The progressive evolution of conservative approaches to breast cancer has been influenced over the years by the development of advanced screening programs that have allowed for early diagnosis of the tumors and increasing use of preoperative chemotherapy in patients with locally advanced breast cancer. Mainly, four steps characterize the conservative approach: breast conservation, axillary lymph node conservative dissection (e.g., sentinel node biopsy), minimal breast irradiation, and breast reconstruction. This great revolution began in the early 1970s with the advent of quadrantectomy procedure which has led to the actual multidisciplinary approach with which breast lesions are managed in breast nits by dedicated teams composed of breast surgeon, plastic surgeon, radiologist, pathologist, clinical oncologist, physiotherapist, psychooncologist, and clinical geneticist who synergically discuss and choose the appropriate treatment to individual patients.^1–3

Oncoplastic surgery represents the combined approach of plastic surgery procedures with breast-conservation therapy to achieve better cosmetic results without compromising complete tumor extirpation.^4–6 The purpose of this chapter is to expose many of the principles, concepts, and techniques of oncoplastic breast surgery.

The approach to repair immediate defects following breast conservative surgery varies by the volume of resection and tumor location. Different authors, to facilitate management and predict postoperative outcomes, have defined a classification of post–breast conservation surgery (BCS) defects. Clough et al⁷ proposed a bilevel classification system based on volume of breast tissue excised to practical guide of oncoplastic surgery techniques: type 1 defects less than 20% of breast volume excision, possibly managed by breast surgeons without specific training in plastic surgery; type 2 defects of 20% to 50% of breast volume excision, requiring a two-team approach with both breast and plastic surgeons, or breast surgeons with specific training in oncoplastic surgery. The location of tumor is a second most common way to classify post-BCS defects. Even if some authors have assigned numbers to specific areas of the mammary gland,⁸ traditionally the breast is divided into four quadrants: superolateral, superomedial, inferolateral, and inferomedial. Among these areas, specific quadrants are more favorable locations for good aesthetic results, while other quadrants are at the higher risk of deformity following BCS. Excisions of superolateral quadrant of the breast are less likely affected by poor aesthetic outcomes, while resections of tissue from superomedial quadrant often expose to major risk of breast deformity. However, in relative terms, location and size of tumor excision must always be compared to the size of the breast in order to correctly evaluate the final cosmetic impact of BCS. Appropriately, the larger the breast, the more easily it tolerates larger resections; small to medium breasts show lower compliance to accommodate increasing resection volumes than larger breasts. If immediate reconstruction is not performed in cases with unfavorable locations, different breast deformities will finally impair the aesthetic outcome. Berrino et al⁹ classified post-BCS deformities into four types: type 1, displacement of the nipple-areola complex; type 2, localized deficiency of parenchyma and/or skin; type 3, generalized breast contracture with no localized defects; type 4, severe damage with heavily scarred parenchyma and skin. At Plastic Surgery Unit of Sant’Andrea Hospital of Rome, our preference is to perform immediate reconstruction following BCS for the more difficult scenario that delayed reconstruction presents due to reduced breast volume, scarring, irradiated tissue, distorted anatomy, and altered vascularity.

Anatomic Boundaries and Structures

The breast is a secretory gland, located on the anterior thorax extending superiorly to the second rib, inferiorly to the sixth costal cartilage, medially to the sternal edge, and laterally to the mid-axillary line. Its form, volume, shape, and contents differ with age, making precise characterization impossible. It is made up of three major structures: skin, subcutaneous tissue, and breast parenchyma. It is divided into 15 to 20 lobes that converge at the nipple in a radial way. The lobes consist of 20 to 40 lobules and in turn are made up of 10 to 100 tubulosaccular secretory units that produce milk for lactation. Superficial pectoral fascia envelops the breast, while its posterior face lies on the deep pectoral fascia. Cooper suspensory ligaments are fibrous structures that provide support for the breast connecting the two fascial layers.

Blood Supply

Arterial supply of the mammary gland forms a rich anastomotic plexus. With considerable variation, it is supplied with blood from three sources: the internal thoracic artery, the branches of the axillary artery, and the intercostal arteries. Perforating branches arising from the internal thoracic artery pass through the intercostal muscles of the first six interspaces and the pectoralis major muscle supplying the medial half of the breast and surrounding skin. Perforating arteries pierce the thoracic wall adjacent to the sternal edge in the first to fourth intercostal spaces. The first and the second of these perforating branches are the largest. About 2 cm lateral to the main perforating vessel, a second perforating branch is usually found. These arteries go down laterally toward the nipple–areolar complex (NAC) making the main arterial supply derived above the level of the nipple.^10–12 As a consequence, radial incisions in the upper half of the breast are less likely to injure the major arterial supply than are transverse incisions.

Axillary branches that contribute to vascular supply to the lateral portion of the breast include the supreme thoracic artery, the lateral thoracic artery, the pectoral branches of the thoracoacromial artery, and the subscapular artery. Branches of the third, fourth, and fifth intercostal arteries also provide a supply to the lateral half of the breast. In most breasts, there are free anastomoses between the three main sources while occasionally they remain separate.

Lymphatic Drainage

The primary pathway of lymphatic drainage of the mammary gland is through lymph nodes in the axilla. About three-quarters of all lymphatic drainage of the breast passes to the axillary nodes; the remainder drains into the internal mammary, supraclavicular, transpectorally toward Rotter’s nodes.¹³

Innervation

Cooper¹⁴ in 1840 first described the nerves supplying the breast as arising from the second to the sixth intercostal nerves and two additional mammary branches from the fourth lateral cutaneous nerve.¹⁴ In breast surgery, it is important to remember that the nerve supply to the NAC is attributable to the anterior ramus of the lateral cutaneous branch of the fourth thoracic (T4) or intercostal nerve. Whenever possible, reconstructive and aesthetic procedures should preserve such important branch to the NAC, thereby leaving the patient with a sensitive and responsive nipple maintaining one of the main aspects of her femininity.^15–18

Breast-conservation surgery is considered a safe and reliable option for most patients with early breast cancer. Five-year survival of BCS with radiation therapy in patients with stage I and II breast cancer is indeed not statistically different if compared with mastectomy alone.^19,20 Lumpectomy and quadrantectomy are habitually considered BCS techniques; while most defects can be managed with primary closure, aesthetic outcomes may not be optimal due to asymmetry, retraction, and volume changes in the breast. Therefore, oncoplastic procedures may be required, taking into account several factors.^21–23

Radiation Therapy and Timing of Reconstruction

Breast reconstruction can be achieved immediately, combining oncoplastic techniques to BCS, or delayed after oncologic excision. An immediate oncoplastic approach combined with BCS has demonstrated to be as safe as mastectomy in tumors less than 2 cm and, allowing for a wider tumor excision hence potentially reducing the incidence of margin involvement, can possibly be considered safer than BCS alone.

The timing of the reconstruction may be influenced by the eventual need for adjuvant radiation therapy. Indeed, irradiation is broadly considered the most significant factor affecting aesthetic results, as it may cause some degree of fibrosis and shrinkage of the tissues.^24–27 Some authors observed that immediate oncoplastic reconstruction in patients scheduled for adjuvant radiation therapy could be advantageous in cases of volume displacement techniques, according to the observation that large-volume breasts present more radiation-related complications than small-volume breasts.^6,7,28 In addition, the utilization of a distant flap should be avoided in such cases in which the effects of postoperative radiotherapy on the reconstruction are not predictable and may endanger the results.

In delayed cases, instead, reconstruction of irradiated breasts may be better achieved with autologous, nonirradiated flaps.^6,29

Not only radiation therapy can affect cosmetic outcomes of the reconstruction and increase postoperative complications, but immediate breast reconstruction itself may also impair delivery and efficacy of radiotherapy.^30–32

Tumor Location and Breast Size

The position and size of the tumor and the volume of patient’s breasts have a relevant importance in determining the correct approach and the achievable aesthetic results. Particularly, the tumor/breast volume ratio is more significant than the absolute size of BCS resection, and several classifications have been developed proposing different approaches to different kinds of breast deformities.^{5,6,9,33–35}

Reduction/remodeling techniques allow for immediate correction of the defect together with safe resection of the cancer. If resection of the skin laying outside the boundaries of the Wise pattern and especially on upper quadrants is requested, the pattern can be modified as to incorporate the resected skin still achieving a safe and satisfactory result.^6,36–41

While a wide tumor resection in larger breasts can be approached with local tissue rearrangement techniques, many patients presenting with smaller breasts and large tumor/breast ratio are not candidates for immediate repair with remodeling techniques because the remaining breast tissue is inadequate to be rearranged and requires reconstruction with local or distant flaps (e.g., latissimus dorsi (LD), thoracodorsal artery perforator (TDAP), deep inferior epigastric perforator (DIEP)). However, considering the significant number of patients reporting positive postoperative tumor margins after immediate BCS⁴² and abdominal flaps being the gold standard in breast reconstruction, it is advisable not to use such flaps in immediate reconstructions after BCS and to preserve them for possible reconstruction after eventual total mastectomy.^6,20,43–45 Another important factor in planning the surgical procedure for breast reconstruction is the involvement of the NAC and the surrounding skin, which may lead to contour deformities and distortion of the nipple position. Such deformities will develop and will be certainly worsened by irradiation unless both skin and parenchyma are adjusted.

Patient preparation involves a detailed anamnesis, with particular attention to cardiovascular and respiratory pathologies and risk factors for delayed wound healing such as diabetes, obesity, and smoking.⁴⁶ Moreover, attention should be paid to accurately identify the risk for deep vein thrombosis and pulmonary embolism.⁴⁷ Patient’s clinical records should be meticulously controlled, including important information regarding radiological assessment (mammography, breast MRI, etc.), laboratory tests, and biopsy histological results. All patients should sign an informed consent.

Identification of Risk Factors

During the preliminary visit, the surgeon should decide, based on the location, size, and type of tumor, the appropriate oncoplastic technique for the patient. Patient’s age, breast size, tumor/breast ratio, and the need of adjuvant radiotherapy are important when deciding which technique to apply. The challenge for the surgeon is to assure oncologic safety and offer good aesthetic results. Moreover, if radiotherapy risk is high and since the risk for positive margins after BCS is not low, the possibility to choose a more radical approach (total mastectomy) and complete reconstruction with autologous tissues should be considered.⁴⁸

Key Points in Surgical Procedures

In case of local tissue remodeling techniques, attention should be paid so as to retain NAC vascularization as intact, and predict and correct any aesthetic defects and asymmetry. When a distant flap technique is chosen, the type of flap to be used should be decided based on patient’s characteristics including the availability of donor tissues, and preoperative breast shape and volume. Resection and reconstructive preoperative markings are done with patient in standing and supine positions and include the midline, midclavicular point, inframammary fold, and the breast meridian. Finally, after accurate preoperative assessment of breast volumes possibly performed with the assistance of reliable tools (i.e., 3D-MRI, BREAST-V App for iOS and Android devices²²), the contralateral breast markings are performed for breast reduction or mastopexy procedure if required.

Operative

Conservative surgical procedures of the breast can be included into two basic categories: (1) volume replacement procedures, which imports volume from local or distant areas to replace the amount of tissue resected; and (2) volume displacement techniques, which uses local breast tissue by transposing dermoglandular flaps to restore the defect site. The choice of an appropriate procedure depends on variable factors, such as extension of resected tissue, tumor location, surgeon attitude and experience, and timing of surgery.^4,9,20,33 Volume replacement techniques usually restore shape and volume of the breast, obtaining good and symmetric aesthetic outcomes. They are particularly useful for women who prefer to avoid volume loss and contralateral symmetrization, either for immediate or for delayed reconstruction, representing the method of choice for correcting secondary deformity following radiation therapy. However, these procedures require extra operative time with risk of donor-site complications, flap necrosis, and longer hospital stay. Instead, volume displacement techniques can reduce scars on the breast and donor-site morbidity, while requiring less operative time. These procedures can be optimally applied to hypertrophic-breasted patients, being mostly represented by therapeutic mammaplasty procedures. Despite these advantages, dermoglandular flaps are less reliable in radiated breasts and can be impaired by necrosis, and contralateral symmetrization is usually required to restore breast symmetry.

VOLUME REPLACEMENT TECHNIQUES

Volume replacement techniques should be applied when resections of more than 20% of breast volume are indicated and the amount of residual breast tissue is not adequate for tissue rearrangement. Those cases are typically affected by multifocal disease where wide tissue resections from central, medial, and inferior locations often result in significant and unpleasant breast deformity.^4–6,8 Even if these procedures can be performed as delayed reconstructions, the gold standard is to restore the tissue defect immediately. A “two-team” approach involving breast and plastic surgeons make easier planning of both resection and reconstructive steps that can be performed as a one-stage procedure, reducing the risk of complications while enhancing final cosmetic result. Regional and distant flaps are used as volume replacement sources in BCS, as autologous flaps provide similar tissue in consistency and texture to the breast, remaining stable over time with comparable static and dynamic symmetry to the healthy contralateral breast with no need for surgical symmetrization. Dissimilarly, the use of implants for correction of partial mastectomy defects is strongly discouraged, as implant-related complications more likely occur following breast radiation with poor aesthetic outcomes and thoracic pain. Among regional flaps, the LD and TDAP flaps are mainly used for lateral and superior defects, and in small breasts where the resection can cause distortion of breast contour. Even if rare thoracodorsal pedicle injuries during axillary lymph node dissection are described in the literature,⁴⁹ LD flap is technically easier than TDAP flap, being reliable and constant in its anatomy and possibly harvested with a skin paddle to provide additional volume and cutaneous tissue. During its harvesting, LD flap should be denervated as proximal as possible to avoid undesirable postoperative effects such as jumping breast, dynamic distortion due to voluntary contraction.⁵⁰ The TDAP flap represents the evolution of the LD flap, as no muscle or a small part of the muscle is harvested. It is based on cutaneous perforators from the thoracodorsal artery. Sparing the muscle reduces donor site morbidity even if advanced technical skills are required for perforator’s dissection.⁵¹ The intercostal artery perforator (ICAP) flap is developed from the thoracoepigastric flap. It is based on perforators from intercostal vessels, which are dissected to their origin sparing the thoracodorsal pedicle. They are particularly helpful to reconstruct lateral pole defects and showed also possible application in patients with massive weight loss for autologous breast augmentation based on the side-rolls.