Oncoplastic and Reconstructive Breast Surgery: A Comprehensive Review

Abstract

Most of the approaches that were valid until recently in breast cancer surgery have undergone significant changes with rising awareness, increasing number of patients, and knowledge. It is important to repair the damage caused by surgical treatment performed in accordance with oncological principles and to obtain good cosmetic results. The quality-of-life indexes increase and body image is positively affected by the development of oncoplastic surgery and reconstruction techniques. The oncoplastic techniques are commonly used for the closure of glandular defects. Surgeons must pay attention to the breast volume, tumor location, the amount of breast tissue that would be removed, and the oncoplastic technique that may be required. Oncoplastic breast surgery allows wide local excision of the mass with good cosmetic results. In addition, a contralateral breast lift, breast augmentation or breast reduction may be required to accommodate the conceptually reconstructed breast. The use of oncoplastic breast surgery techniques results in lower mastectomy rates with equivalent local and long-term survival rates as compared with mastectomy and offers women the option of plastic and reconstructive interventions performed at the time of initial surgery. Mastectomy may be needed for large tumors, as breast-conserving surgery may not be possible or may not produce satisfactory cosmetic results. Breast reconstruction methods after mastectomy include autologous or implant-based breast reconstructions, which can be performed at the same time as the breast cancer surgery (immediate reconstruction) or at a later time (delayed reconstruction). Oncoplastic and reconstructive breast surgery minimizes the impact of breast cancer surgery and yields equivalent survival outcomes without psychological morbidity. With advanced techniques, better breast image than before can also be achieved. In this review, the technical details of oncoplastic breast surgery, surgical margin positivity management, reconstruction methods, radiation therapy given after reconstruction surgery, radiologic imaging modalities, and management of complications are discussed.

Keywords: breast-conserving surgery; incision; oncoplastic breast surgery; radiotherapy; reconstruction; surgical margin.

Figure 1. Forty-six-year-old female patient has left retro areolar ductal carcinoma in-situ. Right breast reduction mammoplasty, left breast wise pattern mastopexy and NAC reconstruction with graft was planned. A, B, C: Preoperative view. D, E, F: Postoperative one-month views.

NAC: Nipple-areolar complex

Figure 2. Fifty-seven-year-old female patient. A mastectomy was performed on the left breast three years ago due to invasive ductal carcinoma. A, B: Breast reconstruction plan with latissimus dorsi muscle skin flap and expander. C: Post-expanded view of the left breast. D: Reduction mammoplasty to the right breast, NAC reconstruction plan to the left breast. E and F: Postoperative one-month views.

NAC: Nipple-areola complex

Figure 3. Forty-five-year-old female patient. Mastectomy was performed on the left breast seven years ago for invasive ductal carcinoma. Breast reconstruction with a DIEP flap was planned for the left breast. A, B, C: Preoperative views. D, E, F: Postoperative one-year views.

DIEP: Deep inferior epigastric perforators

Figure 4. Thirty-eight-year-old female patient planned for subcutaneous mastectomy and immediate implant-based reconstruction due to ductal carcinoma in situ of the left breast. A, B, C: Preoperative images. D, E, F: Postoperative eighth-month views.

Figure 5. Fifty-one-year-old female patient with family history of breast cancer and BRCA gene positivity. The patient underwent a bilateral subcutaneous mastectomy, wise pattern skin reduction, dermal flap, and implant-based immediate breast reconstruction. A, B, C: Preoperative views. D, E, F: Postoperative views.

BRCA gene: Breast cancer gene

Figure 6. Thirty-nine-year-old female patient planned for NSM and immediate implant-based breast reconstruction due to right ductal carcinoma in situ. A: Preoperative view. B: Partial nipple necrosis, postoperative one-month view. C: Postoperative two months. D: Postoperative eight months, pigment loss in the nipple.

NSM: Nipple-sparing mastectomy

Figure 7. Forty-two-year-old female patient. The patient planned for left subcutaneous mastectomy and breast reconstruction with simultaneous DIEP flap due to invasive ductal carcinoma. A: Preoperative image. B: DIEP flap elevation. C: Immediate postoperative view. D: Abdominal hernia, postoperative first-year view.

DIEP: Deep inferior epigastric perforators