A summary of oncoplastic breast surgery definition, classification and safety

1. Our Topic:
Principles of Techniques and
Indications
Sadaf Alipour
Professor of Surgical Oncology
Tehran University of Medical Sciences
Tehran, Iran

2. Any breast cancer
That is undergoing surgery
And has no contraindication for BCS

3. Contraindications of RT
Because BCS should be followed by RT
E.g.
Pregnancy
Previous local RT
Extreme skin conditions
Incompetent patient
No access to RT facilities

4.  Contraindications of RT
Because BCS should be followed by RT
E.g.
Pregnancy
Previous local RT
Extreme skin conditions
Incompetent patient
 No access to RT facilities
Diffuse or extensive microcalcifications
High mass/breast size ratio (~ >20%)
Multiple masses in more than one quadrant

5. Any BC that is undergoing surgery
And BCS is contraindicated
because of high mass/breast size
ratio
~ when the ratio is 20-40%
And there is no other
contraindication for BCS

6. Resection of the cancer and breast tissue
While observing
Oncologic concerns
Resection of suitable margins
At least as good as BCS
• Usually better
Cosmetic concerns
Breast re-shaping
Far more than simple closure of
lumpectomy site

7. Bernozzi et al, 2017
Wider excision margin with OBS
Local control and oncological safety
Better than BCS
BUT
In OBS
Tumor size usually larger
Positive margin lower after OBS (12% vs. 21%)
Re-excision higher after BCS (14.6% vs. 4%)
Local recurrence rate lower after OBS (4% vs. 7%)
Completion mastectomy more common after
OBS (6.5% vs. 3.79%)
These confirm the
safety of OBS

8. Bernozzi et al, 2017
Tissue manipulation, scar, and fat necrosis
may impair ability for adequate screening
Breast exam + imaging + biopsy can
overcome this issue
Mammographic sensitivity not affected
Time to mammographic stability:
longer after OBS (25.6 months vs. 21.2
months)
Need to biopsy in screening
After OBS: 53%
After BCS: 13%

9. Bernozzi et al, 2017
Tissue manipulation, scar, and fat necrosis
may impair ability for adequate screening
Breast exam + imaging + biopsy can
overcome this issue
Mammographic sensitivity not affected
Time to mammographic stability:
longer after OBS (25.6 months vs. 21.2
months)
Need to biopsy in screening
After OBS: 53%
After BCS: 13%

10. Rose et al, 2020
200 OBS and 1304 BCS
No increase in physical discomfort for OBS
despite more extensive surgery
Better Psychosocial Well-being with OBS
No difference in
Satisfaction with Breast
Physical Well-being
Sexual Well-being
Hernanz et al, 2020 (response to previous)
57 OBS and 108 BCS
Scores similar in all domains including
Psychosocial Well-being

11. Bertozzi et al, 2017:
Unsatisfactory aesthetic outcome
BCS: 30%
OBS: 18%

12. Chatterjee et al, 2019 and Bertozzi et al, 2017
The American Society of Breast Surgeons
(ASBrS)
A classification system for OBS:
Volume displacement
= Transposing dermo-glandular flaps
into the defect
Volume replacement
= Flaps or implants to correct the
defect

13. Chatterjee et al, 2019
Technique
Classification/
Definition
Examples
Volume displacement
Level 1: <20% breast
tissue removed
Local tissue
rearrangement
Crescent mastopexy
Level 2: 20–50% of
breast tissue removed
Reduction
mammoplasty
Volume replacement
> 50% of breast tissue
removed
Implant-based
reconstruction
Local/regional flap
reconstruction
Thoracodorsal artery
perforator, etc

14. Chatterjee et al, 2019
The cut-off point
20% between levels 1 and 2
50% between volume displacement and
replacement
are not fix
Are only suggested planning guides

15. Chatterjee et al, 2019
The ASBrS does not always suggest OBS
BCS excellent in low mass/breast ratio
 Also, OBS better for some small masses
E.g. a 10% defect at 6 o’clock below the
NAC

16. Bertozzi et al, 2017
Type 1 suitable for
Small- to medium-sized breasts when
No significant volume alteration
No significant asymmetry
Type 2 suitable for
Medium- to Large breasts when
Significant volume alteration
Small volume resection in large or ptotic
breast

17. Bertozzi et al, 2017
Type 1 main procedures
Dermo-glandular advancement
Rotation or transposition flap placement

18. Type 1

19. Bertozzi et al, 2017
Suitable for
Large tumors
High mass/breast ratio
Small breasts
 Residual breast insufficient

20. Examples of
most common
autologous
techniques

21. Holmes et al, 2011

22. Berry et al, 2010

23. Munhoz et al, 2013

24. Bertozzi et al, 2017
 Complication rates of OBS: 16%
= Acceptable
Common complications
Volume-displacement
Delayed wound healing (3-15%)
Fat necrosis (3- 10%)
Infection (1-5%)
Breast fibrosis
Volume-replacement
Similar complications
Rate slightly higher due to
Additional donor site complications
Potential flap loss issues

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