Oncoplastic breast surgery

Principles

• Retain as much of the natural breast size and contour as possible
• Symmetry
• Perform the simplest procedure that gives an acceptable result
• Do not compromise oncologic outcomes
• Only perform techniques within your own skill set
• Aim for all necessary surgery to be completed at one operation

When to consider oncoplastic techniques

• Significant area of the skin is to be resected with the tumour
• Large-volume resection expected
  • >5-10% superiorly, medially or inferiorly
  • >10-20% laterally
• Area with poor cosmetic outcomes - e.g. lower hemisphere below the nipple
• Resection may lead to nipple malposition
• High risk of a poor outcome with mastectomy and reconstruction:
  • Need for radiotherapy
  • Obese
  • No good or acceptable reconstructive option

Causes of deformity after BCS

• Collapse and contraction of the excision cavity
• Poor scar placement/orientation
• Radiotherapy - induces fibrosis
• High-risk areas - medial and superior
• Very fatty breast tissue (BIRADS 1 and 2) - prone to fat necrosis and scarring, hard to mobilise tissue

Deformities to avoid

• Volumetric deformity from a large parenchymal resection
• Skin-pectoral muscle adherence deformity
• Lower pole deformity with downward turning of the nipple (bird beak deformity) caused by excision of a lower hemisphere tumour
• Correct deformities prior to radiotherapy - accentuates asymmetry, and makes it harder to correct in future

Classification of oncoplastic techniques

• Level I
  • Principles
    • Choose the correct incision
    • Accomplish dual plane mobilisation
    • Complete full-thickness excision of the breast
    • Volume displacement
    • Glanduloplasty
  • Techniques
    • Skin undermining - facilitates wide excision and glandular mobilisation for reshaping
    • NAC undermining - avoids displacement of NAC towards excision defect
    • De-epithelialisation and NAC repositioning - re-centres NAC
• Level II

Techniques

• Volume
  • Displacement (for larger breasts, where existing tissue can be rearranged)
    • Simple parenchymal advancement into a defect
    • Round block
    • Round block with nipple centralisation (tennis racquet)
    • Therapeutic mastopexy
    • Therapeutic reduction mammoplasty
  • Replacement (when there is insufficient volume for displacement techniques - need to bring tissue from elsewhere)
    • Immediate lipofilling
    • Perforator flaps - ICAP, TDAP, LD
    • Free flap