Chapter 150: Principles and Overview of Oncoplastic Approaches in the Surgical Treatment of Breast Cancer

BACKGROUND: HISTORICAL PERSPECTIVE

The surgical management of breast cancer has changed greatly since the late 1880s when Halsted started utilizing radical mastectomy for breast cancer treatment.¹ Although this approach obtained local control, it resulted in horrible deformities and a constant physical reminder of the cancer operation with numerous psychological impacts. It was not until the advent of screening mammograms that the disease could be discovered in earlier stages and less extreme surgical interventions could be established.

In the 1970s several studies showed that portions of the breast could be preserved and that survival was improved using radiation as an adjuvant therapy (breast conservation therapy or BCT). BCT compared to total mastectomy proved to hold equivalent disease-free, distant disease-free, and overall 5-year survival.¹ With numerous other studies demonstrating the oncological safety of BCT, breast conservation has become a popular and, in many centers, the preferred surgical treatment of breast cancer.^2-6 However, the aesthetic outcomes after a lumpectomy or partial mastectomy and radiation are unpredictable and frequently unacceptable, leaving 20% to 30% of patients with residual deformities.^7,8 Figure 150-1 is an example of a patient who had a disfiguring result after being treated with BCT for a lower pole lesion. As many as 25% to 50% of women who undergo BCT have been reported to be dissatisfied with their aesthetic outcome.^7-10

Despite the risks of poor aesthetic outcomes, many patients and surgeons choose the opportunity to preserve one's breast. To counteract the potential disfigurement of BCT while providing oncologically successful outcomes in BCT, breast remodeling techniques are being developed and refined. In 2000, Werner Audretsch coined the term “Oncoplastic Surgery,” which appropriately combined the aspects of the oncological resection of the tumor and plastic surgery reconstruction.^1,11 Oncoplastic surgery can also be referred to as partial mastectomy reconstruction. These techniques combine the principles of proper oncologic resection with the tenets of aesthetic breast surgery.¹² Oncoplastic surgery is now an option that should be offered to women undergoing BCT to optimize their aesthetic outcomes.

Utilizing the skillset required in breast reductions and mastopexy, oncoplastic procedures help to reduce the deforming effects of radiation therapy upon seroma cavities. At the same time, the remaining breast tissues can be recontoured with potential improvement in ptosis of the breast mound and skin. In addition to determining the oncological safety of breast conservation, patient selection and timing for the reconstruction are crucial for successful outcome. It is essential that early referral is made to the plastic surgeon to allow preoperative planning and, if feasible, to avoid performing the procedure in a delayed setting when complications are much higher.

TYPES/CLASSIFICATION OF LUMPECTOMY DEFECTS

There ...