|Year : 2015 | Volume
| Issue : 1 | Page : 49-53
Oncoplastic breast-conserving surgery
Mahmoud A Elkhateb1, Ayman A Shmilla2, Soliman A El-Shakhs3, Ahmed M Al-Barah3, Abdelmoniem F Mohamed3, Moharram A Mohammed3
1 Department of General Surgery, Shebin El-Koum Teaching Hospital, Egypt
2 Department of General Surgery, Damanhour Oncology Center, Egypt
3 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||12-Jun-2014|
|Date of Acceptance||15-Aug-2014|
|Date of Web Publication||29-Apr-2015|
Mahmoud A Elkhateb
Shebin El-Koum Teaching Hospital
Source of Support: None, Conflict of Interest: None
To assess different techniques of oncoplastic breast-conserving surgery, according to breast shape, protrusion, size, and symmetry.
Oncoplastic surgery has emerged as a new approach to allow wide excision for breast-conserving surgery without compromising the natural shape of the breast. It is based on integration of plastic surgery techniques for immediate breast reshaping after wide excision for breast cancer.
Patients and methods
This prospective study was carried out on 35 patients; all patients had breast tumor and were being managed at Menoufia University Hospitals by different modalities of oncoplastic breast surgery during the period from April 2012 to December 2013. The appropriate oncoplastic technique was selected for every patient taking into consideration the location and size of the mass and breast size and ptosis.
Seven patients underwent simple oncoplastic procedures with volume displacement techniques, 20 patients underwent more advanced oncoplastic techniques of volume replacement with local dermoglandular flaps, and eight patients required reconstruction with distant pedicle musculocutaneous flaps. All our patients had negative clear specimen margins. Only three complications were encountered: one case of skin necrosis in the skin envelope after skin-sparing mastectomy and two cases of traumatic fat necrosis with the inverted-T technique.
This study showed that creative use of reconstructive techniques can yield excellent results, fulfilling all patient and surgeon expectations with a minimum rate of morbidity. Younger women with a small-size breast will benefit from a simple oncoplastic technique with volume displacement procedures. Women with large ptotic breasts need more complex mammoplastic techniques with or without flaps.
Oncoplastic surgery should be the standard approach to breast cancer treatment whenever feasible.
Keywords: Breast oncoplastic surgery, breast cancer, therapeutic mammoplasty, vertical scar mammoplasty
|How to cite this article:|
Elkhateb MA, Shmilla AA, El-Shakhs SA, Al-Barah AM, Mohamed AF, Mohammed MA. Oncoplastic breast-conserving surgery. Menoufia Med J 2015;28:49-53
|How to cite this URL:|
Elkhateb MA, Shmilla AA, El-Shakhs SA, Al-Barah AM, Mohamed AF, Mohammed MA. Oncoplastic breast-conserving surgery. Menoufia Med J [serial online] 2015 [cited 2020 Feb 24];28:49-53. Available from: http://www.mmj.eg.net/text.asp?2015/28/1/49/155941
| Introduction|| |
An increasing number of treatment options are available for breast carcinoma, and some patients can now be cured by a combination of surgery, radiotherapy, and systemic adjuvant therapy .
Over the last 30 years, the major change in the surgical treatment of breast carcinoma has been the shift toward breast-conservation treatment. Breast-conserving surgery (BCS) was introduced to reduce the physical and psychological consequences of removing the entire breast; several studies reported equivalent survival when comparing BCS and radiotherapy with mastectomy .
Oncoplastic surgery (OPS) has emerged as a new approach to allow wide excision for BCS without compromising the natural shape of the breast. It is based on integration of plastic surgery techniques for immediate breast reshaping after wide excision for breast cancer .
OPS refers to resection of the tumor (either partial or total mastectomy) and immediate reconstruction of the defect using plastic surgical techniques (local parenchymal/muscle flaps or free flaps) with contralateral breast symmetrization and reconstruction of the nipple-areola complex (NAC) when needed .
There are three factors in the selection of patients who may benefit from an oncoplastic approach. The two factors already recognized as major indications for OPS are excision volume and tumor location. The third additional factor is glandular density .
The oncoplastic classification system provides a practical guide of OPS techniques. This guide allows for selection of the most appropriate OPS procedure during surgical planning. The level I group includes cases with excision volume less than 20%, with no skin excision, and the level II group includes cases when excision volume exceeds 20% with skin excision .
| Patients and methods|| |
This prospective study was carried out on 35 patients; all the patients had breast tumor and were being managed at Menoufia University Hospitals and El-Salam Oncology Center by different modalities of oncoplastic breast surgery during the period from April 2012 to December 2013.
We chose patients with a unilateral breast mass. The mass was less than 5 cm and patients had stage 1 or 2 breast cancer. We excluded patients with multicentric breast cancer, recurrent breast mass, patients older than 60 years of age, patients with a positive family history, patients with other malignancy, and patients with connective tissue diseases.
All patients were subjected to a full clinical examination, especially to exclude metastasis signs of the other systems; local examination, bilateral breast and axilla examination, and assessment of the location, size, and mobility of the mass.
Laboratory investigations (preoperative investigations) included complete blood count, and liver functions tests, especially alkaline phosphatase and 5'-nucleotidase and renal functions tests, and ECG for patients older than 40 years of age.
Bilateral sonomammography, FNAC, or true-cut needle biopsy, and metastatic work-up such as chest radiography, abdominal ultrasound, and bone scan were also performed for all patients. A written informed consent was obtained from every patient before surgery. The consent included approval for surgery, photographs, and research publication.
We began our surgery with preoperative marking, which included midline starting from the suprasternal notch to the umbilicus, the inframammary line, which begins at the midline and ends at the anterior axillary line, the breast meridian, which begins at the midclavicular point through the breast passing at the middle of the inframammary line, usually cutting through the nipple, nipple and areola as a complete circle of 4-6 cm diameter, and the new nipple position at the breast meridian 19-22 cm from the suprasternal notch. The pedicle according to the technique used may be the inferior pedicle, which begins at the inframammary line, encircling the NAC by about 1-2 cm around the NAC; its width is about 8-10 cm. The superomedial pedicle begins at the parasternal line at the second, third, and fourth intercostal spaces, encircling the NAC by about 1-2 cm around the NAC, The superior pedicle begins at the upper border of the breast at the second intercostal space with 8 cm width and encircles the NAC. The area for de-epithelialization above the pedicle should also be marked [Figure 1]. The mass with a 2 cm safety margin was marked.
In the operating room, under general anesthesia, the patient was placed supine with the arms abducted 90°. Then, we began by infiltrating the breast with a saline solution by adding (adrenaline with a concentration 1: 200 000 and lidocaine 3 mg/kg) over the entire breast, especially subdermally in the de-epithelialized area, except at the original NAC. Then, we made a skin incision around the original NAC and all around the de-epithelialized area. After de-epithelialization, we dissected around the pedicle, separating it from the surrounding breast tissue down to the pectoral fascia. We dissected the mass with a safety margin, marking it as the first specimen. In simple oncoplastic techniques such as Melon slice that we used in two cases, only the mass with its safety margin was included in a transverse elliptical incision. Finally, we placed the NAC in the new position, and then closed the wound by 3-0 monocryl subcuticular sutures. Level II axillary clearance was performed through a separate transverse axillary incision. Two separate suction drains were performed: one for the breast removed after 2 days and one for the axilla removed after 6-8 days. After changing gloves and with a new set of instruments, we followed the same procedure for the other breast, but without axillary clearance [Figure 2],[Figure 3] and [Figure 4].
|Figure 3: Preoperative marking for skin-sparing mastectomy and latissimus dorsi flap.|
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|Figure 4: Postoperative for skin-sparing mastectomy and latissimus dorsi flap after 3 months.|
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| Results|| |
The appropriate technique was selected for every patient taking into consideration the location, size of the mass, and breast size.
Patients with a breast lump were classified according to the location of the mass in the breast as follows:
Upper outer quadrant mass (16 patients, 45.7% of patients).
Lower outer quadrant mass (five patients, 14.2% of patients).
Lower inner quadrant mass (four patients, 11.4% of patients).
Upper inner quadrant mass (two patients, 5.7% of patients).
Retroareolar mass (eight patients, 22.8% of patients).
Eleven patients underwent therapeutic mammoplasty using an inferior pedicle with an inverted-T scar technique. The other five patients had normal or medium-sized breast: three patients underwent therapeutic mammoplasty using the lateral radial incision technique and two patients underwent therapeutic mammoplasty using the anterior axillary incision technique.
Five patients presented with masses at the lower outer quadrant. Three of these patients had a large-sized breast and underwent therapeutic mammoplasty using a superomedial pedicle with the inverted-T scar technique and the other two patients underwent therapeutic mammoplasty using a superior pedicle with the vertical scar mammoplasty technique as they had a normal-sized breast with first-degree ptosis only.
Four patients with masses at the lower inner quadrant underwent therapeutic mammoplasty using a superior pedicle with the vertical scar mammoplasty technique.
Two patients with masses at the upper inner quadrant underwent skin-sparing mastectomy with breast reconstruction by the latissimus dorsi muscle (LD) flap as they had large-sized masses relative to the breast size.
Eight patients presented with masses at the retroareolar region. Three of these patients underwent skin-sparing mastectomy with breast reconstruction by an LD flap as they had large-sized masses relative to the breast size. Three patients underwent skin-sparing mastectomy with breast reconstruction by a transverse rectus abdominus myocutaneous flap as they had a small-sized breast and a thin trunk with small-sized LD muscle. The last two patients underwent therapeutic mammoplasty using the Melon slice technique as the patient refused to undergo any complex plastic techniques.
In terms of complications, there were three significant ones.
One case of skin necrosis in the skin envelope was observed after skin-sparing mastectomy with a transverse rectus abdominus myocutaneous flap; it was mild and was managed conservatively. Two cases of traumatic fat necrosis were encountered with the inverted-T technique, and these were also managed conservatively.
| Discussion|| |
Breast carcinoma is a major health issue in modern society. The National Cancer Institute estimates that 12.7% of women born today will be diagnosed with breast carcinoma during the course of their lifetime. Breast carcinoma can impact patients psychologically as well as organically, which can manifest as postmastectomy depression, increased anxiety, shame, and occasional thoughts of suicide .
OPS has emerged as a new approach to allow wide excision for BCS without compromising the natural shape of the breast .
There are three factors to consider when selecting patients who may benefit from an oncoplastic approach for BCS. The two factors already recognized as major indications for OPS are excision volume and tumor location. The third additional factor is glandular density. When taken into consideration together, these three factors comprise a sound guideline for determining when and what type of OPS to perform and, more importantly, to reduce the guesswork in performing BCS .
Chan et al.  observed in his study on 162 patients that younger women with a small-size breast would benefit from a level I procedure with a simple oncoplastic technique with volume displacement, with high patient satisfaction and a favorable cosmetic outcome. Clough et al.  observed in his study on 100 patients that women with a large ptotic breast benefited from a level II procedure as they had a smaller, higher, and rounder breast, with high patient satisfaction and favorable cosmetic outcome.
This study of 35 patients showed that younger women with a small-size breast benefited from a level I procedure (seven patients, 17.5% of all patients) and women with a large ptotic breast were more satisfied with a level II procedure (33 patients, 82.5% of all patients).
In terms of the technique used for reconstruction, Vallejo da Silva and colleagues [8,9] found in his study of 30 cases that in the tumors of the upper quadrants, the inferior gland flaps (inferior pedicle) are the most useful for replacing the glandular defects and, at the same time, they reshape the breast in an easy and predictable manner; and our results are in agreement with theirs as 14 patients (35% of all patients) underwent a level II procedure with a local parenchymal flap as the inferior pedicle with very good results in terms of breast shape, protrusion, size, and symmetry.
The inverted-T mammoplasty technique is preferable for different quadrants of the breast, with excellent cosmetic results for the upper pole, but the implementation of the same reduction mammoplasty pattern for tumors in all locations of the breast has significant limitations. Advancement of distant breast tissue to fill the defect may lead to complications because of tissue necrosis .
Vertical scar mammoplasty is ideal for inferior pole tumors, which can be widely excised within the boundaries of the standard markings. The NAC is raised on a superior or a superomedial pedicle, with very good cosmetic results [8,9].
The so-called receptor breast, small glands that do not have spare tissue to donate, are better handled with the use of distant flaps, LD being more useful among these. In addition to the simplicity of its execution, it can be used with or without skin .
In our study, an LD flap was used for reconstruction of the breast after skin-sparing mastectomy in six patients; four of these patients had a retroareolar mass and two patients had a mass at the upper inner quadrant, but all had a small-size breast, with good results in terms of patient satisfaction and breast symmetrization.
In the study carried out by Chan and colleagues in 2010, there was no difference in patient satisfaction with cosmetic outcome when different tumor locations or tumor distance from nipple were taken into account. Patient satisfaction remained high enough with both when the tumor was medially located and when the tumor was close to the nipple as with laterally located masses away from the nipple .
The surgical complication rate of 7.5% in the present study is comparable with those in other similar studies. Losken reported a surgical complication in 30%, Caruso in 9.8%, McCulley and Macmillan in 16%, and Vallejo da Silva and colleagues in 13.3% of patients: hematoma, NAC necrosis, and wound infection .
| Conclusion|| |
Partnerships between breast and plastic surgeons should be encouraged, and indeed two surgeon teams can be very time efficient. Once a working and successful team is established, more complex cases can be easily dealt with.
| Acknowledgements|| |
Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]