C H A P T E R

5
Oncoplastic Breast
Conservation Surgery
Melvin J Silverstein
Introduction
Oncoplastic breast conservation surgery combines oncologic principles with
plastic surgical techniques. But it is much more than a combination of two
disciplines it is a philosophy that requires vision, passion, a knowledge of
anatomy, and an appreciation and understanding of aesthetics, symmetry
and breast function. The oncoplastic surgeon must be constantly thinking
How can I remove this cancer with large margins of normal tissue while at
the same time making the patient look as good or better than she looks now?
(Box 5.1).
The ultimate oncoplastic achievement would be to convert what would
normally be an oncologic and/or cosmetic failure using standard techniques
into both an oncologic and cosmetic success. Avoiding mastectomy when it
seems inevitable and ending with an excellent cosmetic result is one way to
achieve that goal. The following case demonstrates just such a scenario.
A 58-year-old female presented with recurrent ductal carcinoma in situ
(DCIS) in the left lower inner quadrant of the breast. A previous excision had
been performed 2 years earlier obtaining a minimal margin of clearance. The
left breast was severely deformed following this procedure (Fig. 5.1). Follow-
ing the local recurrence, she was told by multiple surgeons that mastectomy
was the only option. After re-evaluation, including digital mammography,
ultrasound, and magnetic resonance imaging (MRI), it was determined that
the only disease present was at the edge of the previous excision. A left wire-
directed segmental resection using a reduction incision with a contralateral
(right) reduction was performed (Figs 5.25.5). This procedure excised the
residual DCIS with a margin of excision that exceeded 10 mm in all directions.
The cosmetic appearance was much improved and was persistent 4 years later
(Fig. 5.6).
The history of oncoplastic breast conservation surgery
in the United States
There is little written about the origins of oncoplastic breast conservation
surgery in the United States. We began developing oncoplastic techniques in
the early 1980s by accident.
The rst free-standing Breast Center in the United States was founded in
Van Nuys, California, in 1979.
1,2
Our group consisted of plastic surgeons,
oncologic surgeons, medical oncologists, radiologists, radiation oncologists,
and a psychiatrist. In the early years, due to stafng issues it was not uncom-
mon for an oncologic surgeon to assist a plastic surgeon with a reduction and
for a plastic surgeon to assist an oncologic surgeon with a mastectomy or

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Oncoplastic breast conservation surgery
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48
Figure 5.1 A 58-year-old white female
presented with recurrent DCIS in the left lower
inner quadrant. She had been excised twice, 2
years earlier. Minimal clear margins were
achieved but the left breast was severely
deformed. She was advised to have a left
mastectomy by multiple surgeons.
Figure 5.2 The plan for excision using a
reduction pattern. Two wires are in place,
bracketing the calcications marking the
recurrence.

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Figure 5.3 The lower inner quadrant has been
excised.
Figure 5.4 Specimen radiograph shows the
excised calcications with widely clear margins
radiographically.
The history of oncoplastic breast conservation surgery in the United States

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Oncoplastic breast conservation surgery
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Figure 5.5 The patient is 5 days postoperative
with drains in place.
Figure 5.6 The patient is 4 years postoperative
without recurrence. The cosmetic result has
been maintained.

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Oncoplastic resection
51
axillary dissection. Because of this, both disciplines
(plastic and oncologic surgery) became quite familiar
with what the other discipline could accomplish.
Our rst true oncoplastic case occurred in 1982. A
young pregnant woman was referred with a biopsy-proven
giant broadenoma of pregnancy (Fig. 5.7). We waited
until she delivered her baby and then a few weeks later a
team of one oncologic and one plastic surgeon removed
the benign tumor using a reduction approach and simul-
taneously reduced the opposite side (Fig. 5.8). Owing to
the large size of the tumor (about 20 cm), the nipples
ended up a bit too high, but overall it was an outstanding
oncoplastic result (Fig. 5.9).
Shortly thereafter, one of our plastic surgeons did a
reduction by removing a large segment of superior breast
tissue in an older woman who did not want a standard
reduction. When asked what he called this strange inci-
sion, he answered Batwing because it looks like the
Batman symbol. At the same time, we were learning
more about the importance of widely clear margins,
something that had not been appreciated prior to the mid
1980s. We quickly adopted the batwing for women with
breast cancer in the upper half of a larger breast that could
benet from lifting of the nippleareola complex (NAC).
The rest, as they say, is history. We rapidly added more
and varied excisions to our oncoplastic armamentarium,
many of which will be illustrated below.
Oncoplastic resection
When treating a patient with biopsy-proven breast cancer,
the non-oncoplastic approach would be to make a small
cosmetically placed curvilinear incision over the area to
be removed (Fig. 5.10). This would typically include no
skin and a relatively small piece of breast tissue. The
denition of a clear margin was based on non-transection
of the tumor. Complete and sequential tissue processing
is not usually performed and postoperative radiation
therapy is the usual protocol.
But the trend is changing. During the last 25 years, my
colleagues and I have developed a comprehensive multi-
disciplinary oncoplastic approach for the excision of
breast cancer.
35
It requires surgical coordination with a
pathologist, a radiologist and, often, a plastic surgeon.
Oncoplastic surgery combines sound surgical oncologic
principles with plastic surgical techniques. Coordination
of the two surgical disciplines may help to avoid poor
cosmetic results after wide excision and may increase the
number of women who can be treated with breast-
conserving surgery by allowing larger breast excisions
with more acceptable cosmetic results. These techniques
are applicable to patients with both noninvasive (DCIS)
and invasive breast cancer.
Oncoplastic resection is a therapeutic procedure, not a
breast biopsy. It is performed on patients with a proven
diagnosis of breast cancer. This approach was strongly
supported by the 2005 Consensus Conference on Image-
Detected Breast Cancer.
6
An important goal in caring for
a woman with breast cancer is to go to the operating
room a single time and to perform a denitive procedure
Box 5.1
The goals of oncoplastic breast conservation surgery include:
1. Complete removal of the lesion
2. Clear margins the larger the better
3. Good to excellent cosmetic result
4. Going to the operating room one time to perform the
denitive procedure
Figure 5.7 A 27-year-old pregnant patient with
a biopsy-proven giant broadenoma of
pregnancy.

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Oncoplastic breast conservation surgery
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Figure 5.8 The tumor was excised and
measures 20 cm.
Figure 5.9 Redundant skin was excised using a reduction pattern and the
contralateral breast reduced. The patient is pictured here 7 years
postoperative.
that does not require re-operation. Whenever possible,
the initial breast biopsy should be made using a mini-
mally invasive percutaneous technique.
6
This usually pro-
vides ample tissue for diagnosis.
When excising breast cancer, the surgeon faces two
opposing goals: clear margins versus an acceptable cos-
metic result. From an oncologic point of view, the largest
specimen possible should be removed in an attempt to
achieve the widest possible margins. From a cosmetic
point of view, a much smaller amount of tissue should
be removed in order to achieve the best possible cosmetic
result. The surgeon must tread a ne line as he or she tries
to satisfy two masters. The rst attempt to remove a can-
cerous lesion is critical. The rst excision offers the best
chance to remove the entire lesion in one piece, evaluate
its extent and margin status, and to achieve the best pos-
sible cosmetic result.
Currently, as many as 4050% of new breast cancer
cases are discovered by modern state-of-the-art imaging
(mostly mammography) and, intraoperatively, are grossly
both non-palpable and non-visualizable. Under these
circumstances, the surgeon essentially operates blindly.
Multiple hooked wires can help dene the extent of the
lesion radiographically. Using bracketing wires, the
surgeon should make an attempt to excise the entire
lesion within a single piece of tissue. This often will
include overlying skin as well as pectoral fascia (Figs 5.11
and 5.12). The tissue should be precisely oriented for the
pathologist.
If the specimen is removed in multiple pieces rather
than a single piece, there is little likelihood of evaluating
margins and size accurately. Figure 5.13 shows an excision

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Oncoplastic resection
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Figure 5.10 A patient with biopsy-proven
breast cancer. The cancer has been excised
through a small cosmetically placed curvilinear
incision over the lesion. No skin has been
removed. Until now, this has been the standard
way of excising breast cancer.
Figure 5.11 An excised, color-coded specimen
(from skin to fascia) with guide wires in place.

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Oncoplastic breast conservation surgery
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Figure 5.12 Intraoperative specimen radiography showing skin, bracketing
wires, clip marking the biopsy cavity, and the specimen oriented using
Margin Map (Beekley, Inc, Bristol, CT).
Figure 5.13 An excision specimen with four
additional pieces of tissue that allegedly
represent the new margins. The additional
pieces are too small and do not reect the true
margins of the original specimen. If one makes a
judgment on margin clearance based on these
small additional pieces, that judgment might
very well be wrong.
specimen with four additional pieces that allegedly rep-
resent the new margins. The additional pieces are too
small and do not reect the true margins of the original
specimen. If one makes a judgment on margin clearance
based on these small additional pieces, that judgment
might very well be incorrect.
Oncoplastic steps
There are several important steps to a proper oncoplastic
operation.
1. Preoperative planning (includes surgeon and
radiologist) and should include:
(a) mammography (preferably digital);
(b) breast ultrasound (at a minimum, the involved
quadrant but preferably both breasts);
(c) axillary ultrasound and needle biopsy, if
indicated;
(d) breast MRI;
(e) an evaluation of the size of the cancer versus
the size of the breast;
(f) detailed family history and genetic counseling,
if appropriate;
(g) integration of patient wishes.
2. Excision of lesion in one piece (often includes skin,
breast segment and pectoral fascia).
3. Reshape the breast.
4. Symmetry.

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Figure 5.14 Preoperative markings for a patient
with a lesion in the 9:00 position of the right
breast. Three wheals of isosulfan blue dye have
been injected intradermally for sentinel node
localization. The sentinel node incision has been
marked.
Preoperative planning requires discussion between the
oncoplastic surgeon and the radiologist. All of the preop-
erative tests must be evaluated and integrated along with
information about the pathologic subtype of the lesion.
Is it an invasive lobular cancer that might be larger than
expected? Is there a signicant DCIS component? Does
this patient want symmetry? If yes, should it be done
during the same operative procedure or as a delayed pro-
cedure? And so on.
Oncoplastic excisions
There are a wide range of oncoplastic incisions. These
include:
1. Upper pole:
(a) crescent;
(b) batwing;
(c) hemi-batwing;
2. Lower pole:
(a) triangle;
(b) trapezoid;
(c) reduction;
(d) inframammary (hidden scar) (does not remove
skin);
3. Any segment of the breast:
(a) radial ellipse (most versatile);
(b) circumareola with advancement ap (does not
remove skin);
(c) donut mastopexy.
Some of these excisions are illustrated below, using
selected cases.
Radial ellipse
Figure 5.14 shows the preoperative markings for a
patient with a lesion in the 9:00 position of the right
breast. Three wheals of isosulfan blue dye have been
injected intradermally for sentinel node localization.
(Do not use intradermal injections unless skin is going
to be removed. It will tattoo the skin.) The entire lateral
segment down to and including the pectoralis major
fascia was removed and the surrounding tissue under-
mined (Fig. 5.15). A sentinel node biopsy was per-
formed. The remaining tissue was then advanced with
deep sutures and the breast remodeled (Fig. 5.16).
Figures 5.175.20 show the cosmetic results of radial
elliptical excisions.
Following segmental resections, all women will have
drains inserted that will remain for 2448 hours (Fig.
5.19). All incisions are closed in a layered fashion. The
cosmetic result should be constantly monitored and reap-
praised during wound closure. It is prudent to elevate the
head of the operating table to re-evaluate the cosmetic
result and symmetry.
A radial segmental resection may alter the size and
shape of the breast but good cosmetic results are usually
achieved (Figs 5.175.20). A radial excision generally will
not displace the NAC even though overlying skin is
removed. If it does, the nipple can be re-centralized by
excising a crescent-shaped piece of skin (see crescent exci-
sion below).
In contrast to the old axiom the seroma is your friend,
when doing oncoplastic breast surgery the exact opposite
is true. It is best if the wound heals with as little seroma
and blood as possible. Regardless of how the wound is
Oncoplastic excisions

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Oncoplastic breast conservation surgery
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Figure 5.15 The entire lateral segment down to
and including the pectoralis major fascia has
been removed and the surrounding tissue
undermined. Clips are used to mark the superior,
inferior, medial, lateral and deep margins of the
excision. A sentinel node biopsy has been
performed.
Figure 5.16 The remaining tissue has been
advanced with deep sutures and the breast
remodeled. The skin has been clipped together
prior to suturing and the breast has been
drained through a small incision in the
inframammary sulcus.
Nahabedian_ch05_main.indd 56 1/13/2009 4:32:11 PM
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