Oncoplastic and reconstructive breast surgery

Abstract

This article provides an overview of the principles and techniques of oncoplastic and reconstructive breast surgery for patients with early-stage breast cancer. Oncoplastic breast surgery (OPBS) with partial breast reconstruction is a natural evolution in the application of breast conserving surgery and permits wide surgical resection of tumours that might otherwise mandate mastectomy and whole breast reconstruction. These reconstructive techniques must be optimally selected and integrated with ablative breast surgery together with non-surgical treatments such as radiotherapy and chemotherapy that may be variably sequenced with each other. A multidisciplinary approach with shared decision-making is essential to ensure optimal clinical and patient-reported outcomes that address oncological, aesthetic, functional and psychosocial domains. Future practice of OPBS must incorporate routine audit and comprehensive evaluation of outcomes.

Keywords: autologous free flap; breast implants; breast reconstruction; fat grafting; nipple sparing mastectomy; oncoplastic breast surgery.

Figure 1

Left therapeutic mammaplasty in a patient with gigantomastia necessitating contralateral balancing breast reduction. Symmetrisation surgery is an integral part of therapeutic mammaplasty specifically and oncoplastic surgery in general.

Figure 2

Right modified Grisotti flap based on the inferior pedicle, used for partial reconstruction to create a neo-areola after right therapeutic wise pattern mammoplasty with axillary clearance and left inferior pedicle based contralateral balancing reduction mammoplasty. Right therapeutic reduction weight 778g. Left breast reduction weight 842g.

Figure 3

Right therapeutic wise pattern mammoplasty and contralateral symmetrising left breast wise pattern reduction mammoplasty using inferior pedicles. White arrows indicate the direction of flap rotation and final placement. Illustrated by Shiuan Shyu.

Figure 4

(A) Superolateral pedicle and secondary (de-epithelialised totally buried) inferior pedicle: Bilateral breast cancers – different locations, multifocal left breast cancer. (B) Intraoperative sequence.

Figure 5

Schematic diagrams showing the intercostal artery perforator flaps: nomenclature and anatomy.

Figure 6

TDAP flap vascular anatomy and intraoperative harvest. Courtesy of Plastic Surgery Key. TDAP flap with key perforator 3cm posterior to the anterolateral border of the LD muscle. Intraoperative images show location of the perforator and the muscle split required to increase vascular pedicle length and increase its arc of rotation. No muscle is sacrificed. A small part of muscle can be sacrificed (type 1) vs type 2.

Figure 7

(A) Fat grafting of contour defects of bilateral LD + expandable implants for risk reducing surgery. (B) Fat necrosis of an immediate SIEA flap: treated by a TDAP flap and serial fat grafting from the abdomen and flanks.

Figure 8

Superolateral pedicle and secondary (de-epithelialised totally buried) inferior pedicle. White arrows indicate the direction of flap rotation and final placement. Illustrated by Shiuan Shyu.

Figure 9

Effects of radiotherapy following inferior pedicle technique therapeutic mammaplasty in a 44 year old showing severe radiotherapy reaction and follow up 5 years later showing changes have largely settled.

Figure 10

Access incisions for nipple-sparing mastectomies and flap reconstruction (85).

Figure 11

Intraoperative sequence of skin-reducing mastectomy with nipple-preservation, pre-pectoral implant and dermal sling reconstruction.

Figure 12

Skin reducing mastectomy, expandable implant and dermal sling reconstruction.

Figure 13

Bilateral DIEP flap immediate breast reconstruction following right therapeutic and left prophylactic skin sparing mastectomies. Illustration by Shiuan Shyu.