Oncoplastic partial breast reconstruction: concepts and techniques

Abstract

Immediate oncoplastic breast reconstruction performed at the time of breast conserving surgery for the treatment of breast cancer merges the therapeutic goals of complete oncologic extirpation with preservation of breast form and function. A constellation of surgical techniques that employs breast volume displacement and/or replacement methods of varying complexity levels have emerged, thus broadening the potential applications for breast conservation therapy to include cases with increased tumor-to-native breast-volume ratios, multicentric or multifocal disease, and/or previous margin-positive resections. This review describes the various reconstructive methods, including the use of local tissue rearrangement, oncoplastic reduction-mastopexy, and locoregional flaps. Classification of the surgical options into levels I and II volume-displacement and volume-replacing techniques is made. Additionally, we explore the oncologic safety and effectiveness of this treatment paradigm by summarizing existing supportive evidence regarding associated risk of surgical complications, rate of margin-positive resection, implications for radiographic surveillance, local recurrence rates, and patient-reported outcomes. In conclusion, surgeons may use a wide variety of oncoplastic techniques for partial breast reconstruction at the time of segmental mastectomy to deliver effective breast conserving treatment for women with breast cancer. A growing body of literature affirms the oncologic safety of this approach. Future directions for research include long-term follow-up data with emphasis on outcomes from patient perspectives.

Keywords: Breast conservation; breast cancer; breast reconstruction; lumpectomy; segmental mastectomy.

Figure 1

Wise pattern mastopexy-reduction techniques may be used to for patients with ptosis, macromastia, and skin excess. (A) Preoperative photo of 45-year-old female with left T3N1 breast cancer and bilateral ptosis who presents for breast conservation therapy. (B) Postoperative photo at four weeks after patient underwent segmental mastectomy with bilateral immediate superomedial pedicle Wise pattern oncoplastic mastopexy. Radiation markers are in place.

Figure 2

For patients with ptosis without significant macromastia or skin excess, circumvertical mastopexy techniques may be useful. Intraoperative photos of a 47-year-old female with right upper outer quadrant breast cancer undergoing segmental mastectomy via coordinated incisional approach. A circumvertical superomedial mastopexy was performed with preservation of the inferior pole wedge, which was rotated with the pedicle for defect obliteration.

Figure 3

For patients without indication for mastopexy or in whom mastopexy is contraindicated, central sub-areolar tumors, or large tumor-to-breast size ratios, use of a pedicled locoregional flap is an alternative. Intraoperative photos of a 53-year-old female with left upper outer pole breast cancer who underwent segmental mastectomy and immediate tissue replacement with a lateral intercostal artery perforator flap based off of the fifth intercostal vascular pedicle. The flap was de-epithelialized, islanded, and transposed for defect obliteration.