Skin incision Allow access for tumour excision
Skin undermining To facilitate wide excision of tumour and for dermoglandular mobilization
NAC undermining To avoid displacement of NAC toward excision defect
Full thickness excision R0 resection
Glandular re-approximation To avoid post-excision deformity
De-epithelialization and NAC
repositioning
Re-centres NAC on new breast mound
45
Fig. 6.5 Various steps of level I oncoplasty (left upper
outer quadrant tumour is used for illustration): (a) Skin
incision and de-epithelialisation around NAC, (b) skin
and NAC undermining, (c) and (d) full thickness excision
and specimen orientation, (e) glandular re-approximation,
(f) skin closure
46
ab
cd
ef
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S. V. S. Deo et al.
Fig. 6.6 Various types of level II oncoplasty (left upper
outer quadrant tumour is used for illustration): (a) Round
block mammoplasty for upper quadrant tumours, (b)
racket mammoplasty for upper outer quadrant tumours,
(c) and (d) central quadrantectomy for central tumours,
(e) vertical mammoplasty for 6 o clock tumour, (f) wise
pattern therapeutic mammoplasty for various tumour
locations in large ptotic breast
6 General Principles ofOncoplastic Breast Surgery
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47
a
c
Fig. 6.7 Various perforator aps. (a) LICAP ap used to
reconstruct outer quadrant defects, (b) AICAP ap used to
reconstruct lower quadrant defects, (c) MICAP ap used
b
d
to reconstruct lower inner quadrant defects, (d) TDAP ap
used to reconstruct upper and inner quadrant defects
6.4 Conclusion
OBS is an approach integrating plastic surgical
principles into breast surgery to facilitate expansion of indications of BCS and to improve cosmetic outcomes. All surgeons dealing with breast
cancer should be familiar with basics of OBS in
order to provide better cosmesis and quality of
life to patients.
References
1. Fisher B, Redmond C, Poisson R, et al. Eight-year
results of a randomized clinical trial comparing
Total mastectomy and lumpectomy with or without
irradiation in the treatment of breast cancer. N Engl
J Med. 1989;320:822–8. https://doi.org/10.1056/
nejm198903303201302.
2. Veronesi U, Zucali R, Luini A. Local control and
survival in early breast cancer: the Milan trial. Int J
Radiat Oncol Biol Phys. 1986;12:717–20. https://doi.
org/10.1016/0360- 3016(86)90027- 1.
3. van Maaren MC, de Munck L, de Bock GH, et al.
10 year survival after breast-conserving surgery plus
radiotherapy compared with mastectomy in early
breast cancer in The Netherlands: a population-based
study. Lancet Oncol. 2016;17:1158–70. https://doi.
org/10.1016/S1470- 2045(16)30067- 5.
4. Van Limbergen E, van der Schueren E, Van Tongelen
K.Cosmetic evaluation of breast conserving treatment
for mammary cancer. 1. Proposal of a quantitative
scoring system. Radiother Oncol. 1989;16:159–67.
https://doi.org/10.1016/0167- 8140(89)90016- 9.
5. Hopwood P, Fletcher I, Lee A, Al Ghazal S.A body
image scale for use with cancer patients. Eur J
Cancer. 2001;37:189–97. https://doi.org/10.1016/
S0959- 8049(00)00353- 1.
6. Petit JY, Rietjens M, Garusi C, etal. Integration of
plastic surgery in the course of breast- conserving
surgery for cancer to improve cosmetic results
and radicality of tumor excision. Recent Results
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Cancer Res. 1998;152:202–11. https://doi.
org/10.1007/978- 3- 642- 45769- 2_19.
7. Spear SL, Pelletiere CV, Wolfe AJ, et al. Experience
with reduction mammaplasty combined with breast
conservation therapy in the treatment of breast cancer.
Plast Reconstr Surg. 2003;111:1102–9. https://doi.
org/10.1097/01.PRS.0000046491.87997.40.
8. Bulstrode NW, Shrotria S. Prediction of cosmetic
outcome following conservative breast surgery using
breast volume measurements. Breast. 2001;10:124–6.
https://doi.org/10.1054/brst.2000.0197.
9. Clough KB, Kaufman GJ, Nos C, et al. Improving
breast cancer surgery: a classication and quadrant
per quadrant atlas for Oncoplastic surgery. Ann Surg
Oncol. 2010;17:1375–91. https://doi.org/10.1245/
s10434- 009- 0792- y.
Patient Counselling forBreast
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Oncoplasty andReconstruction
SadafJaerbhoy , SumohanChatterjee ,
andLucyCooke
7
Mastectomy is performed as part of cancer treatment when breast conservation is not oncologically feasible or if the patient chooses it but with
increased understanding of genetic mutations,
the number of patients requiring risk reducing
mastectomy has increased [1]. Majority of
patients undergoing risk reducing surgery are
young and their recovery can be greatly affected
by the physical changes and psychological distress which may manifest following a mastectomy. Many studies have reported that breast
reconstruction lowers the probability of depression onset and improves emotional, social, and
physical well-being [2]. All patients are therefore
be given the option of having breast reconstruction either in the immediate setting if feasible or
as a delayed procedure. Breast reconstruction has
additional complications and patients need to be
adequately informed about the potential risks and
complications with additional procedures.
Women undergoing breast reconstruction are
often a specic patient population with different
psychological and aesthetic expectations.
S. Jafferbhoy
Department of Breast Surgery, University Hospitals
of North Midlands, Stoke-on-Trent, UK
S. Chatterjee (*) · L. Cooke
The Nightingale Centre, Wythenshawe Hospital,
Manchester Foundation NHS Trust, Manchester, UK
Choosing the appropriate reconstructive technique to achieve satisfactory results entails multiple factors such as the extent of disease, patient’s
desire, body habitus, available tissue for autologous reconstruction. Imparting information to
patients about the options for breast reconstruction including potential outcomes and complications is essential. If women are adequately
informed about potential complications, they are
better equipped to move through the physical
recovery phase. Women often require guidance
through the complex choices and enough time to
reach an informed decision and this is associated
with improved long-term psychological outcome
[3, 4].
Patients’ satisfaction largely depends on the
interaction between the patient and information
provider [5]. It is not always possible to have an
in-depth discussion with a patient in one consultation and most of the patients require two or
three pre-operative visits to the clinic before
making any nal decision. This includes consultation with their surgeon to discuss their reconstructive options and a separate consultation with
a breast care nurse is often helpful [6]. During
these consultations, a thorough discussion takes
place regarding each reconstruction option, postoperative recovery, and potential complications.
Such information is provided in a variety of
forms and this multimodal approach has been
shown to have a positive effect on numerous
patients’ outcomes such as knowledge and recall,
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
S. V. S. Deo (ed.), Breast Oncoplasty and Reconstruction,
https://doi.org/10.1007/978-981-99-5536-7_7
49
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S. Jaerbhoy et al.
symptom management, satisfaction, health care
utilisation, and affective states [7–9]. Patients
also get the opportunity to feel the implants and
view a selection of photographs demonstrating
the results and complications of breast
reconstruction.
The selection of the reconstructive technique
should be made after the patient has been thoroughly informed on the available reconstructive
options and understands the risk and benets of
each option. Tailoring the appropriate reconstructive modality is a shared decision between the
patient and the surgeon but adequate preoperative counselling has a major impact on
recovery which in turn affects the quality of life
and survivorship. The pre-operative counselling
takes into account patients’ co-morbidities, the
oncological aspects of treatment as well as managing the aesthetic expectations.
It is of paramount importance that comorbidities are taken into account when deciding
about breast reconstruction and consider whether
these can be modied particularly in cases having
risk reducing surgery. It is well known that
patients with obesity, smoking, diabetes mellitus,
or having immunosuppressants are at a higher
risk of reconstruction failure. These patients
either undergo a staged procedure for reconstruction or if only a particular type of reconstruction
is being offered, it is judicious to counsel and
advise them the rationale for the decision. In
patients undergoing risk reduction surgery where
surgery is not time sensitive, patients should be
advised on the measures to reduce the risk such
as weight loss or smoking cessation.
complications following reconstruction and this
has a negative impact on their quality of life.
Post-operative complications can have a bearing
on adjuvant treatment but studies have shown
that this does not result in clinically signicant
delay on adjuvant treatment [10].
Cancer diagnosis has a negative impact on a
woman’s ability to retain information [11]. Preoperative counselling for breast reconstruction is
often a staged process which includes the options
for reconstruction and the complication associated with each technique. The discussion
becomes more complex when patients are given
the option for breast conservation with oncoplastic techniques such as therapeutic mammaplasty
and local perforator aps or having a mastectomy
with immediate reconstruction. Patients often
nd the whole information process quite overwhelming as there are many aspects that should
be discussed with patients considering breast
conserving surgery or mastectomy.
The information regarding surgical options is
often given in the form of information leaets but
evidence shows that the use of visual aids helps
in improving the understanding of the surgical
procedure and its complications. Various tools
such as patients’ decision aid videos and use of
tablet devices to show images for patients preoperative counselling have shown benet in
shared decision making process [12, 13]. There
are many aspects that need to be discussed in preoperative counselling for breast reconstruction
but the following should be discussed with every
woman considering breast reconstruction.
7.1 Aspects ofPre-operative
Counselling
Women may choose to have breast reconstruction
to improve quality of life physically and
emotionally.
When aesthetic outcomes are satisfactory to
women, breast reconstruction can be integral part
of the whole healing process. Post-operative
recovery can be prolonged if patients develop
7.1.1 Breast Conservation or
Mastectomy
Mastectomy has traditionally been offered to
women with small to moderate size breasts where
a simple breast conserving procedure would
result in poor cosmetic outcome. With modern
oncoplastic techniques, breast conservation with
mammaplasty or local perforator aps is increasingly being offered. Patients often perceive mastectomy being superior to breast conserving
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