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Oncoplastic breast surgery

Oncoplastic breast surgery
Literature review current through: Jan 2024.
This topic last updated: Aug 02, 2022.

INTRODUCTION — The goal of oncoplastic procedures is to resect the breast cancer with negative histologic margins while preserving the contour of the breast. Oncoplastic surgery merges the principles of oncologic and reconstructive surgery, utilizing a spectrum of aesthetic-enhancing techniques to address tissue defects and optimize cosmesis from breast cancer surgery. In addition, it has the opportunity to address existing reshaping desires of the patient. The goals of treatment are to provide optimal local control while maintaining or reconstructing a cosmetically acceptable breast, whether via breast-conserving surgery or mastectomy.

While breast-conserving surgery is appropriate for 60 to 80 percent of breast cancer patients [1], a large number of women will still require or request unilateral or bilateral mastectomy. The cosmetic appearance after mastectomy is just as important as after breast-conserving surgery since most women will live long lives after the initial treatment. There are several oncoplastic techniques that may enhance the aesthetic result of mastectomy with or without reconstruction. Current interest in mastectomy without reconstruction ("going flat") requires aesthetic attention to extra skin or fatty tissue and a smooth chest wall [2].

Oncoplastic surgery techniques have been categorized into different skill levels by several groups [3-6]. Most breast surgeons will be able to perform basic techniques, while more complex techniques require either a team approach with a plastic surgeon or additional training/education/experience by breast surgeons.

This topic will focus on basic and some complex oncoplastic breast surgery techniques, which will cover 80 to 90 percent of situations. Advanced techniques requiring the combined efforts of both the breast surgeon and the plastic surgeon are discussed elsewhere. These include use of implants and tissue flap reconstructions. (See "Implant-based breast reconstruction and augmentation" and "Options for autologous flap-based breast reconstruction".)

The techniques of breast-conserving surgery, mastectomy, and breast reconstruction, as well as management of early-stage breast cancer, are reviewed elsewhere.

(See "Breast-conserving therapy".)

(See "Mastectomy".)

(See "Contralateral prophylactic mastectomy".)

(See "Overview of breast reconstruction".)

(See "Overview of the treatment of newly diagnosed, invasive, non-metastatic breast cancer".)

INDICATIONS — Oncoplastic techniques are generally not required for excision of small cancers in adequate or large-sized breasts but are well suited in the following two scenarios [3]:

When the cancer excision volume is large in relation to the size of the breast.

The conventional lumpectomy generally removes 20 to 40 grams of breast tissue, with adverse cosmetic outcomes typically seen when 80 grams or more of breast tissue are removed. The conventional approach to obliterating the postexcision cavity risks significant long-term cosmetic deformities once 20 percent or more of the breast volume has been excised. These deformities include dimpling of the skin, distortion of breast contour, and displacement or deviation of the nipple-areolar complex (NAC). These changes may not be evident for three to six months after surgery but may be anticipated preoperatively based on the surgical plan.

Oncoplastic techniques allow for removal of between 200 and 1000 grams of breast tissue, or 20 to 50 percent of the total breast volume, without causing significant contour deformity by mobilizing and advancing adjacent breast tissue to obliterate the postexcision cavity and reshape the breast. The use of oncoplastic techniques, therefore, broadens the application of breast-conserving surgery (BCS) to patients with larger tumors who would otherwise have to undergo mastectomy. This group of patients may also need symmetry procedures on the opposite breast.

When the cancer location requires repositioning of the NAC. This includes those patients with preexisting aesthetic concerns (eg, macromastia or significant ptosis) that may be addressed at the time of cancer resection. Oncoplastic techniques can maintain a natural breast appearance and reduce preexisting breast ptosis.

Oncoplastic breast surgery techniques are appropriate for most patients undergoing BCS. They can provide adequate or even wide surgical margins around large and/or segmentally distributed breast cancers while preserving the shape and appearance of the breast [7-12].

Often oncoplastic tissue advancement techniques can convert a potential mastectomy patient to a lumpectomy patient, but significant oncoplastic mobilization followed by a positive margin and re-excision may complicate the cosmetic outcome. An alternative approach for large invasive cancers initially not amenable to BCS is the administration of neoadjuvant chemotherapy. This treatment may decrease the size of the cancer and provide the opportunity for the patient to avoid a mastectomy. (See "General principles of neoadjuvant management of breast cancer".)

Oncoplastic breast surgery can be safely combined with axillary staging of any type. This is particularly important in tumors localized in the tail of the breast near the axilla.

Certain issues may limit the mobilization of adjacent tissue, including prior radiation therapy, obesity, poor skin characteristics, and chronic steroid therapy.

PERIOPERATIVE CONSIDERATIONS

Care coordination – For higher-level complex oncoplastic approaches, plastic surgery consultation and/or intraoperative collaboration should be arranged [13]. At the time of mastectomy, immediate reconstruction may be performed by the plastic surgeon when preoperatively planned. An increase in bilateral mastectomy for unilateral breast cancer has been seen in the last several years. Having a working relationship with a plastic surgeon interested in immediate breast reconstruction at the time of mastectomy is desired. (See "Diagnostic evaluation of suspected breast cancer" and "General principles of neoadjuvant management of breast cancer".)

Informed consent – A conversation with each patient should occur regarding the patient's personal opinion of their breasts. Are they happy with the way they are (the size, ptosis, shape, etc), or have they considered changing the appearance of the breast, which might be achieved simultaneously with the cancer surgery? This discussion will impact oncoplastic decisions.

Informed consent should include a discussion of the risks, benefits, and alternatives of breast-conserving surgery (BCS) and any axillary surgery that is planned, including any symmetry procedures considered. The patient should be counseled regarding the risks of bleeding and infection, breast asymmetry, loss of sensation, seroma formation, fat necrosis, delayed healing, nipple necrosis, and the possibility of needing additional surgery for close or positive surgical margins. If concurrent axillary surgery is planned, the complications of sentinel node biopsy or axillary dissection should be discussed. (See "Overview of management of the regional lymph nodes in breast cancer".)

Photographs – As one of the goals of oncoplastic surgery is to maintain or improve the appearance of the breast, preoperative photographs of each breast should be obtained prior to surgery. Pictures from the front and lateral with arms both at the sides and raised should be obtained. Patients may not recognize existing asymmetries but will notice them postoperatively. Breast surgeons who do not routinely obtain photographs of their patients presurgery should integrate this into their routine preoperative assessment.

Skin marking – Skin landmarks should be marked preoperatively with the patient in the upright sitting position for both breasts. These sites may be challenging to accurately locate once the patient is anesthetized and lying supine on the operating room table. Special attention should be given to scars from prior breast surgery and the placement and location of breast implants. In addition, advanced oncoplastic techniques rely on Wise pattern markings [14]. It is extremely useful for the breast surgeon to learn and understand these markings as well as the concepts behind them. Testing drawing the markings on patients in the office will be helpful in conceptualizing oncoplastic skin incisions.

Relevant landmarks to be identified and marked include:

The inframammary crease (IMF).

The anterior axillary fold at the pectoralis major muscle.

The posterior axillary fold of the latissimus dorsi muscle.

The sternal border of the breast.

The periareolar circle.

The superior border of the breast.

Wise pattern landmarks – The breast meridian, distance from sternal notch to projected new nipple location, and distance from nipple to IMF fold.

Anesthesia – Oncoplastic surgery requires extensive mobilization and advancement of breast tissue, thus requiring general anesthesia. If concurrent axillary surgery is planned, the patient should not be paralyzed until the axillary portion of the surgery is completed, so that testing of the large motor nerves during dissection is possible.

Patient positioning – For all oncoplastic techniques, the patient is positioned supine with their arms extended on arm boards at ≤90 degree abduction from the chest wall. Arm positioning with >90 degrees of abduction from the chest wall increases the potential for stretching the brachial plexus and should be avoided. It is important to position the arm while the patient is awake to make sure the arm is not abducted beyond what is comfortable for the patient, especially if there are preexisting problems with shoulder mobility. If a sentinel node biopsy or axillary dissection is also planned, the ipsilateral arm can be included in the prepped field at the discretion of the surgeon, allowing the arm to be mobilized during the procedure. The lateral chest wall should be positioned along the edge of the operating table for unilateral procedures.

It is preferable to have both breasts prepped and draped into the field so that visual comparison with the patient in a sitting position is possible as the wound is closed. This positioning, as well as sitting the patient upright during the procedure, allows the surgeon to identify areas of unsightly tugging or dimpling inadvertently created during closure, so that they can be addressed at that time. Most women look at themselves while standing, so the final appearance of the breast should be assessed in the upright (sitting) position in the operating room.

Drains – Drains are rarely required in most BCS cases as any seroma will generally be reabsorbed and dead space is completely closed. However, with more extensive dissections, such as the reduction mammaplasty, fluid accumulation is more common and may require postoperative aspiration if the patient is symptomatic. There are no randomized trials examining the use of drains in oncoplastic procedures, but, based on our clinical experience, we place suction drains for one to two days in patients with extensive dissections to diminish excessive fluid accumulation in the dissected breast and avoid distortion of the oncoplastic closure.

ONCOPLASTIC TECHNIQUES BY TUMOR LOCATIONS — A basic premise of choosing oncoplastic techniques relates to the amount of excess skin (ptosis) that is present and how much needs to be removed along with the cancer. In addition, the extent of direct skin involvement with cancer will also alter some of these decisions. Finally, the surgeon's experience with these methods will also affect the surgical approach.

Superior pole or lateral cancers — For a superior pole or lateral breast cancer, a full-thickness fibroglandular resection including an overlying skin island with an advancement closure is the simplest and most commonly employed technique (see 'Basic technique (partial breast reconstruction)' below). Skin excision can be omitted if the breast envelope needs no reduction. (See 'Parallelogram skin incision' below.)

Other approaches to superior pole lesions may include circumareolar skin incision, crescent mastopexy, or donut mastopexy. When removing a large lateral segment, one might reposition the nipple medially with a crescent mastopexy. (See 'Crescent mastopexy' below.)

Lower pole breast cancers — For lower pole (inner and outer quadrant) breast cancers, including those at the three and nine o'clock positions, a lateral segmentectomy or reduction mammaplasty (inverted T incision) can be considered depending on the breast size. A lateral segmentectomy is more appropriate for a small breast, while a reduction mammaplasty would be more appropriate for a larger breast. (See 'Lateral segmentectomy' below and 'Reduction mammaplasty' below.)

Centrally located cancers — Many centrally located breast cancers are too close to the nipple to conserve the nipple or areola. For these breast cancers with associated nipple involvement, breast-conserving surgery (BCS) with removal of the nipple-areolar complex (NAC) provides an alternative to a mastectomy. However, central BCS procedures may result in an inadequate projection of smaller breasts and limit future options for reconstruction. Using the incision that results in an inverted T may preserve breast shape and prevent the flattening that can occur with more horizontally placed central lumpectomy incisions [3]. Another method to mobilize skin into a resected nipple site is the Grisotti flap. (See 'Central breast resection' below.)

For centrally located breast cancer without nipple involvement, the batwing mastopexy also allows resection of cancers adjacent to or deep to the NAC without sacrifice of the nipple itself. Using the batwing includes movement of the nipple, which may or may not be desired. Another alternative is a donut mastopexy. This approach gives good exposure without any radial scars emitting from the nipple area. (See 'Batwing mastopexy' below and 'Donut mastopexy' below.)

Upper outer quadrant cancers — For segmentally distributed upper outer quadrant breast cancers, the donut mastopexy can be a demanding but helpful technique. The donut incision is confined to the periareolar area, keeping the full skin envelope intact. (See 'Donut mastopexy' below.)

When the cancer is far removed from the NAC, the donut mastopexy is less practical because the major key dissection around the cancer is distant from the incision. In these peripherally located cancers, a parallelogram approach is generally preferred. (See 'Parallelogram skin incision' below.)

When the lesion is in the tail of the breast, a single incision based near the axilla may achieve both breast and sentinel node procedures. Improved marking of the breast site is necessary to appropriately target any focal radiation treatment, either boost or partial breast irradiation [15].

Upper inner quadrant cancers — For upper inner quadrant breast cancers, where the breast tissue is the thinnest, a simple reapproximation of breast tissue and skin without removal of the skin is performed. If a small skin island is included with the fibroglandular resection, excessive superomedial displacement of the NAC must be avoided to preserve breast symmetry [16]. The skin incision may be a circumareolar or donut mastopexy depending on the distance from the nipple.

ONCOPLASTIC TECHNIQUES BY COMPLEXITY LEVELS — An alternative way of categorizing oncoplastic techniques is by complexity levels [17]. The level of complexity of an oncoplastic technique is primarily determined by the amount of tissue excised: the basic technique permits removal of up to 20 percent of the breast volume, whereas complex or advanced techniques allow 20 to 50 percent of the breast volume to be removed while still maintaining cosmesis.

Complex oncoplastic techniques are typically performed by plastic surgeons in the United States but by breast surgeons in South America and some European countries. Advanced breast reconstruction techniques such as breast implants and major flap reconstructions are discussed elsewhere. (See "Implant-based breast reconstruction and augmentation" and "Options for autologous flap-based breast reconstruction".)

Basic technique (partial breast reconstruction) — This basic technique is used after up to 20 percent of the breast volume is removed. This technique is based on dual-plane undermining (including the nipple-areolar complex [NAC] when necessary) and reapproximation of tissues. No skin excision or major nipple relocation is required.

A general principle common to all oncoplastic techniques is to resect the fibroglandular tissue inclusive of the cancer and advance the deep fibroglandular tissues over the chest wall to obliterate the postresection defect. Removal of excessive skin may be necessary as well. Primarily supplied by the axillary, intercostal, and internal mammary arteries, the fibroglandular tissue of the breast has a rich anastomotic circulatory bed, which allows the surgeon to remodel large amounts of breast tissue within the skin envelope without a major risk of devascularization or necrosis. However, because of the requirement for dual-plane undermining, which could cause fat necrosis, this technique is more suitable for a dense glandular breast than a fatty breast [3,5,18-20].

This procedure can be performed using the same sequence of steps to excise cancer in any breast quadrant (figure 1):

Skin incision – The location of the incision is determined by the operating surgeon based on the location of the breast cancer [3,17]. When an incision is placed directly over the cancer, the Kraissl's lines of tension are usually followed to limit visible scarring [21]. However, an oncoplastic approach will suggest a variety of options to hide the incisional scar.

Skin undermining – Perform skin undermining within the mastectomy subcutaneous plane, and extend the undermining beyond the planned lumpectomy site. The skin undermining can extend anywhere from a quarter to two-thirds of the skin envelope if there is no risk factor for fat necrosis present (eg, smoking, fatty breast).

NAC undermining (as needed) – Extensive resection can lead to NAC deviation toward the excision area. NAC repositioning requires NAC undermining, which can be accomplished by transecting the terminal ducts and separating the NAC from the underlying breast tissue while leaving a width of 0.5 to 1 cm of glandular tissue attached to maintain blood supply. With undermining of skin and NAC, some numbness of the overlying skin will occur, and some decreased skin sensation may be permanent.

Full-thickness excision of tumor and margins – After completion of the undermining, the tumor is excised in a full-thickness manner extending from the subcutaneous fat to the pectoralis fascia. Four to six marking clips or an alternative marker [15] are then placed at the base of the defect within the surrounding fibroglandular tissue to mark the cancer bed for the radiation oncologist. (See "Adjuvant radiation therapy for women with newly diagnosed, non-metastatic breast cancer" and "Radiation therapy techniques for newly diagnosed, non-metastatic breast cancer".)

Full-thickness breast tissue reapproximation – Once the cancer has been removed, advance the surrounding breast tissue to close the lumpectomy defect. Further undermining, both in the superficial mastectomy plane and in the retromammary space, may be necessary to avoid skin dimpling when the patient stands.

The breast tissue is elevated off the chest wall at the plane between the pectoralis muscle and breast gland and advanced to close the defect that results from resection of the cancer. The direction of tissue advancement can be adjusted, depending upon the location of the fibroglandular defect and the excess tissue that can be shifted to close it. The defect is sutured at the deepest edges using interrupted 3-0 absorbable mattress sutures. We typically do not place anchoring stitches into the chest wall, thus allowing the reapproximated breast tissues to move on the chest wall and shift into a natural position when the patient is upright. The subcutaneous tissue is then closed with interrupted absorbable sutures, and the skin is closed with absorbable subcuticular sutures.

Minor NAC repositioning – After extensive resection, NAC repositioning is generally recommended to avoid NAC displacement toward the excision area. Minor NAC repositioning can be accomplished by de-epithelializing a crescent-shaped area of periareolar skin opposite the excision defect [3]. NAC recentralization should be performed during the initial resection as it is difficult to attempt after radiotherapy. (See 'Crescent mastopexy' below.)

Complex techniques — These more complex techniques are derived from mastopexy procedures with the purpose of reshaping the breast and repositioning NAC on the skin envelope while providing access for the cancer resection. These techniques can be used to excise between 20 and 50 percent of the breast volume [3].

The most widely utilized complex oncoplastic techniques include lateral segmentectomy, batwing mastopexy, central breast-conserving surgery (BCS), reduction mammaplasty, vertical mastopexy, and donut mastopexy [5,13,18-20,22,23]. One or more of these techniques can be selected for each patient based on the location of the breast lesion as well as the amount of tissue to be removed relative to the size of the breast [15,24,25]. (See 'Oncoplastic techniques by tumor locations' above.)

Other complex oncoplastic techniques include nipple-sparing mastectomy and breast reduction and mastopexy performed for resectional or symmetry purposes. (See 'Nipple-sparing mastectomy' below and 'Symmetry procedures' below.)

Parallelogram skin incision — A straightforward method for planning the skin incision is to draw an outline of a parallelogram on the skin. An elongated ellipse or parallelogram incision is made by narrowing and rounding the skin incision pattern, so that two incisions of equal length will join in a tight "V," which on closure will minimize any degree of "dog ear" deformity at the corners. Removal of the overlying skin prevents skin dimpling or hollowing of the breast. The technique is illustrated in the figure (picture 1).

A rounded parallelogram with two equal-length lines is drawn, thus marking the skin island to be excised in conjunction with the underlying target lesion and surrounding tissues. The surgeon should be cautious when designing the skin ellipse because removal of too broad of an island can cause substantial shifting of the NAC.

Lateral segmentectomy — The lateral segmentectomy is a variation of the parallelogram-based BCS and is especially useful for cancers located within the lateral breast, including the three and nine o'clock positions. The skin markings and procedure are illustrated in the picture (picture 2).

The skin parallelogram is placed radially, and, at the corner of the parallelogram that comes closest to the nipple, the design should be positioned such that the closed incision after resection will approach the NAC tangential to the periareolar line. This reduces deviation of the NAC toward the lesion, a condition that can result from scar contraction. This radial approach gives more projection to the nipple, avoiding the downward displacement that can be caused by a purely horizontal scar.

Batwing mastopexy — The batwing mastopexy allows resection of cancers adjacent or deep to the NAC without sacrifice of the nipple itself. This approach can be used in any quadrant of the breast for more centrally located lesions. The batwing approach simultaneously preserves NAC viability and the breast mound by using mastopexy closure to close the resulting fibroglandular defect of the full-thickness resection. As this procedure can cause some lifting of the nipple, it may create asymmetry when compared with the contralateral breast. If desired, a contralateral lift can be performed, either concurrently with the ipsilateral BCS or after adjuvant radiation has been completed and the treated breast has "declared" its new size and shape. The skin markings and procedure are illustrated in the picture (picture 3).

Two semicircular incisions are made with angled "wings" on each side of the areola. The two half-circles are positioned to allow them to be reapproximated to each other at wound closure. Removal of these skin wings allows the semicircles to be shifted together without creating redundant skin folds at closure.

Central breast resection — Patients with a centrally located cancer and associated NAC involvement do not require mastectomy and are candidates for BCS that includes removal of the NAC and the cancer with negative margins of the fibroglandular tissue. Use of a Wise pattern for these central lesions may preserve the forward projection of the breast. The 10 year actuarial survival, distant disease-free survival, and breast recurrence-free survival for central cancers are not significantly different from those of patients who present with breast cancer elsewhere in the breast [26-28]. Central BCS is particularly valuable in women with large breasts where total mastectomy may create prominent asymmetry [13]. (See "Breast-conserving therapy", section on 'Not a contraindication for BCT'.)

For a central cancer resection, the incision is made in the pattern of a large parallelogram that encompasses the entire NAC. The skin markings and procedure are illustrated in the picture (picture 4). A variation gaining in popularity is to rotate the incision so that the resulting scar is an inverted T, which can later be utilized in NAC reconstruction and results in a breast reduction-type appearance.

Crescent mastopexy — For the patient who has a mild ptosis and wishes for a slight lift at the same time as a lumpectomy, a crescent mastopexy is a good option. The crescent mastopexy is an entry-level mastopexy moving the nipple only 1 to 2 cm superiorly. The patient must be marked accurately so that the amount of breast lift is appropriate and centralized. A crescent incision is made through the epidermis, and a crescent of tissue is de-epithelialized (figure 1). Once the tissue is de-epithelialized, the lumpectomy may be approached through the crescent. That is followed by closure of the crescent, thus lifting the nipple to the level of the crescent. The de-epithelialized skin is folded within the skin closure. This provides a small but noticeable breast lift (1 to 2 cm). A symmetry procedure is often performed at the same time.

Reduction mammaplasty — For patients with large breasts (macromastia), a reduction mammaplasty can be used for resection of lesions in the lower hemisphere of the breast, between the four and eight o'clock positions. Breast reduction can help ensure consistent positioning of the breast for radiotherapy, which improves dosing homogeneity [29]. Reduction mammaplasty also prevents the downturning of the nipple that can result from traditional BCS using a circumareolar incision. This procedure is more complicated than most other oncoplastic techniques and should be performed in conjunction with a plastic surgeon. A contralateral reduction should be considered to improve postoperative symmetry. The skin markings and procedure are illustrated in the picture (picture 5).

A keyhole pattern (Wise pattern) incision is made, and the skin above the areola is de-epithelialized in preparation for skin closure. This creates a pedicle on which the NAC can be advanced and helps preserve the nipple's blood supply. Depending on the location of the cancer and the size of the breast, it is sometimes preferable to use an inferiorly based pedicle for the NAC. For cancers located in the inferolateral or inferomedial quadrants, the keyhole pattern can be rotated slightly to allow for a more lateral or medial excision, while the NAC is moved in a direction opposite to that of the surgical defect [16]. An inframammary incision is made, and breast tissue is dissected off the pectoral fascia to mobilize the NAC and underlying tissues. A full-thickness excision of the lesion with the overlying skin is accomplished, with at least a 1 cm macroscopic margin of normal tissue. Clips or another marker should be placed for subsequent radiation planning. (See 'Basic technique (partial breast reconstruction)' above.)

Recentralization of the NAC is performed to recreate a harmonious breast size and shape. The medial and lateral breast flaps are undermined and sutured together to fill the excision defect, leaving a typical inverted-T scar.

Donut mastopexy — The donut mastopexy technique is best utilized for segmentally distributed cancers located in the upper or lateral breast to achieve resection of long, narrow segments of breast tissue. The donut mastopexy avoids a visible long radial scar, while allowing for adequate margin resection. Only a periareolar scar is visible after this operation. The donut mastopexy lifts the NAC and may create mild asymmetry in comparison to the untreated breast (as high as 2 cm). A contralateral breast lift can be performed to achieve symmetry. The skin markings and procedure are illustrated in the figure (picture 6).

Two concentric incisions are made around the areola, and a periareolar "donut" of skin is excised, taking care to avoid full devascularization of the areolar skin. The width of the "donut" skin island should be approximately 1 cm but is somewhat dependent on the size of the areola and expected extent of excision. Removal of this skin is required to allow for both adequate access and exposure to the breast tissue and closure of the skin envelope around the remaining fibroglandular tissue that will reduce tissue volume overall.

Skin flaps are raised circumferentially around the NAC.

The segment of breast tissue with the cancer is resected in a wedge-shaped fashion, dissected from the underlying pectoralis muscle, and delivered through the circumareolar incision.

The remaining breast tissue is advanced, and the peripheral apical corners of the tissue are secured to each other and then anchored to the chest wall. This anchoring, which is generally not required with smaller oncoplastic resection, maintains proper orientation of the mobilized fibroglandular tissue within the skin envelope during the initial phases of healing and is necessary to prevent the unsightly displacement of the breast that would otherwise result from the large amount of dissection performed. Clips or another marker are placed for subsequent radiation planning. (See 'Basic technique (partial breast reconstruction)' above.)

A purse-string suture is placed around the areolar opening at a size that reapproximates the original NAC using absorbable suture. Interrupted inverted absorbable sutures are placed subdermally around the NAC, the purse-string suture is tied, and absorbable subcuticular sutures are used to close the wound. Some surgeons use nonabsorbable suture for the purse string (or wagon wheel stitch) to avoid widening of the nipple over time.

Vertical mammaplasty — The candidate for this procedure should have only mild-to-moderate degree of ptosis with an inferior pole lesion. A vertically oriented ellipse of skin is marked without using lateral reduction skin resections. This includes a section of tissue removed from the inferior pole with approximation of both medial and lateral tissue flaps. In addition, an associated round-block incision around the nipple will lift the NAC at the same time the inferior pole is reduced. The final result has a circumareolar incision with a vertical midline extension down to the inframammary fold.

Nipple-sparing mastectomy — For most breast surgeons, nipple-sparing mastectomy is an approachable technique. Most of the time, it is scheduled with a plastic surgeon who will perform immediate breast reconstruction at the same time. There are some breast surgeons who have learned breast reconstruction and perform their own complete procedure, but most surgeons will partner with a plastic surgeon. In view of the increased popularity of prepectoral tissue expander placement, some breast surgeons are learning how to place the expander at the time of mastectomy due to the unavailability of plastic surgeons in some locales. Nipple-sparing mastectomy requires several points to be successful:

Choose an incision that allows you access to the entire breast and axilla. The most common are lateral radial and inframammary incisions. Avoid incisions around the areola.

Dissect even subcutaneous planes of the mastectomy. Irregular thickness in dissection challenges vascularity of the skin.

Avoid cautery when dissecting behind the nipple. Conduction of current jeopardizes the nipple viability. Preoperatively notify the patient of the possibilities of postoperative nipple ischemia or loss.

Perform frozen section analysis of the retroareolar nipple tissue to confirm there is no cancer in the nipple.

Limit excessive traction on the skin edges to avoid edge necrosis.

The indications and outcomes of nipple-sparing mastectomy are discussed elsewhere. (See "Mastectomy", section on 'Nipple-areolar-sparing mastectomy'.)

Symmetry procedures — Symmetry procedures are those performed on the noncancer (contralateral) breast to achieve a cosmetic appearance similar to that of the cancer-treated breast. Those procedures may include the repeat procedure that was performed on the ipsilateral side, or a lesser mammaplasty procedure. It may often include repositioning or adjustment of the nipple. The symmetry procedure may be performed at the same time as the primary cancer procedure or later when the final size and shape of the treated breast is known. A delayed symmetry procedure may better compensate for any cosmetic defects that develop in the postradiation period.

Oncoplastic breast surgery includes performing symmetry procedures on the noncancer side at the request of the patient. For breast surgeons who feel comfortable performing a symmetry procedure, it is appropriate for them to do so; otherwise, referring the patient to or partnering with a plastic surgeon is appropriate.

Advanced techniques — The descriptions of implant- and flap-based techniques of breast reconstruction are beyond the scope of this topic, and their use is generally reserved for advanced oncoplastic surgeons or plastic surgeon-breast surgeon teams [3,17].

Breast implants are used for reconstruction after mastectomy and can be placed in the prepectoral or retropectoral space. (See "Implant-based breast reconstruction and augmentation".)

All tissue flap procedures of breast reconstruction move viable fatty tissue from one site in the body to the breast. Pedicled flaps, including the transverse rectus abdominis myocutaneous (TRAM) flap and latissimus flap, maintain the blood supply from the original anatomic source. The tissue is mobilized along with its blood supply and simply rotated into the original breast space.

By contrast, free flaps are harvested from one site of the body (donor site) and taken to another site (the mastectomy or recipient site). The recipient site has been explored to find an adequate blood supply of both artery and veins to which the free flap will be connected. These free flaps have become the most common method of postmastectomy reconstruction. A common free flap is the deep inferior epigastric artery perforator (DIEP) flap. (See "Options for autologous flap-based breast reconstruction".)

MARGINS — Negative margins are a basic tenet for oncologic breast surgery. Patients with a positive margin require a re-excision, typically through the same incision. Those with a positive margin involving a small portion of the specimen only need to have that portion of the margin re-excised, instead of the entire biopsy cavity. For patients with multiple positive margins, a mastectomy may be necessary. In such patients, it may be technically challenging to incorporate both the initial oncoplastic incision and the nipple-areolar complex into the mastectomy incision. Consultation with a plastic surgeon is recommended, especially if breast reconstruction is planned after mastectomy.

Re-excision rates for oncoplastic surgical cases are low [10,11,30-32]. In a retrospective series of 272 patients who underwent breast-conserving surgery (BCS) with oncoplastic techniques, a positive margin was found in 12 percent of patients, which necessitated a second operation in 33 patients and a third operation in three patients [8-11,33,34]. Nine percent of patients ultimately required mastectomy because of positive margins, with 55 percent of the mastectomy specimens revealing residual disease [33].

Indications for re-excision in BCS are discussed elsewhere. (See "Breast-conserving therapy", section on 'Margins of resection'.)

The techniques of intraoperative margin assessment are discussed in another topic. (See "Techniques to reduce positive margins in breast-conserving surgery".)

The techniques of mastectomy are discussed in another topic. (See "Mastectomy", section on 'Breast reconstruction'.)

COMPLICATIONS — Postoperative complications unique to oncoplastic resections include nipple necrosis, fat necrosis, and delayed healing [3,13,17,35]. They can be minimized by staying in true anatomic planes, maintaining meticulous hemostasis, and avoiding overly aggressive undermining in patients with a fatty breast [3]. The complication rates are typically higher in smokers, patients with diabetes, and those who are overweight. Reported rates of complications for oncoplastic surgical procedures are low [8,10,36,37].

Other complications that are common to all breast surgeries (eg, wound infection) are discussed elsewhere. (See "Breast-conserving therapy", section on 'Complications'.)

OUTCOMES — Long-term outcomes of oncoplastic surgery are comparable or superior to those of standard breast-conserving surgery (BCS). A 2014 meta-analysis found that patients treated with oncoplastic resections had a lower rate of positive margins (12 versus 21 percent) and a lower rate of re-excisions (4 versus 15 percent), but a higher rate of completion mastectomies (7 versus 4 percent), when compared with patients who underwent standard BCS [36,38,39]. At three to five years, patients who underwent oncoplastic resections developed fewer complications (16 versus 26 percent) and local recurrences (4 versus 7 percent) and had a higher satisfaction with the appearance of their breast (90 versus 83 percent) [36]. Several reports note the safety of oncoplastic procedures with high rates of overall and disease-free survival and low rates of local recurrence, distant recurrence, re-excision, conversion to mastectomy, and complications [9,10,34,40-42].

A retrospective comparative study of close to 3000 patients found that therapeutic mammaplasty, which is wide local excision to remove the cancer with breast reduction and mastopexy techniques to reshape the remaining tissue, allowed preservation of the breast in 87 percent of patients and was associated with lower complication rates than mastectomy with or without immediate reconstruction (21 versus 36 versus 37 percent) [43].

AESTHETIC BREAST CANCER THERAPY — The concept of aesthetic breast cancer therapy is not limited to oncoplastic surgery. Radiation treatment and neoadjuvant systemic therapy may also impact the cosmesis of the breast. Integrating oncoplastic procedures with other breast cancer treatments achieves the comprehensive goal of aesthetic breast cancer therapy.

Radiation changes to the breast vary by patient but often are inevitable. Working with the radiation oncologist to properly target the right amount of radiation to the specific sites within the breast will contribute to improving the final look of the breast. Similarly, the use of partial breast radiation or no radiation may impact the final appearance of the breast as well. (See "Adjuvant radiation therapy for women with newly diagnosed, non-metastatic breast cancer".)

In addition, the use of neoadjuvant chemotherapy may contribute to the overall cosmesis by downsizing the primary tumor, allowing for less drastic surgery. (See "General principles of neoadjuvant management of breast cancer".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Breast surgery".)

SUMMARY AND RECOMMENDATIONS

Definition – Oncoplastic breast surgery merges the principles of oncologic and reconstructive surgery, with the goals of achieving optimal survival while maintaining or reconstructing a cosmetically acceptable breast, whether via breast-conserving surgery (BCS) or mastectomy. (See 'Introduction' above.)

Indications – Oncoplastic surgical techniques are not required for small cancers in large breasts but are well suited for patients who have a large tumor relative to their breast size, a need to reposition the nipple-areolar complex (NAC) after the excision, or preexisting aesthetic concerns (eg, macromastia or significant ptosis) that may be addressed at the time of cancer resection. (See 'Indications' above.)

Techniques – Oncoplastic breast surgery techniques can be classified by increasing complexity. The basic technique can be readily learned and perfected by most breast surgeons; mastery of complex techniques generally requires additional training in the field or the assistance of a plastic surgeon at the time of cancer surgery (see 'Oncoplastic techniques by complexity levels' above):

The basic technique for lumpectomy is a single technique based on dual-plane undermining (including the NAC when necessary). It can be used to excise up to 20 percent of the breast volume. No skin excision or major nipple relocation is required; minor NAC relocation is included (figure 1). (See 'Basic technique (partial breast reconstruction)' above.)

Complex techniques are derived from mastopexy procedures with the purpose of reshaping the breast and repositioning the NAC on the skin envelope. These techniques can be used to excise between 20 and 50 percent of the breast volume. One or more of these techniques can be selected for each patient based on the location of the breast lesion as well as the amount of tissue to be removed relative to the size of the breast. (See 'Complex techniques' above.)

Choices of techniques – The choice of oncoplastic surgical technique is based upon multiple factors, including the location of the cancer in the breast, the degree of anatomic ptosis, the desires of the patient, the patient's overall health, and the skill set of the surgeon or team of surgeons. (See 'Oncoplastic techniques by tumor locations' above.)

Outcomes – Oncologic outcomes of oncoplastic surgery (eg, positive margin and re-excision rates) are comparable or superior to those of standard BCS, and the reported complication rates are low. Thus, oncoplastic options should be considered for every breast cancer patient. (See 'Outcomes' above and 'Complications' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Benjamin O Anderson, MD, who contributed to an earlier version of this topic review.

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References

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