Oncoplastic Surgery of the Breast - 2nd Edition

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viii List of Contributors

Sadia Khan, DO, FACS Bridget A. Oppong, MD

Program Advisor - Breast Surgical Services Reston Breast Care Specialists
Breast Surgical Oncology Surgery
Hoag Memorial Hospital Presbyterian Reston Hospital Center
Newport Beach, CA, USA Reston, VA, USA
Assistant Clinical Professor Adjunct Faculty
Department of Surgery Lombardi Comprehensive Cancer Center
Keck School of Medicine USC Georgetown University
Los Angeles, CA, USA Washington, DC, USA

Steven J. Kronowitz, MD Gemma Pons, MD, PhD

Owner Head of the Microsurgery Unit
Kronowitz Plastic Surgery, PLLC Plastic Surgery
Houston, TX, USA Hospital de Sant Pau
Barcelona, Spain
Albert Losken, MD, FACS
Consultant
Emory University
Plastic Surgery
Division of Plastic and Reconstructive Surgery
Hospital de Sant Pau
Emory University Hospital
Barcelona, Spain
Atlanta, GA, USA
Juliann Marie Reiland, MD
Jaume Masia, MD, PhD
Program Director, Electron-based IORT Breast
Chief and Professor
Oncology
Plastic Surgery
Avera Cancer Institute
Sant Pau University Hospital (Universitat Autonoma de
Sioux Falls, SD, USA
Barcelona)
Barcelona, Spain Clinical Associate Professor
Surgery
Alex N. Mesbahi, MD Sanford School of Medicine
Assistant Clinical Professor Sioux Falls, SD, USA
Plastic Surgery
Chair: ASBrS Oncoplastic Surgery Committee
Georgetown University Hospital
American Society of Breast Surgeons
Washington, DC, USA
Partner Jordi Riba Vílchez, MD
National Center for Plastic Surgery Plastic Reconstructive and Aesthetic Surgery Department
McLean, VA, USA Hospital de Sant Pau
Barcelona, Spain
Alexandre Mendonça Munhoz, M, PhD
Plastic Surgery Rachel Rolph, MBBS MA(Oxon) MRCS
Hospital Sírio-Libanês, São Paulo Clinical Research Fellow
São Paulo, Brazil Department of Plastic and Reconstructive Surgery
Guys and St Thomas’ NHS Foundation Trust
Professor
London, UK
Plastic Surgery
Instituto do Câncer do Estado de São Paulo, São Paulo
Nirav B. Savalia, MD
Sao Paulo, Brazil
Clinical Assistant Professor of Surgery
Plastic Surgery
Maurice Y. Nahabedian, MD
USC/Keck School of Medicine
Professor
Los Angeles, CA, USA
Department of Plastic Surgery
Virginia Commonwealth University - Inova Branch Program Director for Oncoplastic and Aesthetic Breast
Falls Church, VA, USA Surgery
Hoag Hospital Memorial Presbyterian
Newport Beach, CA, USA
 List of Contributors ix

Hani Sbitany, MD, FACS Christine Teal, MD

Associate Professor of Surgery Director, Breast Care Center
Plastic and Reconstructive Surgery Surgery
University of California George Washington University
San Francisco, USA Washington, DC, USA

Melvin J. Silverstein Peter W. Thompson, MD

Hoag Hospital Memorial Presbyterian Assistant Professor of Plastic Surgery
Newport Beach, CA, USA Surgery
Department of Surgery, Keck School of Medicine, Emory University
University of Southern California Atlanta, GA, USA
Los Angeles, CA, USA
Mark Venturi, MD, FACS
Toni Storm-Dickerson, BS, MD Private Practice
Director Plastic Surgery
Surgical Services Compass Breast National Center for Plastic Surgery
Compass Oncology McLean, VA, USA
Vancouver, WA, USA
Louisa Yemc, PA-C
Medical Director Surgical Services
National Center for Plastic Surgery
Kearney Breast Center
McLean, VA, USA
PeaceHealth Vancouver
Vancouver, WA, USA
 I would like to dedicate this second edition of Oncoplastic Surgery of the Breast to my long-
time friend and associate, Scott Spear, MD. Scott was an inspiration to plastic and breast
surgeons around the world whose valuable insights and pearls of wisdom helped thousands
of surgeons who ultimately were able to help tens of thousands of patients. I was fortunate
to work with him at Georgetown University Hospital from 2005–2013, where he was the
founding Chairman of the Department of Plastic Surgery. Scott taught me to think critically,
analyze precisely, and to plan and execute accordingly. He raised the bar for all of us when it
came to surgical and aesthetic outcomes following reconstructive and aesthetic breast surgery.
I would also like to dedicate this book to the 69 plastic surgery chief residents that I have
had the privilege to work with and train while on the faculty at Johns Hopkins and George-
town Universities from 1996–2017. Their desire to learn was my inspiration to teach both in
the operating room and in the research arena. The friendships that have been established have
stood the test of time, and I am so proud of each and every one of them. Special thanks to
Mark Venturi, MD, and Alex Mesbahi, MD, who were two of my plastic surgery residents. It
has been a privilege to become a partner in their practice where we continue to provide state
of the art reconstructive and aesthetic breast surgery for our patients.
Finally I would like to thank my wife, Anissa, and my two daughters, Danielle and
Sophia. Their endless support and encouragement have made it possible to continue to educate
and teach surgeons around the world and to provide patients with the highest quality care
possible.

Maurice Y. Nahabedian, MD, FACS

1
Introduction to Oncoplastic
Breast Surgery
MAURICE Y. NAHABEDIAN

Oncoplastic breast surgery has become a common option been the widespread acceptance of nipple-sparing mastec-
for women with breast cancer. Oncoplastic surgery is tomy for malignant disease that has been applied to women
defined as tumor excision with a wide margin of resection in select situations.11-15
followed by immediate or staged immediate reconstruction The common feature of the early mastectomy tech-
of the partial mastectomy defect. It differs from traditional niques was that the breast was removed, and the likeli-
breast conservation in that the margin of excision is signifi- hood of disfigurement was high. This ultimately led to the
cantly wider ranging from 1–2 cm rather than 1–2 mm. need for reconstructive techniques that could minimize
Oncoplastic breast surgery has been demonstrated to be this disfigurement. The advancements in breast recon-
safe and effective and results in high patient satisfaction. struction paralleled the advancements in mastectomy so
This introductory chapter will review the evolution and these disfigurements could be eliminated. Reconstructive
many of the milestones associated with ablative breast can- options have included prosthetic devices, musculocutane-
cer surgery and how oncoplastic breast surgery has evolved ous flaps, and perforator flaps.16-23 The evolution of these
as a primary option for women diagnosed with breast can- techniques has made a significant impact when it came
cer. to mastectomy and outcome; however, the breast conser-
vation therapy (BCT) movement had been initiated and
History of Mastectomy represented a new frontier in the management of breast
cancer.
The management of breast cancer has been subject to
several paradigm shifts over the past century. Before the History of Breast Conservation
era of William Stewart Halstead, the diagnosis of breast
cancer was often associated with few options for manage- The breast conservation movement began to move forward
ment and poor patient survival. With the introduction of as our understanding of the pathophysiology of breast can-
the radical mastectomy, the morbidity and mortality of cer improved and optimal utilization of radiation therapy
breast cancer was markedly improved; however, the dis- became standardized. The notion that total mastectomy
figurement following this operation was significant.1 The was not an absolute requirement and that lumpectomy
modified radical mastectomy (MRM), in which the pec- could be performed with equivalent safety and efficacy was
toral major muscle was preserved and the axillary lymph a significant breakthrough.24,25 Benefits included preserva-
node basin was dissected, maintained similar survival tion of the nipple–areolar complex in many cases as well
statistics with slightly less physical disfigurement.2-4 The as maintaining breast shape in the majority of women.26
simple mastectomy in conjunction with radiation therapy Common to all patients having BCT is the need for postop-
was introduced at the same time and continued to provide erative radiation to eradicate microscopic disease that may
less aggressive surgical techniques.5 Further refinements in be present.
mastectomy techniques allowed for skin-sparing patterns Outcomes following BCT have been generally favor-
that were demonstrated to equivalent local recurrence and able with survival statistics that have remained essentially
survival rates.6-8 With the introduction of sentinel lymph equal to that of MRM.27 However, local recurrence rates
node biopsy (SLNB) for breast cancer, the need to per- are slightly increased. Although the aesthetic outcomes fol-
form an axillary dissection was significantly reduced, and lowing BCT have been good to excellent in the majority
the simple mastectomy with SLNB has become a common of women, some have required secondary procedures to
mastectomy strategy.9,10 The most recent innovation has improve the appearance and achieve symmetry.28

2
 CHAPTER 1 Introduction to Oncoplastic Breast Surgery 3

History of Oncoplasty It is known that larger tumors have an increased likeli-

hood of a positive margin; therefore, obtaining wider mar-
In an effort to reduce the incidence of local recurrence and gins may decrease the likelihood of a positive margin. Kaur
maintain natural breast contour, the concept of oncoplastic et al demonstrated that, as resection margins increase, the
surgery was introduced.29,30 Oncoplastic surgery differs from incidence of a positive margin is reduced, especially when
standard BCT in that the margin and volume of excision is comparing oncoplastic resection to standard quadrantec-
typically greater than that of lumpectomy or quadrantec- tomy.36 Mean resection volume in this study was 200 cm3
tomy. With BCT, an excision margin of 1–2 mm is usu- following oncoplastic resection and 117 cm3 following
ally sufficient; whereas with oncoplastic surgery, excision quadrantectomy. Giacalone et al have demonstrated that,
margins typically range from 1–2 cm and resection volumes following oncoplastic resection, glandular removal was
typically range from 100–200 cm3. The resultant deformity increased, histological margins were wider, and the need for
is usually reconstructed immediately using volume replace- re-excision was decreased.37 In addition, there was a trend
ment or displacement techniques; however, a staged imme- toward fewer mastectomies following oncoplastic resection
diate reconstruction can also be considered. Reconstructive (2/42, 4.8%) compared with standard lumpectomy (12/57,
options include adjacent tissue rearrangement, reduction 21.1%). Additional studies and supportive data will be
mammaplasty, or distant flaps. When symmetry is desired, reviewed in upcoming chapters.
contralateral procedures can be performed immediately at
the time of partial breast reconstruction or on a delayed
basis and include reduction mammaplasty, mastopexy, or Immediate Reconstruction of the Partial
augmentation. Breast conservation using oncoplastic tech- Mastectomy Deformity
niques has resulted in survival and local recurrence rates that
are essentially equal to that of MRM.31,32 The techniques currently used for the reconstruction of
The purpose of this introductory chapter is to review the partial mastectomy defect are based on two different
the history of these oncoplastic procedures and several of concepts: volume displacement and volume replacement.
the landmark studies as well as highlight some of the sur- Volume displacement procedures include local tissue rear-
geons that have made significant contributions to onco- rangement, reduction mammaplasty, and mastopexy. Vol-
plastic surgery. As oncoplastic surgery gains acceptance ume replacement procedures include local and remote flaps
and popularity, an optimal and systematic approach to from various regions of the body. These techniques are usu-
management is becoming increasingly necessary. This ally applied independently; however, new strategies can uti-
introductory chapter will review many of the relevant lize them simultaneously.
vignettes of oncoplastic surgery, and the subsequent chap- The indications for volume displacement and replace-
ters will expand upon many of the principles, concepts, ment are different and, various algorithms have been devised
and techniques. to assist with the decision-making process.38-40 In general,
women with smaller breasts with minimal ptosis were found
Safety and Efficacy of Oncoplastic Surgery to be better candidates for volume replacement procedures
(e.g., local flap, latissimus dorsi, and lateral thoracic flap),
The indications and patient selection criteria for oncoplastic whereas, in women with larger and more ptotic breasts,
surgery is now well appreciated and accepted. Oncoplastic volume displacement procedures (e.g., adjacent tissue rear-
surgeons should be aware of all aspects related to the indi- rangement, reduction mammaplasty, and mastopexy) are
cations, techniques, and recovery for women considering usually performed. The simultaneous use of replacement
partial mastectomy. Safety in oncoplastic surgery requires and displacement has recently been described for women
an appreciation of tumor biology and an understanding with small to moderate breast volume in which parenchy-
of what constitutes an appropriate margin. The process mal rearrangement is combined with the use of a small
begins by obtaining a diagnosis that can be accomplished device.41-43 The history of these techniques as they relate to
using various techniques that include fine-needle aspiration, oncoplastic surgery will be further reviewed.
core needle biopsy, and excisional biopsy. The next step is
the excision. The importance of obtaining a clear margin
becomes evident when one considers that the relative risk Volume Displacement with Reduction
of developing a recurrence is 15-fold higher in patients in Mammaplasty
whom the surgical margin was not clear of tumor.33,34 A
positive margin can be related to the size of the primary Reduction mammaplasty as an oncoplastic modality has
tumor (T3 > T2 > T1) and to histological subtype (lobu- been performed since the early 1980s.44 Over the years,
lar > ductal).33 Preoperative identification of these women this has become the principal method by which oncoplas-
with infiltrating lobular carcinoma who may be at higher tic reconstruction has been performed.45,46 Clough et al
risk of a positive surgical margin can be sometimes made reported on their 14-year experience in 101 women who
via mammography based on the presence of architectural were selected for oncoplastic resection because a standard
distortion.35 lumpectomy would have resulted in a significant contour
4 S EC T I O N I Oncoplastic Breast Surgery – Getting Started

abnormality.45 The primary technique utilized was an

inverted “T” with nipple–areolar complex based on a supe-
rior pedicle. A contralateral reduction mammaplasty for
symmetry was performed immediately in 83% of women
and secondarily in 17% of women. Mean tumor excision
weight was 222 grams. The 5-year local recurrence rate was
9.4%, the overall survival rate was 95.7%, and the metas-
tasis-free survival rate was 82.8%. Cosmetic outcome was
satisfactory in 82% of women. It was demonstrated that
cosmetic outcome tended to deteriorate when radiotherapy
was delivered preoperatively compared with postoperatively.
Spear et al have reported on their 6-year multidisci-
plinary experience combining wide excision of tumor
with immediate bilateral reduction mammaplasty.47 All
women had mammary hypertrophy with a mean exci-
sion volume of 1085 grams per breast. Follow-up ranged
• Fig. 1.1Preoperative marking of a woman with mammary hypertro-
from 1–6 years with a mean of 24 months. Complications phy and left breast cancer in preparation for left oncoplasty and right
included fat necrosis (n = 3), nipple hypopigmentation reduction mammaplasty.
(n = 2), hematoma, and complex scar. Patient satisfaction
was scored on a visual analog scale that ranged from 1–4
with a mean score of 3.3. A panel of independent observ-
ers also graded the outcomes and scored the pre-radiation
outcome as a 2.9 and the post-radiation outcome as 3.03.
No woman developed a local recurrence, although one
woman died of metastatic disease. The principal con-
clusions from this study were that partial mastectomy
followed by oncoplastic and contralateral reduction mam-
maplasty was oncologically safe and avoided the asymme-
try that was typically observed following BCT alone or
following total mastectomy with immediate total breast
reconstruction.
Losken et al have reported on their 10-year experience
utilizing reduction mammaplasty in the setting of onco-
plastic surgery.39,48 A total of 20 women were included
in this review. Mean tumor size was 1.5 mm, and the
mean weight of the tumor specimen was 288 grams. The
excised surgical margins were negative in 80%. The most
common reduction technique was a superomedial or • Fig. 1.2
Postoperative image at 1 year following left breast radiation
therapy demonstrating good volume, contour, and symmetry.
inferior pedicle. Postoperative abnormal mammograms
were noted in eight women (40%), all of whom under-
went additional biopsy. No woman was noted to have a Volume Displacement with Adjacent Tissue
recurrence with a mean follow-up of 23 months. Breast Rearrangement
aesthetics and patient satisfaction were acceptable in all
women. Adjacent tissue rearrangement is the most common method
These studies and others have demonstrated the utility by which the partial mastectomy defect is reconstructed.
of reduction mammaplasty in the setting of oncoplastic sur- These techniques rarely require a two-team approach, as the
gery. It is important to note that no two oncoplastic reduc- ablative surgeon is usually able to use these techniques and
tion procedures are the same and that oncoplastic reductions close these defects. Adjacent tissue rearrangement is indi-
are different from standard breast reductions. Parenchymal cated when the partial deformity extends to the chest wall
displacement may take the form of a flap of vascularized and there is sufficient adjacent tissue to close the defect and
parenchyma or as parenchymal rotation advancement. If maintain a natural contour. Volume displacement is per-
there is doubt about obtaining a clear margin at the time of formed but without the need to create parenchymal flaps.
the primary excision, a staged immediate reconstruction can Volume replacement is usually not necessary because there
be performed following margin confirmation. Figs. 1.1–1.2 is sufficient local tissue. The primary goal of adjacent tis-
illustrate a patient before and after oncoplastic reduction sue rearrangement is to avoid the contour deformity that is
mammaplasty. sometimes seen with traditional breast conservation. With
this method of oncoplastic reconstruction, the excision is
 CHAPTER 1 Introduction to Oncoplastic Breast Surgery 5

usually extended to the chest wall, and the adjacent paren-

chyma is undermined and mobilized to permit the closure
of small or large deformities without creating a contour
abnormality.
Specific parenchymal rearrangement procedures include
batwing mastopexy, radial segment quadrantectomy, donut
mastopexy, and reduction mastopexy. Veronesi et al intro-
duced the concept of segmental parenchymal wide exci-
sion including the overlying skin.49 This allowed for the
quadrantectomy approach that was instrumental in estab-
lishing the feasibility of BCT. These operations were gener-
ally performed using a radial approach for tumors that were
laterally based. An alternative to the radial approach was the
periareolar approach initially described by Amanti et al.50
This permitted excisions that resulted in less conspicuous
scars. With the introduction of the periareolar subcutane-
ous quadrantectomy, also known as the periareolar donut
mastopexy, incisions could be created circumferentially
around the nipple–areolar complex and remain relatively
inconspicuous. Anderson et al. introduced various concepts
that include skin incisions using a parallelogram pattern and
batwing mastopexy.44 These parallelogram incisions allowed
for wider excision margins while maintaining the natural • Fig. 1.3 A lower pole defect is demonstrated following partial mas-
contour of the breast. The batwing mastopexy is an exten- tectomy.
sion of this concept and is used primarily for centrally situ-
ated tumors near the nipple–areolar complex. Clough et al the need to incise or excise remote skin. Kat et al have
introduced the technique of reduction mastopexy lumpec- reviewed their 3-year experience in 30 women who had
tomy.45 This technique has been especially useful for tumors oncoplastic surgery using the latissimus dorsi musculocu-
situated near the lower pole of the breast. Standard lumpec- taneous flap.52 Flap survival was 100%, and all patients
tomy of these tumors would often result in an inferiorly were pleased with aesthetic outcomes. Losken et al have
displaced nipple–areolar complex. reviewed their 5-year experience using the latissimus dorsi
muscle flap harvested endoscopically in 39 women.53
Donor site morbidities occurred in 12 women (31%) and
Volume Replacement with Local and included a seroma in 7 women as well as skin necrosis,
Remote Flaps lymphedema, dehiscence, hypertrophic scarring, and a
persistent sinus tract.
Local and remote flaps for volume replacement are most Harvesting the latissimus dorsi as a mini-flap is advan-
useful for defects in which volume displacement procedures tageous because the size of the flap can be tailored to fit
would not be adequate due to small breast volume or due the size of the defect.54,55 The LD mini-flap is generally
to extensive resection. The selection of a local or remote flap harvested through an extended anterolateral breast inci-
will depend upon the abilities of the reconstructive surgeon sion that is used for the resection as well. Rainsbury has
and the location of the defect. Flaps can be musculocutane- demonstrated that this flap extends the role of BCT and
ous and perforator-based and can be transferred on a vas- oncoplastic surgery; enables reconstruction for a deformity
cularized pedicle or as a free tissue transfer. Many of these involving 20–30% of the breast; can be used for central,
options will be reviewed in the subsequent chapters. What is upper inner, and upper outer quadrant tumors; and can
provided in this chapter is a brief overview of the techniques be performed immediately or on a delayed basis.55 Gendy
and their origins. et al have used the latissimus dorsi mini-flap for oncoplasty
The most common flap for immediate reconstruction in 89 women and compared outcomes with immediate
following partial mastectomy has been the latissimus dorsi breast reconstruction following total skin-sparing mastec-
musculocutaneous flap.51-56 This flap is indicated for tomy.54 Findings were favorable for the oncoplastic tech-
deformities of the superior, lateral, and inferior aspects niques with regard to postoperative complications (8% vs
of the breasts. There are several methods by which the 14%), further surgical interventions (12% vs 79%), nip-
latissimus dorsi flap can be harvested. The traditional ple sensory loss (2% vs 98%), restricted activities (54%
technique involves making a posterolateral thoracic inci- vs 73%), and cosmetic outcome (visual analog score: 83.5
sion, whereas more modern techniques utilize an endo- vs 72). Figs. 1.3–1.6 illustrate a patient following partial
scope.53,56 With the endoscopic technique, the muscle is breast reconstruction with a latissimus dorsi musculocu-
accessed through the breast and axillary incision without taneous flap.
6 S EC T I O N I Oncoplastic Breast Surgery – Getting Started

Perforator flaps for partial breast reconstruction include

the thoracodorsal artery perforator (TDAP) flap, the lateral
thoracic flap, and the intercostal perforator flap.57-60 The
TDAP is an adipocutaneous flap in which the latissimus
dorsi muscle is totally spared. The vascularity of the flap is
derived from the perforating branches of the thoracodorsal
artery and vein. The lateral thoracic flap is a fasciocutaneous
flap that is perfused via the lateral thoracic, axillary, or tho-
racodorsal artery and vein. The intercostal perforator flap is
perfused via a perforating intercostal artery and vein that is
based along the inferior aspect of the anterior axillary line.
These flaps are usually transferred on a vascularized pedicle
but may be transferred as a free tissue transfer as well.
Clinical experience with these flaps has been encourag-
ing. Levine et al have provided an algorithm for perfora-
tor flap utilization.57 The first choice is the TDAP flap,
followed by the lateral thoracic flap, and finally the inter-
• Fig. 1.4 A latissimus dorsi musculocutaneous flap is harvested in
costal perforator flap. The decision is based on the quality
preparation for delayed reconstruction. of the vessels during the operative procedure. Munhoz et al
have used the lateral thoracic flap in 34 women for partial
breast reconstruction.59 Complications included partial flap
necrosis in three (8.8%), fat necrosis in two (5.8%), and
infection in one (2.9%). Donor-site complications included
a seroma in five women (14.7%) and wound dehiscence in
three (8.8%). Patient satisfaction was achieved in 88% of
women with a mean follow-up period of 23 months.

Combining Volume Displacement and

Replacement
A relatively recent innovation in the oncoplastic armamen-
tarium is to combine volume displacement and replacement
simultaneously.41-43 This technique is primarily indicated in
women with smaller breasts who desire oncoplasty but seek
an alternative to the classical volume replacement techniques
• Fig. 1.5 The latissimus dorsi flap is inset into the defect. described. Alternatives to the use of mini-flaps or perforator
flaps can include the use of devices, namely implants, but also
resorbable materials that are available as three-dimensional
constructs that have been used for radiation imaging.
The biplanar oncoplasty was initially described by
Nahabedian et al. and Miraliakbari et al, and incorporates
the use of breast implants or tissue expanders placed under
the pectoralis major muscle as well as parenchymal rear-
rangement that occurs above the pectoralis major mus-
cle, hence, the name biplanar oncoplasty.41-42 The use of
prosthetic devices such as breast implants in the setting of
oncoplasty and radiation therapy has historically resulted in
higher complication rates such as capsular contracture, pre-
mature removal, and decreased patient satisfaction. How-
ever, the increased use of prosthetic devices coupled with
the use of acellular dermal matrices in the setting of radia-
tion therapy has reduced the incidence of capsular contrac-
ture and made the biplanar technique more feasible. Barnea
et al will discuss this operation in greater detail in one of the
later chapters. Figs. 1.7–1.10 illustrate a patient following
•Fig. 1.6 Postoperative follow-up demonstrating restoration of vol-
simultaneous volume displacement and replacement using
ume, contour, and symmetry. a prosthetic device.
 CHAPTER 1 Introduction to Oncoplastic Breast Surgery 7

• Fig. 1.7
Preoperative image of a patient with multifocal breast cancer
scheduled for partial mastectomy.

• Fig. 1.9
One-week follow-up in which the defect was reconstructed
with a biplanar technique consisting of tissue rearrangement and
placement of a 180mL subpectoral silicone gel implant.

• Fig. 1.8 The 201-gram specimen is excised.

A second option that incorporates volume displacement

and replacement simultaneously utilizes an entirely different
prosthetic device called BioZorb®.61,62 This is an implant-
able, resorbable, three-dimensional coil that is used to mark
the site of tumor extirpation for radiation therapy localiza- • Fig. 1.10 One-year follow-up demonstrating good volume, contour,
tion. Its other benefit is that it can behave like a filler mate- and symmetry.
rial to act as a volume replacement device. The difference
between this approach and the biplanar approach is that the the remaining chapters. All of the principles, concepts, and
volume replacement and displacement occur above the pec- specific techniques will be discussed in greater detail in the
toralis major muscle. Following insertion of the BioZorb® forthcoming chapters.
device at the base of the partial mastectomy defect, paren-
chymal rearrangement occurs to cover the device followed References
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problem? J Am Coll Surg. 2006;203:704–714. cal margins in oncoplastic surgery and quadrantectomy in breast
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the breast after total or subtotal extirpation of the mammary 37. Giacalone PL, Roger P, Dubon O, El Gareh N, Daures JP, Laf-
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17. Snyderman RK, Guthrie RH. Reconstruction of the female breast Annales de Chirurgie. 2006;131:256–261.
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18. Arnold PG, Hartrampf CA, Jurkiewicz MJ. One-stage recon- approach to breast reconstruction after partial mastectomy. Plast
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Case report. Plast Reconstr Surg. 1976;57:520–522. 39. Losken A, Styblo TM, Carlson GW, Jones GE, Amerson BJ.
19. Schneider WJ, Hill Jr HL, Brown RG. Latissimus dorsi myocu- Management algorithm and outcome evaluation of partial mas-
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277. Ann Plast Surg. 2007;59:235–242.
20. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with 40. Clough KB, Cuminet J, Fitoussi, et al. Cosmetic sequellae after
a transverse abdominal island flap. Plast Reconstr Surg. 1982;69: conservative treatment for breast cancer: classification and results
216–225. of surgical correction. Ann Plast Surg. 1998;41:471–481.
21. Argenta LC. Reconstruction of the breast by tissue expansion. 41. Nahabedian MY, Patel KM, Kaminsky AJ, Cocilovo C, Miraliak-
Clin Plast Surg. 1984;11:257–264. bari R. Biplanar oncoplastic surgery: a novel approach to breast
22. Grotting JC, Urist MM, Maddox WA, Vasconez LO. Con- conservation for small and medium sized breasts. Plast Reconstr
ventional TRAM flap versus free microsurgical TRAM flap for Surg. 2013;132:1081–1084.
immediate breast reconstruction. Plast Reconstr Surg. 1989;83: 42. Kaminsky AJ, Patel KM, Cocilovo C, Nahabedian MY, Miral-
828–841. akbari R. The biplanar oncoplastic technique case series: a 2-year
23. Allen RJ, Treece P. Deep inferior epigastric perforator flap for review. Gland Surgery. 2015;4(3):257–262.
breast reconstruction. Ann Plast Surg. 1994;32:32–38. 43. Barnea Y, Friedman O, Arad E, Barsuk D, Menes T, Zaretski A,
24. Crile G, Esselstyn CB, Hermann RE, Hoerr SO. Partial mastec- Leshem D, Gur E, Inbal A. An oncoplastic breast augmentation
tomy for carcinoma of the breast. Surg Gynecol Obstet. 1973;136: technique for immediate partial breast reconstruction following
929–933. breast conservation. Plast Reconstr Surg. 2017;139:348e–357e.
 CHAPTER 1 Introduction to Oncoplastic Breast Surgery 9

44. Anderson BO, Masetti R, Silverstein ML. Oncoplastic approaches 53. Losken A, Schaefer TG, Carlson GW, Jones GE, Styblo TM,
to the partial mastectomy: an overview of volume displacement Bostwick J. Immediate endoscopic latissimus dorsi flap. Ann Plast
techniques. Lancet Oncol. 2005:145–157. Surg. 2004;53:1–5.
45. Clough KB, Lewis JS, Couturaud B, Fitoussi A, Nos C, Fal- 54. Gendy RK, Able JA, Rainsbury RM. Impact of skin sparing mas-
cou MC. Oncoplastic techniques allow extensive resections tectomy with immediate reconstruction and breast sparing recon-
for breast-conserving therapy of breast carcinomas. Ann Surg. struction with miniflaps on the outcomes of oncoplastic breast
2003;237:26–34. surgery. Br J Surg. 2003;90:433–439.
46. Munhoz AM, Montag E, Arruda EG, et al. Critical analysis of 55. Rainsbury RM. Breast sparing reconstruction with latissimus
reduction mammaplasty techniques in combination with breast dorsi miniflaps. EJSO. 2002;28:891–895.
conservation surgery for early breast cancer treatment. Plast 56. Monticciolo DL, Ross D, Bostwick 3rd J, et al. Autologous breast
Reconstr Surg. 2006;117:1091–1103. reconstruction with endoscopic latissimus dorsi musculosubcuta-
47. Spear SL, Pelletiere CV, Wolfe AJ, Tsangaris TN, Pennanen MF. neous flaps in patients choosing breast-conserving therapy: mam-
Experience with reduction mammaplasty combined with breast mographic appearance. Am J Roentgenol. 1996;167:385–389.
conservation therapy in the management of breast cancer. Plast 57. Levine JL, Soueid NE, Allen RJ. Algorithm for autologous breast
Reconstr Surg. 2003;111:1102–1109, 2003. reconstruction for partial mastectomy defects. Plast Reconstr Surg.
48. Losken A, Elwood ET, Styblo TM, Bostwick J. The role of reduc- 2005;116:762–767.
tion mammaplasty in correcting partial mastectomy defects. Plast 58. Holmstrom H, Lossing C. The lateral thoracodorsal flap in breast
Reconstr Surg. 2002;109:968–975. reconstruction. Plast Reconstr Surg. 1986;577:933.
49. Veronesi U, Luini A, Galimberti V, Zurrida S. Conservation 59. Munhoz A, Montag E, Arruda EG, et al. The role of the lat-
approaches for the management of stage I/II carcinoma of the eral thoracodorsal fasciocutaneous flap in immediate con-
breast: Milan Cancer Institute trials. World J Surg. 1994;18:70–75. servative breast surgery reconstruction. Plast Reconstr Surg.
50. Amanti C, Moscaroli A, Lo Russo M, et al. Periareolar subcutane- 2006;116:1699–1710.
ous quadrantectomy: a new approach in breast cancer surgery. G 60. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocuta-
Chir. 2002;23:445–449. neous flap without muscle. Plast Reconstr Surg. 1995;96:1608–
51. Noguchi M, Taniya T, Miyazaki I, Saito Y. Immediate transposition 1614.
of a latissimus dorsi muscle for correcting a postquadrantectomy 61. Harms S, Lebovic G, Kaufman CS, Cross M. Mammographic
breast deformity in Japanese patients. Int Surg. 1990;75:166–170. imaging after partial breast reconstruction: impact of a bioab-
52. Kat CC, Darcy CM, O’Donoghue JM, Taylor AR, Regan PJ. The sorbable breast implant. J Clin Oncol. 2015;33(28):111.
use of the latissimus dorsi flap for the immediate correction of the 62. Wiens N, Torp L, Wolff B, et al. Effect of BioZorb® surgical
deformity resulting from breast conserving therapy. Brit J Plast marker placement on post-operative radiation boost target vol-
Surg. 1999;52:99–103. ume. Int J Radiat Oncol. 2018;7:175–179.
2
Safety of Oncoplastic Breast
Reconstruction
PETER W. THOMPSON AND GRANT W. CARLSON

Introduction o­ ncoplastic procedures, appropriate patient ­counseling re-

quires attention to several important clinical questions:
Historically, early stage breast cancer has been treated with • Do oncoplastic techniques affect the rate of positive
either mastectomy or breast conservation therapy (local margins in breast conservation, and how should positive
tumor excision with adjuvant radiation therapy). Clinico- margins be managed?
pathologic characteristics such as tumor size and extent of • Do oncoplastic techniques affect the rate of local recur-
breast involvement determine patient suitability for one rence, disease-free survival, and overall survival?
approach or the other. Landmark prospective studies have • Does oncoplastic surgery result in a higher incidence of
shown that these two approaches have equivalent disease- complications?
free and overall survival.1 • Does oncoplastic surgery affect the delivery of radiation
Total mastectomy can be a cosmetically deforming and or future surveillance of breast cancer?
psychologically taxing procedure. Breast reconstruction fol- In this chapter, the available data to answer these impor-
lowing mastectomy involves use of prosthetic techniques or tant questions will be reviewed.
harvesting autologous tissue from distant sites to recreate a
breast mound. Breast conservation is therefore appealing in Margins in Oncoplastic Surgery
its potential to preserve the native breast mound; however,
an acceptable cosmetic result is not guaranteed. Up to 40% The three goals of breast conservation therapy (BCT) are
of patients who undergo breast conservation have had an to remove the primary tumor, decrease breast tumor recur-
unacceptable cosmetic result.2 rence, and optimize cosmesis. Positive margins have been
Oncoplastic techniques utilize plastic surgical methods clearly shown to be a risk factor for local recurrence, but
of volume displacement and replacement to achieve the pri- until recently there was no consensus as to what constitutes
mary goal of negative surgical margins as well as the sec- a “negative” margin. Based on a meta-analysis of 33 stud-
ondary goal of optimal aesthetic result and breast symmetry. ies reporting on more than 32,000 patients, the Society
Oncoplastic breast conservation has become an increasingly for Surgical Oncology and American Society of Radiation
common technique compared with traditional breast con- Oncology released a joint guideline defining a negative
servation over the last 10 years by facilitating reconstruc- margin as “no ink on tumor.”5 There was no evidence that
tion after larger volume resections.3 Oncoplastic surgery has obtaining a wider margin, such as a threshold of >2 mm
greatly expanded the group of patients who may be can- or >5 mm, resulted in a lower rate of local recurrence. This
didates for breast conservation, and studies using validated recommendation is important when considering an onco-
questionnaires have demonstrated excellent levels of patient plastic breast conservation procedure, which is often offered
satisfaction.4 Concerns regarding the oncologic safety to patients with larger tumors who might not be good can-
of these techniques have increased, mirroring their rising didates for standard breast conservation. In a meta-analysis
popularity. Safety data pertaining to oncoplastic breast sur- of more than 8500 patients published in 2014, Losken et al
gery are limited by a lack of prospective data and long-term compared the outcomes of patients who had undergone
follow-up. standard breast conservation with patients who had under-
When discussing reconstructive options with ­pati­ents, gone immediate breast reconstruction using oncoplastic
oncologic risks and benefits should be reviewed. With techniques. They found that, despite overall significantly

10
 CHAPTER 2 Safety of Oncoplastic Breast Reconstruction 11

larger tumor size and lumpectomy specimen weight in the

oncoplastic group, the overall positive margin rate was sig- Local Recurrence, Distant Recurrence,
nificantly lower in the oncoplastic group compared with Disease-Free Survival, and Overall Survival
the standard breast conservation group (12% vs 21%).6 An Following Oncoplastic Breast Conservation
acceptably low positive margin rate following oncoplastic
breast conservation has been confirmed in multiple stud- The primary determinant of the safety and applicability
ies, ranging from 0–21% according to a recent systematic of any oncologic procedure is its effect on recurrence and
review published by Piper et al.7 survival. As mentioned previously, the efficacy of BCT as a
One concern voiced by critics about oncoplastic breast treatment for early stage breast cancer has been established
conservation techniques, which utilize volume displace- by landmark studies demonstrating equivalent disease-free
ment and parenchymal rearrangement to fill the empty and overall survival compared with mastectomy.1 As onco-
space created by tumor excision, is that the architecture plastic modifications of standard breast conservation tech-
and orientation of the lumpectomy cavity becomes dis- niques have only become a mainstream treatment option in
torted. This has the potential to make identification and the last 10–15 years, long-term follow-up data evaluating
re-excision of previous surgical margins more difficult, and safety and efficacy are less readily available. De La Cruz et al
in these cases completion mastectomy may be necessary to performed a systematic review of 55 articles pertaining to
achieve negative surgical margins. Data from Piper et al oncoplastic outcomes including 6011 patients with a mean
suggest that the overall rates of re-excision and comple- follow-up of 50.5 months. Most patients included in this
tion mastectomy in patients undergoing oncoplastic breast analysis had early-stage breast cancers with invasive ductal
conservation are acceptably low (3.5% and 3.7%, respec- histology. The authors analyzed recurrence and survival out-
tively).7 Despite larger tumor size in patients undergoing comes for three different follow-up intervals. Among 871
oncoplastic breast conservation, available data comparing patients with the longest follow-up (at least 5 years), the
re-excision and completion mastectomy rates between rates of overall survival, disease-free survival, local recur-
patients undergoing oncoplastic and standard breast con- rence, and distant recurrence were 93.4%, 85.4%, 6%, and
servation suggest that re-excision of positive margins is 11.9%, respectively.12 The authors noted that these rates
less frequently required in the oncoplastic group, whereas compare favorably with rates of local recurrence and overall
completion mastectomy is required at similar rates between survival after standard breast conservation, suggesting that
the two groups.6,8,9 long-term outcome is more dependent on patient factors
Piper et al suggest placement of clips in the cardinal and tumor biology than on surgical technique. Given the
directions of the lumpectomy cavity to both facilitate re- equivalent recurrence and survival outcomes with onco-
excision in the setting of positive margins and to assist plastic techniques, these procedures may be safely offered
with targeting of the radiation boost. The authors make to most women who might also be candidates for standard
the argument that, because local tumor recurrence usu- breast conservation; the potential benefit of improved cos-
ally occurs in the previous lumpectomy site, marking mesis with oncoplastic surgery does not appear to compro-
with clips also allows a second re-excision of breast tissue mise cancer recurrence and survival.
rather than completion mastectomy in the setting of local
recurrence.7
A good understanding of factors predictive of margin Complications Following Oncoplastic
positivity is necessary to properly counsel patients consider- Breast Reconstruction
ing breast conservation versus total mastectomy, as a find-
ing of positive margins after breast conservation will often Preoperative counseling of patients considering oncoplas-
necessitate additional surgery. In a retrospective review by tic breast reconstruction must also include a discussion of
Clough et al of 272 patients undergoing oncoplastic BCT, complications. Overall safety of the oncoplastic approach
the only factor predictive of margin positivity after multi- can be considered in comparison to standard breast con-
variate analysis was invasive lobular tumor histology.10 A servation, in comparison to bilateral breast reduction, or in
retrospective review by Amabile et al looking at 129 patients comparison to total mastectomy with reconstruction. All of
undergoing oncoplastic breast surgery further identified these analyses have been performed with a finding of favor-
obesity, tumor multifocality, and the presence of microcal- able complication profiles for oncoplastic reconstruction.
cifications on mammogram as predictive of the need for The overall complication rate of oncoplastic reconstruction
re-excision.11 ranges from 14–16% in systematic review and meta-anal-
In summary, oncoplastic breast conservation techniques ysis of the literature.6,12 The most common complications
can be offered to patients with acceptable rates of margin vary depending on publication but include delayed wound
positivity compared with standard breast conservation; healing, fat necrosis, infection, nipple necrosis, seroma,
however, proper patient selection is essential, as margin and hematoma; these complications vary in incidence from
positivity is one of the primary factors predictive of local <1–4%.7,12 Complications requiring operative intervention
recurrence. make up on average around 3% of all complications.6,13
12 S EC T I O N I Oncoplastic Breast Surgery – Getting Started

Compared with standard breast conservation with lum­p­­ oncoplastic reconstruction are limited; most of the available
ectomy, oncoplastic techniques may have a comparable or evidence, although lacking in detail, supports the claim that
slightly lower rate of complications. In a National Surgical complications following oncoplastic reconstruction have min-
Quality Improvement Program (NSQIP) database analy- imal effect on timing of delivery of adjuvant therapy.6,13,16 In
sis of nearly 76,000 patients undergoing BCT, the overall contrast, one retrospective institutional review published by
30-day rate of complications in patients undergoing onco- Hillberg et al examined outcomes of 150 patients undergoing
plastic breast surgery was 1.7% compared with 1.9% in oncoplastic breast reconstruction performed by a single sur-
patients undergoing standard breast conservation.14 In their geon; the authors reported that 8.2% of patients experienced
meta-analysis of oncoplastic breast reconstruction with an a delay in receiving adjuvant radiation due to a complication.
average follow-up of 37 months, Losken et al found that the These results may be affected by a higher than expected over-
overall rate of complications was 15.5% in the oncoplastic all complication rate in this series (37.5%).17 Similarly, evi-
group compared with 25.9% in the standard breast con- dence that oncoplastic reconstruction delays administration
servation group, albeit with a shorter follow-up period in of adjuvant chemotherapy is lacking. A retrospective review
the oncoplastic group.6 Lower rates of seroma in oncoplas- of 169 breast cancer patients performed by Khan et al dem-
tic reconstructions compared with standard breast conserva- onstrated no difference in time to initiation of adjuvant che-
tion may be attributable to filling of the lumpectomy cavity motherapy whether standard breast conservation, oncoplastic
by displacement and rearrangement of the remaining breast breast conservation, mastectomy alone, or mastectomy with
parenchyma in a way that obliterates the dead space.3 immediate reconstruction was performed.18
Oncoplastic reconstruction also appears to have a lower Appropriate patient selection for oncoplastic reconstruc-
rate of complications compared with total mastectomy and tion includes identification of patients at increased risk
reconstruction. In their retrospective cohort study includ- for postoperative complications. In their NSQIP database
ing more than 9800 patients with breast cancer, Carter et al analysis, Cil et al identified several factors that were inde-
found that patients undergoing oncoplastic reconstruction pendently associated with an increased risk of postopera-
had a lower rate of hematoma, infection, and wound heal- tive complication in the 30-day period.14 These included
ing complications compared with patients who underwent obesity, smoking, American Academy of Anesthesiologists
total mastectomy and reconstruction.3 Losken et al demon- (ASA) category 3 or 4, diabetes, bleeding disorder, chronic
strated that, in a population of breast cancer patients with obstructive pulmonary disease (COPD), and a longer oper-
macromastia, patients who underwent total mastectomy ative time. Of these, the presence of a bleeding disorder had
with reconstruction by either implant-based or autologous the highest association with postoperative complications
methods had nearly twice the overall rate of complications (odds ratio 1.8). Multiple other studies have identified ele-
compared with patients who underwent oncoplastic recon- vated body mass index (BMI) as a risk factor for postopera-
struction (22% vs 43%).15 This difference is at least par- tive complications.16
tially attributable to risks associated with implants as well In summary, patients who undergo oncoplastic recon-
as donor-site complications, although in women with very struction have a favorable complication profile compared
large breasts, the potential for seroma, hematoma, infection, with patients undergoing standard breast conservation or
and contour deformities are greater when a reconstruction other methods of reconstruction. Oncoplastic techniques
must fill a larger mastectomy cavity. do not appear to negatively affect timing of radiation deliv-
The oncoplastic reconstruction approach often involves ery. Appropriate technique and patient selection are crucial
a contralateral mastopexy or reduction for symmetry on to minimize postoperative morbidity.
the non-cancer breast. In this instance, the final result is
aesthetically similar to a bilateral reduction mammaplasty
performed for symptomatic macromastia. In a prospective Cancer Surveillance Following
evaluation of patients undergoing bilateral breast reduction Oncoplastic Reconstruction
either with or without breast cancer, the overall rate of com-
plications was similar (18.8% for oncoplastic group, 18.3% Oncoplastic breast conservation techniques by definition
for breast reduction group). Seroma was the most common preserve the majority of the breast parenchyma; therefore,
complication in both groups at around 5–6%. Interestingly, ongoing mammographic surveillance of the remaining
approximately 50% of the complications in the oncoplastic breast tissue is crucially important to detect cancer recur-
group occurred in the non-cancer breast.16 From this, the rence. Critics of oncoplastic reconstruction have voiced
authors conclude that oncoplastic reconstruction with con- concerns that distortion of parenchymal architecture and
tralateral reduction has a safety profile similar to a standard more extensive postsurgical changes compared with stan-
bilateral breast reduction. dard breast conservation may negatively affect the early
Surgical complications immediately following oncoplastic detection of local tumor recurrence. Oncoplastic breast
breast reconstruction can negatively affect oncologic outcome reconstruction combines time-tested techniques of stan-
by delaying the administration of adjuvant therapies. Data dard breast conservation and breast reduction. The mam-
directly analyzing timing of adjuvant therapies following mographic changes following these procedures are well
 CHAPTER 2 Safety of Oncoplastic Breast Reconstruction 13

documented and to a certain extent may be extrapolated 5. Moran MS, Schnitt SJ, Giuliano AE, et al. Society of Surgical
to predict changes following oncoplastic reconstruction. Oncology-American Society for Radiation Oncology consensus
In a small case-control study, Roberts et al compared the guideline on margins for breast-conserving surgery with whole-
mammographic findings of 87 patients who had undergone breast irradiation in stages I and II invasive breast cancer. Ann Surg
Oncol. 2014;21(3):704–716.
breast reduction to those of 30 patients with macromastia
6. Losken A, Dugal CS, Styblo TM, Carlson GW. A meta-analysis
who did not undergo breast reduction. The authors found comparing breast conservation therapy alone to the oncoplastic
that mammographic findings following breast reduction technique. Ann Plast Surg. 2014;72(2):145–149.
did not increase the rate of obtaining additional imaging 7. Piper ML, Esserman LJ, Sbitany H, Peled AW. Outcomes fol-
studies or diagnostic interventions and suggested that this lowing oncoplastic reduction mammoplasty: a systematic review.
finding was likely generalizable to oncoplastic breast recon- Ann Plast Surg. 2016;76(suppl 3):S222–S226.
struction.19 In contrast, two small series comparing post- 8. Losken A, Pinell-White X, Hart AM, et al. The oncoplastic
operative cancer surveillance between patients undergoing reduction approach to breast conservation therapy: benefits for
oncoplastic reconstruction or standard breast conservation margin control. Aesthet Surg J. 2014;34(8):1185–1191.
suggested a higher rate of need for additional imaging and 9. Wijgman DJ, Ten Wolde B, van Groesen NR, et al. Short term
tissue sampling in the oncoplastic group.20,21 Although the safety of oncoplastic breast conserving surgery for larger tumors.
Eur J Surg Oncol. 2017;43(4):665–671.
expected mammographic changes following breast reduc-
10. Clough KB, Gouveia PF, Benyahi D, et al. Positive margins
tion (oil cysts, fat necrosis, calcifications) are distinct from after oncoplastic surgery for breast cancer. Ann Surg Oncol.
those found in patients with breast cancer, it is possible that 2015;22(13):4247–4253.
the increased pretest suspicion in a patient with a history 11. Amabile MI, Mazouni C, Guimond C, et al. Factors predictive of
of breast cancer leads to an increased request for additional re-excision after oncoplastic breast-conserving surgery. Anticancer
imaging and biopsies. Res. 2015;35(7):4229–4234.
12. De La Cruz L, Blankenship SA, Chatterjee A, et al. Out-
Conclusions comes after oncoplastic breast-conserving surgery in breast
cancer patients: a systematic literature review. Ann Surg Oncol.
Oncoplastic reconstruction techniques hold great appeal for 2016;23(10):3247–3258.
their ability to extend the indications for breast conserva- 13. Fitoussi AD, Berry MG, Fama F, et al. Oncoplastic breast surgery
for cancer: analysis of 540 consecutive cases [outcomes article].
tion to patients with larger tumors in whom standard breast
Plast Reconstr Surg. 2010;125(2):454–462.
conservation would not provide acceptable cosmesis. The 14. Cil TD, Cordeiro E. Complications of oncoplastic breast sur-
widespread applicability of these techniques depends on an gery involving soft tissue transfer versus breast-conserving
oncologic safety profile comparable to standard BCT. Avail- surgery: an analysis of the NSQIP database. Ann Surg Oncol.
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pare favorably with outcomes following both breast conser- Reconstr Surg. 2010;125(4):1051–1056.
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17. Hillberg NS, Meesters-Caberg MAJ, Beugels J, et al. Delay
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