EASO2011 BRS 6 Clough

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EASO2011 BRS 6 Clough

  1. 1. ONCOPLASTIC SURGERY Level 1 techniques : Simple principles Krishna B. CLOUGH, Claude NOS, Isabelle SARFATI
  2. 2. ONCOPLASTIC SURGERY <ul><li>Immediate breast reshaping </li></ul><ul><li>Wider excisions </li></ul><ul><li>Better cosmesis </li></ul><ul><li>Increase breast conservation </li></ul>Plastic surgery techniques at the time of tumor excision Audretsch, Clough, Petit, Rainsbury ,...
  3. 3. ONCOPLASTIC SURGERY CLASSIFICATION Ann Surg Oncol 2010
  4. 4. ONCOPLASTIC SURGERY : A CLASSIFICATION <ul><li>Level 1 techniques : </li></ul><ul><li>Less than 20 % of breast volume excised </li></ul><ul><li>Simple reshaping techniques </li></ul><ul><li>No skin excision </li></ul><ul><li>No plastic surgery training </li></ul>Avoids deformities
  5. 5. ONCOPLASTIC SURGERY : A CLASSIFICATION <ul><li>Level 2 techniques : </li></ul><ul><li>20 to 50% of breast volume excised </li></ul><ul><li>Major volume loss </li></ul><ul><li>Skin excision required </li></ul><ul><li>Mammoplasty techniques for reshaping </li></ul>Increase breast conservation rates
  6. 6. &quot; LEVEL 1 &quot;   ONCOPLASTIC TECHNIQUES <ul><li>Simple techniques </li></ul><ul><li>No need for plastic surgeon </li></ul><ul><li>Part of standard breast surgery </li></ul>« Learn on Tuesday, Try on Thursday Keep forever »  
  7. 7. BREAST CONSERVATION: DILEMMNA <ul><li>Free margins </li></ul><ul><li>Reduce reexcision rate </li></ul><ul><li>Wider excisions </li></ul><ul><li>No cosmetic compromise </li></ul>
  8. 8. CONSERVATIVE SURGERY : A CLASH OF INTERESTS
  9. 10. INVOLVED MARGINS <ul><li>Involved margins : 10 to 40% </li></ul><ul><li>Reexcision : 20 to 60% </li></ul><ul><li>Delay adjuvant treatment </li></ul><ul><li>Increased costs, complications, anxiety </li></ul>
  10. 11. “ RED ZONES &quot;
  11. 12. LEVEL 1 OPS GENERAL PRINCIPLES <ul><li>Wide excision from skin to muscle </li></ul><ul><li>No cavity: immediate breast reshaping </li></ul><ul><li>Undermine skin from gland </li></ul><ul><li>Undermine NAC completely </li></ul><ul><li>NAC re-centralization </li></ul>
  12. 13. SKIN UNDERMNING
  13. 14. SKIN UNDERMINING
  14. 15. BREAST DENSITY : BIRADS CLASSIFICATION 1 2 3 4
  15. 16. NAC UNDERMINING
  16. 17. NAC UNDERMINING
  17. 18. NAC UNDERMINING
  18. 19. WIDE EXCISION FROM SKIN TO MUSCLE
  19. 20. POSITIVE MARGINS FOR BCT <ul><li>Standard excision : 10 to 30% </li></ul><ul><li>Oncoplastic surgery : 5 to 18 % </li></ul>Clough 2003, Kaur 2005, Rietjens 2007, Fitoussi 2010 <ul><li>The Paris Breast Center : 8 % </li></ul>2010, 1215 cases BCT, unpublished data
  20. 21. WIDE EXCISION
  21. 22. BREAST RESHAPING ?
  22. 23. BREAST RESHAPING : GLANDULAR FLAPS
  23. 24. GLANDULAR FLAPS
  24. 25. GLANDULAR FLAPS
  25. 26. GLANDULAR SUTURE
  26. 27. ROTATIONAL GLANDULAR FLAPS
  27. 28. ROTATIONAL GLANDULAR FLAP
  28. 29. ROTATIONAL GLANDULAR FLAP
  29. 30. PREVENT NAC DEVIATION ? RE-CENTRALIZATION
  30. 31. NAC RE-CENTRALIZATION <ul><li>Opposite to the lumpectomy bed +++ </li></ul>
  31. 34. Upper inner Q Upper outer Q
  32. 35. BCT FOR SUBAREOLAR CANCERS
  33. 36. WIDE CENTRAL EXCISION : RESHAPING
  34. 37. WIDE CENTRAL EXCISION : RESHAPING
  35. 44. PARIS BREAST CENTER <ul><li>600 new cases +ve margins : 8% </li></ul><ul><li>Excision from skin to pectoralis </li></ul><ul><li>Extensive skin undermining </li></ul><ul><li>NAC undermining </li></ul><ul><li>NAC re-centralization </li></ul>90% Oncoplastic surgery level 1
  36. 45. ONCOPLASTIC SURGERY From CHILDHOOD TO ADOLESCENCE ? <ul><li>Effort for classification </li></ul><ul><li>Level 1 techniques : </li></ul><ul><ul><ul><li>Solve 90% of the cases </li></ul></ul></ul><ul><ul><ul><li>Simple, no specific training </li></ul></ul></ul><ul><ul><ul><li>Good cosmetic results </li></ul></ul></ul><ul><ul><ul><li>Reexcision rate < 10% </li></ul></ul></ul><ul><li>Level 2 techniques : mammoplasty techniques </li></ul>

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