Oncoplastic breast cancer surgery is a relatively new surgical sub-speciality that involves removal of the breast cancer using plastic surgical techniques to reconstruct the defect produced when the cancer is removed. It includes excision of the tumour with adequately wide free-margins to achieve locoregional control and immediately remodelling of the defect to improve the cosmetic result. It can also involve contralateral (opposite) breast symmetrisation and reconstruction of the nipple and areolar complex when necessary and includes immediate and delayed breast reconstruction after mastectomy.
Some patients who have primary breast cancer may also be able to have the cancer removed with a reduction mammoplasty (breast reduction) or a mastopexy to correct breast ptosis (breast lift).
Poor cosmetic results are expected after standard breast-conserving surgery (standard wide local excision) due to unfavourable tumour to breast size ratio, for example when greater than 20% of the breast volume will be required to be removed, or if the tumour is located in an unfavourable cosmetic position in the breast. The patient may be suitable for an oncoplastic technique which can often involve placing the incision in an area remote from the cancer and employing plastic surgical techniques such as a mastopexy/reduction mammoplasty to improve the cosmetic outcome.
Not all patients will be suitable for oncoplastic surgery but every opportunity should be taken to discuss the use of oncoplastic surgery to improve the cosmetic outcome preoperatively.
Breast-conserving surgery followed by radiation therapy is comparable to total mastectomy with respect to local recurrence and survival (Veronesi et al.1995). The major concern with breast-conserving surgery is unfavourable cosmetic results which have been found in up to 30% of patients.
Breast tissue deformities are seen in the immediate postoperative period and can also develop over time, particularly after radiotherapy is delivered to the breast. The extent of these cosmetic changes will depend on the amount of breast tissue excised, the size of the breast (the cancer to breast size ratio), whether or not skin has been resected at the time of excision of the cancer, the position of the cancer in the breast, the orientation of the surgical incisions on the skin, and the use of postoperative radiotherapy. A greater amount of tissue removed at the time of primary surgery will be associated with a higher risk of poor cosmetic result. However, it is still important that a free margin of healthy tissue is obtained around the tumour to reduce the risk of local recurrence and improve survival.
Oncoplastic surgery has been compared to standard breast-conserving cancer surgery and the advantages of oncoplastic surgery include the ability to resect larger breast volumes. There is also strong evidence to indicate that oncoplastic surgery produces wider free margins and that free margins are obtained more frequently. Thus, fewer patients will require re-operation (return to the operating theatre to clear margins). Better cosmetic results will be achieved especially in women who wish to reduce their breast size or who have a significant degree of ptosis.
Oncoplastic surgery allows some women that would previously have been recommended to undergo a mastectomy (e.g. ladies with large tumours and small breasts) to have breast-conserving surgery. Contralateral (opposite breast) procedures can be performed for symmetrisation and contralateral reduction mammoplasty (breast reduction) as an additional benefit may also reduce the risk of breast cancer.A reduction in breast volume will allow a more uniform dose distribution of postoperative radiotherapy.
However, there are disadvantages of oncoplastic surgery and these include longer duration of surgery. The scars may be longer; however, the scars were usually placed in a position where they will be hidden and therefore will not be well-visualised postoperatively; for example, in the inframammary fold. Some studies indicate that there are higher complication rates, particularly with more complex operations and when there is surgery to the contralateral breast at the time of removing the primary cancer. However there has been no evidence that this delays further postoperative adjuvant treatment (e.g. chemotherapy and radiotherapy). Significant timing and planning is required by the surgeon particularly if a 2-teamed approach (breast cancer surgeon and plastic surgeon) perform the procedure together.