Introduction

Oncoplastic surgery is a form of breast conservation surgery [1, 2]. Its fundamental definition includes an oncologic resection with a partial mastectomy, ipsilateral reconstruction using volume displacement, or volume replacement techniques with possible contralateral symmetry surgery when appropriate [1, 3, 4]. In the realm of surgical options in breast surgery, its place lies in between the minimalistic approach of the standard lumpectomy and the maximalist approach of the mastectomy [5]. In providing the breast surgeon with another breast conservation option, the interest in oncoplastic surgery in the USA has been increasing [6], and there has been more than a doubling in the rate of oncoplastic surgeries performed over the last decade [7]. The goal of this paper is to provide an evidence-based response to address the following questions: (1) What patient population is appropriate for oncoplastic surgery? (2) What are the benefits of oncoplastic surgery? (3) What are the basic technical considerations, approaches, and associated common complications in oncoplastic surgery? (4) Does oncoplastic surgery provide value as a breast surgery option?

Methods

For each of the above questions, the authors provide an answer supported by peer-reviewed published evidence. Additionally, the answer can often come from clinical practice experience. If at any time there is a lack of evidence, this will be declared noting that the recommendation is based on anecdotal personal experience only. The clinical experience is based on a 3-year (2015–2018) single-institution oncoplastic surgery database using various forms of oncoplastic breast conservation techniques in 100 consecutive patients with breast cancer. Institutional review board approval was obtained in using this database.

Results

Oncoplastic Surgery Classification

Table 1 presents a commonly accepted approach for classifying oncoplastic procedures according to the amount of breast tissue that must be removed, rearranged, or replaced [1]. This classification system groups Level 1 volume displacement oncoplastic surgery into operations that correct for less than 20% breast volume defects and Level 2 volume displacement oncoplastic surgery into operations that correct for breast volume defects 20 to 50%. Lastly, for the more uncommon breast volume defects of greater than 50%, this classification system recommends the use of volume replacement techniques using local-regional flaps or implants.

Table 1 Oncoplastic surgery classification
Full size table

What Patient Population Is Appropriate for Oncoplastic Surgery?

Given that oncoplastic surgery is a form of breast conservation, an eligible breast cancer patient cannot have contraindications to breast conservation and fundamentally needs to be open to the option of breast conservation. A history of prior breast radiation and other contraindications to adjuvant radiation are absolute contraindications for oncoplastic surgery. Likewise, inflammatory breast cancer is an absolute contraindication for oncoplastic surgery. Similarly, tumor volume burden relative to breast volume is another contraindication. By this, if a tumor involves the majority of the breast, a patient will likely be served better with a mastectomy and reconstruction when appropriate. Expanding on this reasoning, a breast cancer patient needs to have at least moderately sized breasts or at least Grade 2 ptosis to allow the surgeon to be able to use forms of tissue rearrangement common in oncoplastic surgery. It is extremely difficult to perform most types of oncoplastic surgery in women with small breasts and minimal nipple ptosis. Therefore, a breast cancer patient who wants and is eligible for breast conservation has moderate- to large-sized breasts (relative to tumor burden) or Grade 2 or 3 nipple ptosis should be provided the option for oncoplastic surgery. Possibly the greatest benefit from oncoplastic surgery is seen in those patients with both symptomatic macromastia and breast cancer. These patients have chronic back pain, neck pain, shoulder pain, bra strap indentation and grooving, and inframammary crease rashes in addition to their diagnosis of breast cancer. Performing a Level 2 volume displacement oncoplastic operation using reduction mammaplasty techniques to both remove large quantities of breast tissue result in lower positive margins and symptomatically happier patients [8••, 9•]. Lastly, those patients who have smaller breasts with minimal ptosis and relatively larger breast cancers who would prefer oncoplastic breast conservation options would be eligible for volume replacement options that include either local-regional flap options (such as the thoracodorsal artery perforator flap option) or implants [10,11,12].

What Are the Benefits of Oncoplastic Surgery?

There are several benefits of oncoplastic surgery when applied to the appropriate breast cancer patient. These benefits are best divided into oncologic and reconstructive outcomes.

Oncologic Benefits

One of the most important benefits that oncoplastic surgery provides is its ability to reduce positive margin rates compared to standard partial mastectomy. This makes common sense since the ability to remove larger areas of tissue (especially in Level 2 volume displacement designs using reduction mammaplasty techniques) allows for the entire removal of cancer relative to when removing smaller sections of breast tissue as seen in standard partial mastectomy. This logic has been shown to be true in the shaved margin literature where Chagpar et al. reduced their positive margin rate by half by removing more tissue with shaved margins [13]. Their positive margin rate, at best, after shaved margins was 19%. This was markedly less than their previous 38% positive margin rate in standard partial mastectomy operations. In general, standard partial mastectomy operations have a positive margin rate in the literature ranging between 20 and 40% [13]. While there is variation in oncoplastic positive margin rates in the literature, there is little doubt that there is a true reduction in positive margin rates compared to standard partial mastectomy [14]. Two large meta-analyses have shown that oncoplastic surgery has a positive margin rate between 10 and 12% [8, 15•]. Losken et al. noted that this lower positive margin rate held true in both Level 1 and Level 2 oncoplastic operations compared to standard partial mastectomy [15•]. In the author’s clinical experience, a similar lower positive margin rate of 6% was noted with oncoplastic surgery in the first 100 consecutive operations performed using Level 2 volume displacement oncoplastic surgery techniques (Table 2). During patient counseling, this was one of the most important decision-making factors that patients favor when choosing oncoplastic surgery. To them, it reduces the chances of a second operation for additional surgery whether that entails an additional shaved margin or a completion mastectomy. It allows them to continue on their cancer treatment journey and decreases the likelihood of a delay in adjuvant treatment in the setting of positive margins.

Table 2 One-hundred consecutive volume displacement oncoplastic operations between 2015 and 2018
Full size table

Reconstructive Benefits

In general, the reconstructive outcome in oncoplastic surgery involves autologous tissue most often from the ipsilateral remaining breast in a one stage reconstructive effort. In Level 2 volume displacement (involving reduction mammaplasty or mastopexy designs) or volume replacement operations, a symmetry contralateral breast operation is also performed. Oncoplastic reconstruction that is performed immediately after the large partial mastectomy resection have fewer post-operative complications than delayed efforts, and has the obvious benefit of requiring one surgery with immediate reconstruction rather than an obligatory two staged operation, at minimum, when choosing a delayed approach [16, 17]. From a reconstructive standpoint, a well-performed oncoplastic operation provides one of the most pleasing esthetic outcomes when using patient-reported outcome measures [9•, 18]. Oncoplastic reconstructive options are often utilized in subsequent operations when standard partial mastectomy efforts result in poor cosmesis which can happen as often as 28% of the time [19]. Patients feel that their oncoplastic reconstructive result provides at least the same or better results from a psychosocial perspective more than 50% of the time when compared to their pre-operative state, and these oncoplastic outcomes are reliably superior when compared to mastectomy operations with immediate reconstruction [9•]. Again, from the author’s clinical experience, these outcomes hold true and make sense since the oncoplastic reconstructions, especially using Level 2 volume displacement options, utilize esthetic mastopexy or reduction mammaplasty designs resulting in a less ptotic, cosmetically appealing breast form (Fig. 1). Aside from esthetic advantages, when applying oncoplastic techniques to a patient suffering from symptomatic macromastia, the advantages of the reconstructive effort increase exponentially. As noted earlier, symptomatic macromastia inherently is associated with back pain, neck pain, and shoulder pain among other chronic ailments, and when using a reduction mammaplasty (Level 2 volume displacement) design to remove the cancer and reconstruct the breast, a woman is likely freed of her macroscopic disease and of her macromastia symptoms. There is a large volume of literature touting the incredible value of reduction mammaplasty in macromastia patients [20, 21]. From clinical experience and common sense, the author has noted that patients suffering from both breast cancer and symptomatic macromastia receiving oncoplastic surgery are among the most satisfied breast cancer patients from a surgical outcome perspective (see Fig. 2).

Fig. 1
figure 1

Patient with large right upper outer quadrant breast cancer (pre-op: left photo) treated with a superomedial pedicle, inverted T skin incision oncoplastic surgery design (Level 2 volume displacement). Post-operatively at 6 months (right photo), successful oncologic resection and high patient satisfaction with the esthetic reconstructed breast form

Full size image
Fig. 2
figure 2

Patient (pre-op: left photo) with large left upper outer quadrant breast cancer with symptomatic macromastia treated with an extended superomedial pedicle, inverted T skin incision oncoplastic surgery design (Level 2 volume displacement). Post-operatively 3 months after (right photo), pleased with successful oncologic resection and resolve of her symptomatic macromastia symptoms

Full size image

What Are the Basic Technical Considerations, Approaches, and Associated Common Complications in Oncoplastic Surgery?

There are many approaches and techniques in oncoplastic surgery but one does not have to be a master of every technique to qualify as an able oncoplastic surgeon. Practically speaking, the approach depends on a three key factors: (1) How much tissue is being removed from the breast? (2) How large or ptotic is the breast (grades of breast ptosis are described in Table 3)? (3) Is the breast more glandular or fatty? The author tends to apply these questions to the oncoplastic classification scheme described by Clough et al. [1] (Table 1). Quite simply, if a breast that is moderately large at most and has Grade 1 or minimal Grade 2 ptosis is having less than 20% of the breast volume removed with a partial mastectomy, the Level 1 volume displacement oncoplastic operation is chosen. Typically, the author’s primary choice in this circumstance is a doughnut mastopexy design that can address any quadrant in the breast (Fig. 3). However, if the breast is predominantly fatty, then a Level 1 volume displacement oncoplastic design is not feasible as the approximating sutures will shred the fatty tissue. Additionally, if a doughnut mastopexy design is used in a Grade 3 ptotic or very large breast, then the cosmetic outcome will be suboptimal as this design does not adequately remove enough skin. If a breast is moderately to quite large and has Grade 2 or 3 ptosis and the volume of breast tissue to be removed is estimated to be 20 to 50% of the total breast volume, then a Level 2 volume displacement oncoplastic design is utilized. If the tumor is in the inferior pole, then a superomedial pedicle, inverted T (Wise) skin incision pattern is employed (Fig. 4). If the tumor is in the medial region of the breast, an inferior pedicle, inverted T (Wise) skin incision pattern is chosen (Fig. 5). Understanding when to use either the inferior or superomedial pedicle is essential as it allows the breast surgeon to address a cancer presentation in most regions of the breast. Additionally, given that the pedicles are typically de-epithelialized, the dermis left on the pedicle can be used to capture suture, thus allowing the pedicle to be transposed and fixed into the large partial mastectomy defects. This allows the use of Level 2 volume displacement oncoplastic techniques even in breasts that predominantly contain fatty tissue. The most common complication of the inverted T (Wise) skin incision pattern is wound healing where the inverted T junction dehisces [15•, 22]. Most of the time, this heals within 2 weeks with antibiotic ointment and dressing changes. Rarely, a skin graft has to be employed to cover this dehiscence. Lastly, if the more than 50% of the breast volume needs to be removed, then a volume replacement design is employed with either local-regional flaps or implants [11, 12]. With flaps, patients should be counseled about recipient and donor site complications that include scarring, seroma, and flap failure. With implants, the long-term risk of high-grade capsular contracture especially in the adjuvant setting of breast radiation is possible.

Table 3 Regnault classification of breast ptosis
Full size table
Fig. 3
figure 3

Doughnut mastopexy design

Full size image
Fig. 4
figure 4

Superomedial pedicle, inverted T (WISE) pattern mastopexy design

Full size image
Fig. 5
figure 5

Inferior pedicle, inverted T (WISE) pattern mastopexy design

Full size image

Does Oncoplastic Surgery Provide Value as a Breast Surgery Option?

With an ever cost-conscious health care system, any newer surgical technique or device should undergo rigorous value analysis. It is incumbent upon surgeons to be fair, yet skeptical, with their assessment regarding any new surgical paradigm that can add cost to the system as overall health care costs is a zero-sum game. Oncoplastic surgery does add direct cost to the system. There is additional surgical work being performed on the cancer side in addition to the contralateral breast for symmetry when appropriate. With this work comes costs and additional surgical risks for complications that can add further costs. In such, there is potential for the overuse of oncoplastic surgery in situations when a simple partial mastectomy alone would be appropriate. A small cancer in an older woman with smaller breasts and multiple co-morbidities can certainly be an example of when a partial mastectomy alone may be an optimal choice. Alternatively, a middle-aged woman in reasonable health with symptomatic macromastia and a moderately large tumor who is interested in breast conservation would be an excellent candidate for oncoplastic surgery using a Level 2 volume displacement (breast reduction type) design. Fortunately, there have been both clinical effectiveness studies using patient-related outcomes [9•, 23] and value analysis studies through the use of cost-utility analysis that have underscored the value of oncoplastic surgery when applied to the appropriate breast cancer patient [24••, 25, 26].

Conclusion

Oncoplastic surgery is an excellent breast conservation treatment option when applied to the appropriate breast cancer patient. When the appropriate technique is performed, patients tend to be satisfied from a post-operative psychosocial perspective, pleased with how they look and delighted at the lower positive margin rates afforded by this type of operation. It is becoming an accepted, standard option in the treatment options for breast cancer.