Resection of more than 15–20% of breast volume is likely to result in asymmetry and adverse cosmetic outcomes (◘ Figs. 19.1 and 19.2) as was elegantly shown by the Nottingham group [6] with patient satisfaction rates of over 90% if only 5% or less of breast volume was excised to only 25% satisfied once 20% of breast volume is lost. Whilst this may be addressed by the use of neoadjuvant systemic therapy in some cases, in others, the use of oncoplastic techniques will permit higher percentage volume loss with good cosmesis and better patient satisfaction by reshaping the breast to minimise indentation and deformity.

Some areas of the breast are more difficult to resect tissue from than others whilst maintaining good cosmesis. Areas of concern are medially located tumours where the scar or indentation may lie in the cleavage area and where there is less breast parenchymal volume and superiorly sited tumours for the same reason. Both sites may also result in nipple malposition due to scar retraction. Resection of inferiorly sited tumours may cause nipple malposition or a bird’s beak deformity. Centrally located tumours may necessitate loss of the nipple and, if resected as an ellipse, cause a flattened off breast shape. Oncoplastic techniques allow better cosmesis following resections in these areas. A disc of nipple skin may be imported to create a base for a nipple reconstruction for centrally located tumours.

This is a more controversial indication for oncoplastic surgery [7]. There is little good quality evidence at present in support of this, but for some women who have a strong preference for a conservative approach, oncoplastic operations may contribute to acceptable cosmetic results. Caution is needed in undertaking these procedures as these women will have had breast radiotherapy and may be at higher risk of wound healing problems and pedicle hypovascularity. The oncological safety of these procedures is also not supported by high-level evidence.

There is emerging evidence that BCT in multifocal (MF) disease is oncologically safe [8] but may result in a slightly inferior outcome compared with BCT in unifocal breast cancer. Patients in the MF group had higher 10-year LRR however (0.6% vs. 6.1%, p < 0.001). Oncoplastic surgery may be used to perform segmentectomy in MF disease confined to one segment with subsequent reshaping of the breast. In multicentric disease, oncoplastic techniques may also be used to resect more than one discrete area in different breast quadrants whilst retaining breast shape; however, there is little high-level evidence supporting the oncological appropriateness of this approach at present although a number of case series show acceptable oncological outcomes [9, 10].

For women with pre-existing macromastia, oncoplastic surgery offers an opportunity to simultaneously perform bilateral breast reduction which may have considerable appeal for these women. Macromastia may cause shoulder and back pain, embarrassment, difficulty finding suitable clothes and problems with skin infections in the inframammary fold. For many of these women, bilateral breast reduction may have many benefits by reducing these symptoms, but also, women with large breasts may be technically challenging for the radiation oncologist to administer whole breast radiotherapy to and may also suffer more significant post-radiotherapy complications such as breast oedema and skin reactions. The majority of studies of therapeutic mammoplasty for macromastia achieve low rates of incomplete excisions (approximately 10%) [11]. The wide local excision is usually performed prior to, and as a separate specimen to, the reduction procedure; although the tumour is in one of the primary areas where tissue is excised as part of the reduction, the tumour may be excised en bloc with the reduction sample, but care must be taken with margin marking and orientation. Rates of local recurrence with this technique are acceptable [11].

A large review including data on 276 patients [12] treated with bilateral reduction mammaplasty concluded that women with breast cancer and macromastia can obtain oncologically safe and cosmetically excellent outcomes.

A detailed review [13] of the evidence about therapeutic mammaplasty (TM) concluded that the oncological outcomes appear comparable to simple BCS. However, they note that no randomised controlled trials have been performed and the evidence in support of these techniques is all derived from case series and cohort studies.

Whilst rates of local recurrence are falling steadily following BCS, when it does occur, it is distressing and may result in the need for mastectomy [19] and a slightly higher late mortality disadvantage. Rates are falling due to better adjuvant radiotherapy and systemic therapy regimes, coupled with better surgery and margin assessment by pathologists. However, wider margins are not the answer. Indeed recent evidence and consensus are that a no-tumour at the inked margin is acceptable [20] and wider margins than necessary adversely affect cosmesis. Reoperation for cavity re-excision also has an adverse cosmetic impact as well as the financial costs and personal burden to the patient. There are a range of techniques to ensure that adequate margins are achieved which have proven efficacy in reducing rates of positive margins, but detailed review is out of the scope of this chapter. Excellent reviews are available [21]. Use of these techniques is very relevant in the oncoplastic setting where it may be technically challenging to go back to re-excise a positive margin.

The tumour cavity surgical margins after an oncoplastic procedure may be altered or transferred from the primary tumour location to other quadrants in the breast due to the use of local or distant displacement/replacement flaps as it happens in lateral or J-mammaplasty or reduction mammaplasty techniques such as inverted T mammoplasty. It is therefore imperative that the surgeon keeps detailed notes and diagrams of the operation and marks the original tumour bed with clips and ideally, in complex cases, uses some form of intraoperative margin assessment to minimise the need to go back for cavity shaves. Good communication with the radiation oncologists is essential when boost is planned as the skin scar may be some distance from the tumour bed and use of marker clips to the tumour bed, before rotation/translocation of the tissue, is essential [22, 23]. Placement of six clips has been proposed as optimal (medial, lateral, superior and inferior and to mark the deep fascia and subcutaneous margins).

Specimen orientation in breast surgery is of paramount importance. This is more so in oncoplastic surgery where the specimens may be irregular and asymmetric due to tissue removal for reshaping of the breast in addition to the actual tumour specimen. In oncoplastic cases, the tumour is more likely to be complex: large, multifocal or multicentric tumours or a known area of impalpable DCIS adjacent to an invasive focus, all of which must be communicated to the pathologist. Some cases may have followed primary systemic therapy, and only a marker clip may indicate the original primary location. The pathologist must be made aware of these preoperative tumour characteristics to avoid missing known second lesions at specimen «cut up» which is vital for margin assessment. Specimen X-rays should be sent to the pathology lab, especially in cases with complex tumour patterns (e.g. DCIS extent). This may help the pathologist to locate an impalpable tumour in the specimen. Each margin must be specifically marked and a detailed diagram provided showing which marker indicates which margin in the event that re-excision is needed. This will ensure that only the involved margin needs to be re-excised rather than the entire cavity re-excision [24]. Any intraoperative cavity shaves must be similarly identified and the new cut surface marked. Despite the importance of specimen marking and orientation, there is no universally accepted and implemented specimen marking system. A recent survey in the UK [25] of 117 breast units, nearly one quarter had no specimen orientation protocols. Among these, 11 were national breast screening units.

In general, the surgeon places sutures or clips during surgery, and inking of the specimen margins is done later by the pathologist in the pathology laboratory [26]. However, there may be better re-excision rates if the orientation is done intraoperatively with sutures and ink applied by the surgeon in the presence of the pathologist [27]. There are also commercially available orientation boards/holders to which specimens may be pinned and orientated in some detail to facilitate both cut up and specimen radiology [25, 28–30]. The most common protocol seems to be the method with different length/number of sutures or clips on three of the six margins [25, 31]. However, the suture-only method may not facilitate optimal specimen orientation by the pathologist, especially in small specimens (smaller than 20 cm³), whilst the presence of the skin or muscle on the specimen does not contribute to better orientation [30].

Knowing the exact position of the tumour bed has always been a great help for the radiation oncologists to deliver boost radiotherapy to breast patients. Although there are no data to support that more accurate tumour bed delineation will lead to improvement of local control, it may very well improve cosmetic outcomes [32].

Delineation of the resection cavity by seroma formation or location of the skin incision is relatively largely inaccurate [32]. The best marking method is the placement of metallic clips to the tumour cavity varying from one clip (not very accurate) to six clips for each margin of the cavity and up to 8–10 surgical clips [33] into the tumour bed after resection and before oncoplastic reconstruction. Detailed notes should be kept of clip placement.