Oncoplastic approaches to breast conservation

Abstract

When a woman is diagnosed with breast cancer many aspects of her physical, emotional, and sexual wholeness are threatened. The quickly expanding field of oncoplastic breast surgery aims to enhance the physician commitment to restore the patient's image and self-assurance. By combining a multidisciplinary approach to diagnosis and treatment with oncoplastic surgery, successful results in the eyes of the patient and physician are significantly more likely to occur. As a way to aid oncoplastic teams in determining which approach is most suitable for their patient's tumor size, tumor location, body habitus, and desired cosmetic outcome we present a review of several oncoplastic surgical approaches. For resections located anywhere in the breast, the radial ellipse segmentectomy incision and circumareolar approach for segmental resection are discussed. For resections in the upper or central breast, crescent mastopexy, the batwing incision, the hemibatwing incision, donut mastopexy, B-flap resection, and the central quadrantectomy are reviewed. For lesions of the lower breast, the triangle incision, inframammary incision, and reduction mastopexy are discussed. Surgeons who are interested in adding oncoplastic breast conserving therapies to their skill sets are encouraged to implement these surgical techniques where applicable and to seek out breast fellowships or enhanced training when appropriate.

Figure 1

List of oncoplastic breast conserving procedures discussed in this paper, organized by tumor location.

Figure 2

Radial ellipse segmentectomy. (a) Shows location of radial ellipse segmentectomy skin incision in upper outer quadrant. (b) Shows multiple “stars” indicating possible tumor locations suitable for this approach. (c) Shows resection cavity following excision of malignancy with excised specimen (inset). (d) Shows breast following closure of the skin incision.

Figure 3

Circumareolar approach for segmental resection. (a) Shows location of circumareolar skin incision. (b) Shows multiple “stars” indicating possible tumor locations suitable for this approach. (c) Shows lumpectomy cavity after segmental resection of breast glandular tissue only with arrows denoting the extent of undermining of the overlying skin flap. (d) Shows results of glandular flaps advancements that allow the medial and lateral margins to be sutured together below the skin flap. Frontal and transverse views are shown. (e) Shows breast following closure of the circumareolar incision.

Figure 4

Crescent Mastopexy. (a) Shows location of crescent mastopexy skin incision. (b) Shows multiple “stars” indicating possible tumor locations suitable for this approach. (c) Shows resection cavity following excision of malignancy with excised specimen (inset). (d) Shows breast following closure of the skin incision.

Figure 5

Batwing resection. (a) Shows location of batwing skin incision. (b) Shows multiple “stars” indicating possible tumor locations suitable for this approach. (c) Shows resection cavity of batwing resection with excised specimen (inset). (d) Shows breast following closure of the hemibatwing incision.

Figure 6

Hemibatwing resection. (a) Shows location of hemibatwing skin incision. (b) Shows resection cavity of hemibatwing resection with excised specimen (inset). (c) Shows breast following closure of the hemibatwing incision.

Figure 7

Donut mastopexy resection. (a) Shows location of two circumareolar incisions. (b) Shows frontal and profile views of the breasts with multiple “stars” indicating possible tumor locations suitable for this approach. (c) Shows the area of de-epithelized or excised skin at edge of areola. (d) Shows arrows denoting undermining of skin flaps in the central breast. For illustration purpose, (e) shows medial profile view of the right breast with central lumpectomy cavity and area of undermined skin flaps. Frontal view of left breast shows central lumpectomy behind nipple-areolar complex. (f) Shows results of advancement of glandular tissue which is mobilized and sutured together to fill the central breast. (g) Shows reduction of the diameter of the outer skin margin using a purse-string suture. (h) Shows breast following closure of the skin incision.

Figure 8

B-flap resection. (a) Shows multiple stars with possible tumor locations. (b) Shows location of skin incision, including disk of skin to be preserved. (c) Shows surgical cavity after excision of central lumpectomy with removal of nipple-areolar complex (inset). For illustration purposes, medial profile view of right breast shows multiple “stars” indicating possible tumor locations suitable for this approach. (d) Shows surgical cavity, areas of de-epithelized skin, preserved disk of epithelized skin, and location of incision to be made in the glandular tissue. (e) Shows advancement and clockwise rotation of lower outer quadrant until disk of skin occupies the nipple-areolar complex position. (f) Shows breast following approximation and closure of the skin incisions. De-epithelized skin is buried below the skin of the lower inner quadrant and the disk of skin forms a new areola.

Figure 9

Central quadrantectomy. (a) Shows location of central quadrantectomy skin incision. (b) Shows multiple “stars” indicating possible tumor locations suitable for this approach. (c) Shows resection cavity following excision of malignancy. The nipple-areolar complex was omitted in the left image to allow visualization of surgical cavity. (d) Shows results of glandular flap advancements that allow the surgical margins to be sutured together using purse-string sutures to obliterate the surgical cavity. Arrows showing undermining of skin flaps in the central breast. Nipple-areolar complex omitted in the left image to allow visualization of the approximated glandular tissue. (e) Shows breast following closure of the skin incision.

Figure 10

Triangle resection. (a) Shows location of the triangular skin incision. (b) Shows multiple “stars” indicating possible tumor locations suitable for this approach. (c) Shows resection cavity following excision of malignancy with excised specimen (inset). (d) Shows breast following closure of the skin incision, including extensions of incision along the inframammary skin fold.

Figure 11

Inframammary Resection. (a) Shows location of inframammary skin incision. “Stars” indicate multiple possible tumor locations suitable for this approach. (b) Shows breast following closure of the inframammary incision.

Figure 12

Reduction mammaplasty. (a) Shows multiple “stars” indicating possible tumor locations suitable for this approach. (b) Shows surgical cavity after resection of nipple-areolar complex and inferior breast using Wise pattern. A symmetrical reduction is shown in the opposite breast. (c) Shows advancement of medial and lateral pedicles to inframammary fold. (d) Shows the breasts after closure of the wounds.