Basic description of oncoplastic breast surgery

1. ONCOPLASTIC BREAST SURGERY
RECENT ADVANCES

2. Refers to any surgery that aims to
Maintain the quality of life
And
Acceptable breast appearance
While
Uncompromising on oncological effectiveness

3. • It entails2:
– Complete tumor extirpation
– Reconstruction of wide local excisions
– Symmetrising surgery for the contralateral breast
Achieved by maximising use of breast conservation
surgery.
• Aims of oncoplastic breast conservation surgery3:
– Complete removal of lesion
– Clear margins
– One OT visit for definitive procedure

4. • Excisions over 5-15% of breast tissue are
generally associated with unsatisfactory
outcome if oncoplastic principles aren’t used1.

5. Indications Contraindications
• Breast : tumor size ratio
• Breast tissues with
severe ptosis
• Resection>20% of
breast tissue
• Patient preference
• Previously radiated
breast tissue.
• Small breasts without
ptosis

6. PRE OP EVALUATION
• Volume and location of breast to be resected
(anticipated defect size)
• Downstaging disease with preoperative
neoadjuvant chemotherapy
• Degree of ptosis
• Skin quality
• Need for symmetry achieving surgery

7. Symmetry achieving surgery
• Synchronous vs. Delayed surgery (effects of
hormonal, chemotherapy and radiation on
breast appearance)
• Uncovering occult malignancies in
contralateral breast (4-7)
• Decreased incidence of recurrent breast
cancer in women >50 years of age following
breast reduction (8)

8. General Principles
• Restrict oncoplastic surgery to definitive care.
• Apply radiopaque markers to surgical margins (e.g
hemoclips)
• Use multiple bracketing wires
• Utilize intraoperative Ultrasound for sonographically
apparent lesions.
• Using a surgical drain.
• Orient the surgical specimen
• Obtain intraoperative Pathology consultation.
• Preserve sensation of the Nipple-Areolar Complex: The lateral
cutaneous branch of the fourth intercostal nerve is the predominant source of
sensory innervation for the nipple-areolar complex and maintains a relatively
constant course through the breast

9. SKIN INCISIONS FOR FAVOURABLE
ONCOPLASTIC OUTCOMES9
• For upper pole tumors:
– Crescent incision
– Bat wing incision
– Hemi batwing incision
• For lower pole tumors:
– Triangle
– Trapezoid
– Inframammary
– Reduction
• Any segment:
– Radial-ellipse (most versatile)
– Circumareolar with flap advancement
– Donut mastopexy

10. Radial- ellipse incisions
• Following Langer’s lines or Kraissl’s lines for
incisions over the breast doesnt always result
in cosmesis due to absence of lax skin in the
breast.
• Hence radial incisions prefered
• Avoid contour deformity
• Avoid nipple malposition due to
complementary advancement of parenchyma
and skin

11. 1 = superolateral radial incision
2 = inferolateral radial incision
3 = superior circumareolar incision
4 = periareolar incision
5 = inframammary fold incisions
6 = other incision

12. Batwing excision

13. Crescent excision

14. Hemi batwing

15. Trapezoid

16. Lower pole involvement

17. BREAST SIZE RECONSTRUCTIVE OPTIONS
AVAILABLE3
SMALL REGIONALLY BASED FLAPS
SMALL TO MODERATE
(Small lump-
resection:breast size<1:5)
REGIONALLY BASED FLAPS
LOCAL TISSUE REARRANGEMENT
SMALL –MODERATE
(Large lump-
resection size:breast size >1:5)
•MASTECTOMY WITH
RECONSTRUCTION
LARGE • LOCAL TISSUE REARRANGEMENT
•LOCAL/REGIONAL FLAPS
•REDUCTION
MAMMOPLASTY/MASTOPEXY

18. LOCAL TISSUE REARRANGEMENT
• Moderate sized breasts, small tumors, grade 1
ptosis
• Shifts defect to less conspicuos location by taking
advantage of subcutaneous fat and skin.
• Involves raising of skin/subcutaneous flaps to
allow mobilisation of underlying glandular tissue
to fill defect
• Full thickness breast parenchyma plus skin are
rotated or transposed en bloc.
• Not for large defects-scarring,nipple distortion

20. REGIONAL FLAPS
• Insufficient tissue for local arrangement, large
defect
• E.g Latissmuss dorsi flap, intercostal perforator
flap
• Ideal following mastectomy

21. Latissmuss dorsi flap3
• Based on thoracodorsal vessels
• Ideal for lateral ,superior defects, small breasts
• With or without skin paddle
• Open/Endoscopic
• Split LD flap –either vertical/horizontal branch of TDA
used
• LD mini flap
• Thoracodorsal artery perforator flap(TAP) –minimal
muscle harvested. Proximal/distal perforator (8cm
below posterior axillary fold and 2-3 cms posterior to
lateral border of muscle/ 2-4 cms distal to proximal)

23. Perforator anatomy of lateral chest
wall • The flap is raised from
medial to lateral via an
incision at the lateral breast
crease.
• The LTA is encountered first
(perforators labelled in
yellow)
•next the lateral intercostal
artery perforators (labelled
blue).
• Rarely,when these vessels or
combinations are not
suitable, a TDAP flap is raised
based on a septocutaneous
perforator at the anterior
border of the muscle if
present (labelled green), or
more commonly a
musculocutaneous perforator
(labelled orange).

24. Intercostal artery perforator flap3
• Based on Perforator found anterior to LD
muscle
• Dissect intercostal vessels upto origin (split in
serratus anterior)
• Small, lateral defects

26. Lateral thoracic flap3
• Depends on one or more direct cutaneous
branches of lateral thoracic artery, axillary or
thoracodorsal artery
• Transfer of skin and subcutaneous tissue
based on 1 of 3 direct cutaneous vessels.

27. Distant flaps
• Transverse Rectus Abdominis flaps (based on
perforators throught rectus abdominis,
IEA>SEA)
• Deep inferior epigastric artery flap (DIEP)

28. ONCOPLASTIC REDUCTION
MAMMOPLASTY
• Ideal for patients with preoperative macromastia
• Based on tumor location, a skin pattern and NAC pedicle
designed preoperatively to allow for tumor resection
with margins and fill the defect with remaining breast
tissue.
• Once adequate resection is done on ipsilateral side,
contralateral breast is reduced to match
• Incision pattern such that it maintains viabilitiy of skin
flaps while giving adequate access and exposure for
partial mastectomy to be performed. The dermo
glandular pedicle vascularises the NAC.
• Pattern used depends on tumor location

29. Central tumors
• NAC intact/tumor lies above NAC: Standard
Wise incision /Vertical mammoplasty
• Based on inferior pedicle +/- medial,lateral
pedicles
• If nipple is involved- Inverted T closing
wedge/ melon slice mammoplasty can be
done.
• Reconstruction of nipple/NAC- done with full
thickness skin graft

30. Standard Wise design /Vertical
mammoplasty

32. Grissoti flap

33. Inferior tumors
Easily excised using a superior or superior-medial based pedicle
using the Wise pattern skin envelope or vertical scar technique

34. • Lateral mammoplasty: for lateral pole tumors.
• Can be extended superiorly to access axilla for
node dissections.

35. Medial mammoplasty
• Easily performed using a Wise pattern skin
incision. By extending a superio-lateral nipple
pedicle to the inferior aspect of the breast the
medial defect can be filled with the inferior
pole of the pedicle being rotated upward

36. The blood supply of the different pedicles is as follows:
• the inferior pedicle relies on the perforator from the IMA,
coming through P.major(at 4th ICS)and its venae comitantes;
• a superior pedicle is well supplied by the long branch of the
internal mammary system from the second or third interspace;
• medial vessels supply a medial pedicle;
• the superficial thoracic artery (br. of LTA)supplies a lateral pedicle
The inferior pedicle must therefore be a full thickness
dermoglandular pedicle to survive. In contrast, the
superior, medial and lateral pedicles can all be dermal
because both their venous and arterial blood supply is
superficial. The innervation and the ductal system,
however, will only be preserved with a full thickness
pedicle.

37. Autologous fat grafting12
• Fat grafts are preferred over other graft types for the correction of
volume and contour defects because fat is autologous, abundant, and
easily harvested ,naturally integrates into host tissues and is 100%
biocompatible.
• The ASCs (adipose-derived stem cells) into the fat graft allow the
regeneration of tissue after breast reconstruction,more so in irradiated
tissue.
• Most common donor site is abdominal fat. Traditional Suction assisted
liposuction= Ultrasound assisted liposuction > Laser assisted liposuction
• After processing of fat, under local anaesthesia, the skin of the breast is
punctured with an 18- gauge cannula that is used to release
dermatofascial adhesions and scar tissue. The same cannula is then used
to inject the fat graft in the subcutaneous and subglandular plane of the
breast
• Comlplications: fat necrosis and calcification
• There is no scientific evidence that fat grafting interferes with breast
cancer detection .
• The question of de novo cancer induction or accelerating growth of a pre-
existing cancer by fat grafting has not been answered to date.

38. Complications3
• 15-30%
• Skin/flap necrosis
• Necrosis of nipple and areolar complex
• Seroma/Hematoma
• Infection
• Wound dehiscence (delayed healing of T junction-
decreased vascular perfusion)
• Longer operating time
• Delay in adjuvant treatment
• Effect of radiation- unpredictable

39. Complications
• Low rates of recurrence (1.5-3% at 5 years, none for T1).
• Positive margins: 2.7-22% (4 different studies)
• Higher stage of disease
• Positive nodes
• Lymphovascular invasion
• Higher initial T stage
• Use of neoadjuvant chemotherapy
• ER positive
• Younger age
– Re excision possible but difficult, often completion mastectomy done
– Rates can be decreased by intra operative frozen section
• Completion mastectomy: low requirement (5-10%)
• Aesthetic outcome/patient satisfaction – 87% patients-good
outcome, imporved self esteem, mental health(Veiga et al)
Poor outcome 5-14% patients- likely due to higher expectations

40. References
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3. Piper, Merisa, Anne Warren Peled, and Hani Sbitany. “Oncoplastic Breast Surgery: Current
Strategies.” Gland Surgery 4.2 (2015): 154–163. PMC. Web. 24 Sept. 2017.
4. Chang E, Johnson N, Webber B, et al. Bilateral reduction mammoplasty in combination with
lumpectomy for treatment of breast cancer in patients with macromastia. Am J Surg 2004;187:647-
50; discussion 650-1.
5. Kakagia D, Fragia K, Grekou A, et al. Reduction mammaplasty specimens and occult breast
carcinomas. Eur J Surg Oncol 2005;31:19-21.
6. Petit JY, Rietjens M, Contesso G, et al. Contralateral mastoplasty for breast reconstruction: a good
opportunity for glandular exploration and occult carcinomas diagnosis. Ann Surg Oncol 1997;4:511-
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7. Rietjens M, Urban CA, Rey PC, et al. Long-term oncological results of breast conservative treatment
with oncoplastic surgery. Breast 2007;16:387-95.
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9. Oncoplastic Surgery of the Breast. Ed. By Maurice Nahabedian.2009
10. Dennis R. Holmes,1 Wesley Schooler,2 and Robina Smith.Oncoplastic Approaches to breast surgery.
Review Article. Intl Journal of Breast Surgery. Vol 2011
11. Macmillam RD,Mc Culley SJ. Oncoplastic Breast Surgery. Curr Breast Cancer REP(2016) 8:112-117
12. Simonacci, Francesco et al. “Autologous Fat Transplantation for Breast Reconstruction: A Literature
Review.” Annals of Medicine and Surgery 12 (2016): 94–100. PMC. Web. 24 Sept. 2017.
13. Wuchukwu, Obi & Harvey, J.R. & Dordea, Matei & Critchley, Adam & Drew, Philip. (2011). The role of
oncoplastic therapeutic mammoplasty in breast cancer surgery- A review. Surgical oncology. 21.
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