Oncoplastic Breast Surgery

Oncoplasty Principles - Artful Excision

• Definition: Integration of plastic surgery techniques with breast cancer resection to achieve optimal oncological and aesthetic outcomes.
• Goals:
  • Complete tumor removal (R0 resection).
  • Preserve/reconstruct breast shape and symmetry.
  • Minimize cosmetic deformity.
  • Improve patient satisfaction and quality of life.
• Patient Selection:
  • Tumor size relative to breast volume (favorable tumor-to-breast ratio).
  • Patient preference and expectations.
  • Absence of contraindications (e.g., inflammatory breast cancer, extensive multifocal disease unsuitable for breast conservation).
• Oncological Safety:
  • Paramount; aesthetic goals are secondary.
  • Achieving wide, clear surgical margins is crucial.
  • Does not compromise local recurrence rates or survival compared to standard BCS.

⭐ Key Principle: Oncoplastic surgery aims for

Volume Displacement - Smart Shifts

• Reshapes native breast tissue after tumor removal; no external tissue added.
• Goal: Close defect, optimize shape, maintain oncologic safety.
• Ideal for resections up to 20-25% of breast volume (some sources up to 30%).
  • Depends on breast size, ptosis, density, tumor location.
  • Requires sufficient remaining glandular tissue for mobilization and reshaping.
• Common Techniques:
  • Local parenchymal/glandular flaps (e.g., rotation, V-mammoplasty, J-mammoplasty).
  • Therapeutic mammoplasty: combines lumpectomy with breast reduction/lift patterns.
  • Nipple-areola complex (NAC) repositioning often necessary for central tumors or significant reshaping.
• Benefits: Avoids donor site morbidity, single operative field, often improved aesthetic outcome over simple lumpectomy.
• Symmetrization of contralateral breast frequently performed for optimal balance.

⭐ Therapeutic mammoplasty, a cornerstone of volume displacement, allows for wider excisions (larger tumors) than standard lumpectomy while simultaneously improving breast shape and symmetry.

Volume Replacement - Filling Voids

• Indicated for defects >20-25% of breast volume or when local glandular flaps are insufficient.
• Autologous Flaps (Pedicled):
  • Latissimus Dorsi (LD) Myocutaneous/Muscle-Sparing Flap:
    • Workhorse flap; versatile for most defects.
    • Blood supply: Thoracodorsal artery.
    • Donor site issues: Seroma, back weakness/stiffness.
  • Thoracodorsal Artery Perforator (TDAP) Flap:
    • Muscle-sparing (skin/fat only).
    • Reduced donor site morbidity compared to LD flap.
• Lipofilling (Autologous Fat Grafting):
  • For small-moderate defects, contour correction, post-radiotherapy changes.
  • Technique: Liposuction harvest, processing, meticulous injection.
  • Risks: Fat necrosis, oil cysts, calcifications; requires careful surveillance.
• Implants (Saline/Silicone):
  • For larger defects; used alone or with flaps.
  • Considerations: Capsular contracture, rupture, infection, BIA-ALCL (rare).
  • Often requires tissue expander first, especially in delayed reconstruction.

⭐ The Latissimus Dorsi (LD) flap is the most common and versatile pedicled flap for volume replacement in partial mastectomy defects, particularly when excision involves >20% of breast volume.

Outcomes & Adjuncts - Healing Paths

• Oncological Safety: Equivalent to conventional BCS with negative margins. Low local recurrence.
• Cosmetic Success: High patient satisfaction; improved symmetry. Objective scoring (e.g., BCCT.core).
• Common Complications:
  • Seroma, hematoma, infection, wound dehiscence.
  • Fat necrosis (palpable lump, may need biopsy).
  • Partial/total flap loss, NAC ischemia.
• Adjuvant Therapy:
  • Radiotherapy (RT): Post-op. Potential for ↑ fibrosis, skin changes, affecting cosmesis.
  • Chemotherapy (CT): May delay wound healing; sequence planning vital.

⭐ Post-op RT typically 4-8 weeks after surgery or 2-4 weeks post-chemo to balance oncological control & healing.

High‑Yield Points - ⚡ Biggest Takeaways

• Oncoplastic breast surgery (OBS) integrates oncological principles with plastic surgery techniques.
• Aims for complete tumor removal (negative margins) and optimal cosmetic outcome.
• Volume displacement techniques (e.g., therapeutic mammoplasty) are for defects <20-25% of breast volume.
• Volume replacement techniques (e.g., local flaps, Latissimus Dorsi flap) are for larger defects >20-25%.
• Improves patient satisfaction and psychological well-being post-Breast Conserving Surgery (BCS).
• Key contraindications include inflammatory breast cancer and extensive multicentric disease.
• Careful preoperative planning and patient selection are crucial for successful outcomes.