Oncoplastic surgery (OPS) is a new approach which combines surgical excision of breast cancers with plastic surgery techniques to achieve an aesthetic outcome. It allows resection of up to 50% of breast volume without compromising oncological outcome. A recent meta-analysis published in the American Journal of Surgery (AJS) showed equivalent disease recurrence rates between OPS and traditional breast conserving surgery (BCS). Patients who may have needed a mastectomy in the past can now have breast conserving surgery if appropriate. Many oncoplastic breast surgeons are also trained in breast reconstruction. This is a review of some commonly used oncoplastic surgical techniques and recent advances in breast reconstruction.
What is Therapeutic Mammaplasty?
Patients with mammary hypertrophy often suffer from debilitating shoulder and neck pain. Large-sized breasts have an increased risk of radiotherapy complications such as fibrosis and pigmentation. It would be difficult to achieve symmetry in reconstruction of large-sized breasts and a reduction in breast volume also reduces breast cancer risk. A therapeutic mammaplasty is a procedure whereby the breast tumour is removed during a breast reduction procedure. A contralateral operation can also be performed to achieve symmetry. Various surgical techniques are used, with the wise-pattern incision being most common.
This patient had a wise-pattern incision therapeutic mammaplasty for a tumour in the upp outer breast quadrant
What are Perforator Flaps?
Tissue from the upper abdominal or lateral chest wall can also be used to replace breast volume in “volume replacement” techniques such as pedicled perforator flaps. A perforator flap is a flap of skin and subcutaneous fat perfused by an isolated artery/vein that is rotated into the defect left after breast cancer excision. It allows for resection of larger volumes of breast tissue and minimizes the need for mastectomy.
This is an example of a thoracodorsal or TDAP flap which can be used to fill defects in the outer breast
What is Lipofilling?
Lipofilling is also known as breast fat transfer augmentation or autologous fat grafting. It involves harvesting excess fat from an area with a prominence, like the lower abdomen or outer thighs. This fat can be processed then injected into the breasts. Multiple procedures may sometimes be required to achieve desired breast volume. Lipofilling can be used to correct deficiencies in breast volume post lumpectomy and also used to augment breast implants. From Nov 2021, lipofilling will attract a medicare rebate.
What is Implant Reconstruction?
Implant reconstruction is the most commonly performed breast reconstruction procedure. Traditionally it has been a 2-stage procedure with insertion of a tissue expander at the initial procedure followed by a second operation to changeover to the definitive implant when the tissue expander is fully expanded. Nowadays, there are 1-stage procedures (Direct to implant reconstruction or DTI) where the definitive implant is inserted in a submuscular plane with an acellular dermal matrix (ADM) or synthetic mesh to provide inferior pole coverage. The latest innovation in breast reconstruction is that of pre-pectoral reconstruction where the implant is placed in front of pectoralis major muscle (instead of the traditional subpectoral pocket). It reduces postoperative pain and animation deformity (distortion of the breast with activities that cause contraction of chest wall muscles).
This patient had a nipple-sparing mastectomy and DTI reconstruction with veritas ADM.
