The surgical management of breast cancer has changed greatly since the late 1880s when Halsted started utilizing radical mastectomy for breast cancer treatment.¹ Although this approach obtained local control, it resulted in horrible deformities and a constant physical reminder of the cancer operation with numerous psychological impacts. It was not until the advent of screening mammograms that the disease could be discovered in earlier stages and less extreme surgical interventions could be established.

In the 1970s several studies showed that portions of the breast could be preserved and that survival was improved using radiation as an adjuvant therapy (breast conservation therapy or BCT). BCT compared to total mastectomy proved to hold equivalent disease-free, distant disease-free, and overall 5-year survival.¹ With numerous other studies demonstrating the oncological safety of BCT, breast conservation has become a popular and, in many centers, the preferred surgical treatment of breast cancer.^2–6 However, the aesthetic outcomes after a lumpectomy or partial mastectomy and radiation are unpredictable and frequently unacceptable, leaving 20% to 30% of patients with residual deformities.^7,8 Figure 150-1 is an example of a patient who had a disfiguring result after being treated with BCT for a lower pole lesion. As many as 25% to 50% of women who undergo BCT have been reported to be dissatisfied with their aesthetic outcome.^7–10

Despite the risks of poor aesthetic outcomes, many patients and surgeons choose the opportunity to preserve one’s breast. To counteract the potential disfigurement of BCT while providing oncologically successful outcomes in BCT, breast remodeling techniques are being developed and refined. In 2000, Werner Audretsch coined the term “Oncoplastic Surgery,” which appropriately combined the aspects of the oncological resection of the tumor and plastic surgery reconstruction.^1,11 Oncoplastic surgery can also be referred to as partial mastectomy reconstruction. These techniques combine the principles of proper oncologic resection with the tenets of aesthetic breast surgery.¹² Oncoplastic surgery is now an option that should be offered to women undergoing BCT to optimize their aesthetic outcomes.

Utilizing the skillset required in breast reductions and mastopexy, oncoplastic procedures help to reduce the deforming effects of radiation therapy upon seroma cavities. At the same time, the remaining breast tissues can be recontoured with potential improvement in ptosis of the breast mound and skin. In addition to determining the oncological safety of breast conservation, patient selection and timing for the reconstruction are crucial for successful outcome. It is essential that early referral is made to the plastic surgeon to allow preoperative planning and, if feasible, to avoid performing the procedure in a delayed setting when complications are much higher.

There is no well-accepted classification system for defining lumpectomy defects and the necessary reconstructive algorithm. Several authors have attempted to create a step-wise approach but due to the high number of variables, lumpectomy defects are difficult to classify.^13,14

Generally the factors that are taken into consideration include the size of the breast, size of the tumor, tumor quadrant, proximity of the nipple, and timing of radiation therapy.

The breast is divided into five quadrants: upper outer quadrant, upper inner quadrant, lower outer quadrant, lower inner quadrant, and the central quadrant involving the nipple areola complex (NAC). The tumor location based on these quadrants can help guide the reconstructive options.

When considering oncoplastic surgery, the breast needs to be looked at in its separate parts: skin, parenchyma, and the nipple. The main goal of oncoplastic surgery is to rearrange the parenchyma in such a way as to prevent seroma/hematoma formation while restoring the natural shape of the breast. Understanding the vascular anatomy is essential when choosing a pedicle to perfuse the NAC and the parenchymal flaps to fill in the defect site after the lumpectomy.

The main arterial blood supply to the breast comes from the lateral thoracic artery, internal mammary perforators, and anterolateral intercostal perforators. There is additional arterial blood supply from perforators of the thoracoacromial and serratus anterior vessels. These provide a rich vascular supply and can be combined to utilize various vascular pedicles to the NAC via the superior, superiomedial, inferior, lateral, or the central mound.

In general, stage I and II cancer can be treated with BCT, but not every patient is a good candidate for oncoplastic reconstruction. Breast size versus tumor size is an important consideration.^4,5 Patients with smaller breasts are generally less ideal candidates for breast conservation alone due to poor cosmetic results. If patients have positive margins they will likely require a completion mastectomy, given the paucity of remaining breast tissues.⁴ Preoperative counseling is essential to ensure that the patients understand that if they do have positive margins, they will require a completion mastectomy for oncologic safety, and also for optimal functional and aesthetic outcomes.

Patients with moderate-to-large breasts generally have more favorable results compared to smaller breasted patients. Patients with D-cup breasts can frequently be reconstructed with oncoplastic techniques, even with larger tumors, with the expectation that they will end up smaller. However, a patient with a C-cup and smaller with a large tumor would likely benefit from having a mastectomy and immediate reconstruction as breast conservation given a larger tumor size, particularly in the lower half of the breast, can lend to a poor aesthetic end result.

Any contraindication to BCT is a contraindication to oncoplastic surgery. Oncologic safety should always be the primary goal. This is why a multidisciplinary team with general surgeons or breast/oncologic surgeon, plastic surgeons, radiation oncologists, and medical oncologists is so important to maintaining these priorities.