Overview
Definition:
Oncoplastic therapeutic reduction is a surgical approach that combines oncological resection of breast cancer with simultaneous breast reduction techniques
It aims to achieve negative surgical margins while also addressing macromastia or asymmetry, thereby improving aesthetic outcomes and patient satisfaction compared to traditional lumpectomy alone, especially in patients desiring smaller breasts or symmetry.
Epidemiology:
Macromastia affects a significant percentage of women, leading to symptoms like neck/back pain and functional impairment
The incidence of breast cancer in women with macromastia requiring oncoplastic reduction varies but is an important consideration in breast cancer management
It is particularly relevant for women diagnosed with large breast tumors relative to breast size, where simple lumpectomy might lead to significant deformity.
Clinical Significance:
This technique offers a crucial solution for breast cancer patients who have macromastia or significant breast asymmetry
It allows for oncological safety with wide local excision and immediate aesthetic restoration, avoiding the disfigurement often associated with large tumor excisions in small breasts
It enhances quality of life by resolving macromastia-related symptoms and providing a more pleasing cosmetic result, which can positively impact psychosocial well-being post-treatment.
Indications
Indications For Procedure:
Breast cancer with macromastia requiring significant tissue removal
Large breast tumors where simple lumpectomy would result in unacceptable cosmetic deformity
Patients desiring breast reduction for symptomatic relief or aesthetic reasons who also have breast cancer
Significant breast asymmetry requiring reduction of the contralateral breast for symmetry
Multicentric or diffuse multifocal disease suitable for conservative management but with resulting deformity.
Contraindications:
Inability to achieve clear margins with conservative resection
Locally advanced breast cancer requiring mastectomy
Active infection or inflammation of the breast
Severe comorbidities that preclude major surgery
Patient refusal of oncoplastic approach or preference for mastectomy.
Patient Selection Criteria:
Good overall health
Realistic expectations regarding outcomes
Willingness for follow-up
Tumor amenable to conservative resection with oncological safety
Presence of macromastia or significant asymmetry that would benefit from reduction
Adequate breast tissue volume to allow for reduction and reconstruction.
Preoperative Preparation
Informed Consent:
Detailed discussion of risks, benefits, alternatives, expected outcomes, need for potential future procedures, and oncological safety
Emphasis on the dual nature of the surgery: cancer removal and aesthetic shaping.
Imaging And Staging:
Standard breast cancer workup including mammography, ultrasound, MRI (if indicated), and biopsy
Staging investigations as per protocol (e.g., chest X-ray, abdominal ultrasound, bone scan, CT scan if indicated).
Markings:
Careful preoperative marking of the tumor, planned excision lines, breast mound reshaping, nipple-areolar complex position, and planned reduction pattern (e.g., Wise pattern, vertical scar, inferior pedicle)
Markings should facilitate a oncoplastic surgeon's approach.
Anesthesia Considerations:
General anesthesia is typically required
Multimodal analgesia strategies for postoperative pain control
Consideration of tumescent infiltration for hemostasis and postoperative pain management.
Surgical Planning:
Selection of appropriate oncoplastic technique based on tumor location, size, breast volume, and surgeon's expertise
Consideration of pedicle design for nipple-areolar complex viability if preserved
Planning for contralateral symmetrization surgery, which may be done simultaneously or in a staged fashion.
Procedure Steps
Oncological Excision:
Wide local excision of the tumor with a clear margin of at least 1 cm of normal breast tissue
Specimens should be oriented for pathological assessment of margins
In some cases, intraoperative margin assessment may be considered.
Breast Reshaping And Reduction:
Utilizing standard breast reduction techniques (e.g., superior pedicle, inferior pedicle, central mound) to sculpt the remaining breast tissue
Tissue is mobilized, de-epithelialized where necessary, and repositioned to achieve the desired contour and volume
Preservation of adequate vascularity to the remaining breast tissue and pedicle is paramount.
Nipple Areolar Complex Management:
Depending on tumor location and size, the NAC may be preserved, partially resected, or sacrificed
If preserved, it is typically transposed on a vascularized pedicle
For central tumors or those involving the NAC, mastectomy with immediate reconstruction or NAC resection may be necessary.
Closure And Drainage:
Meticulous layered closure of subcutaneous tissue and skin
Placement of surgical drains to manage seroma formation
Drains are typically removed when output is minimal.
Contralateral Symmetrization:
Often performed simultaneously to achieve symmetry
This involves performing a similar reduction mammoplasty on the contralateral breast to match the volume and shape of the reconstructed breast
Alternatively, it can be done as a delayed procedure.
Postoperative Care
Monitoring:
Close monitoring of vital signs, flap viability, and for signs of infection or hematoma
Assessment of drain output
Pain management is crucial.
Dressing And Support:
Application of a surgical bra or supportive dressing to minimize swelling and provide support to the reconstructed breast
Dressing changes as per protocol.
Drain Management:
Monitoring drain output and timing of removal
Educating the patient on drain care if discharged with drains.
Activity Restrictions:
Guidance on limitations of arm movement and physical activity to protect the surgical site and allow for healing
Gradual return to normal activities over several weeks.
Medications:
Analgesics for pain control
Prophylactic antibiotics may be considered
Anticoagulation may be necessary for high-risk patients.
Complications
Early Complications:
Hematoma
Seroma
Wound infection
Skin necrosis (especially of the nipple-areolar complex or flap edges)
Partial or complete flap dehiscence
Asymmetry
Nerve injury leading to altered sensation.
Late Complications:
Chronic pain
Scar hypertrophy or keloid formation
Fat necrosis
Implant-related complications (if used in subsequent reconstruction)
Persistent asymmetry
Poor aesthetic outcome
Lymphedema
Recurrence of cancer.
Prevention Strategies:
Meticulous surgical technique, careful flap design and preservation of vascularity, judicious use of drains, adequate hemostasis, appropriate antibiotic prophylaxis, patient education on wound care and activity, and careful patient selection
Early recognition and management of complications are key.
Prognosis
Factors Affecting Prognosis:
Stage of breast cancer at diagnosis
Histological subtype and grade
Receptor status (ER, PR, HER2)
Adequacy of surgical margins
Patient's overall health and adherence to adjuvant therapies
Surgeon's experience.
Outcomes:
Excellent oncological outcomes are achievable with adequate margins
Good to excellent aesthetic outcomes are reported, with high patient satisfaction rates
Reduction in macromastia-related symptoms
Improved body image and psychosocial well-being.
Follow Up:
Regular follow-up appointments are essential for monitoring the surgical site for complications, assessing aesthetic outcomes, and surveillance for breast cancer recurrence
Surveillance protocols should follow established breast cancer guidelines, including regular clinical breast examinations and appropriate imaging (mammography, MRI as indicated).
Key Points
Exam Focus:
Understanding the principles of oncoplastic surgery
Indications and contraindications for therapeutic reduction
Key surgical techniques and pedicle designs
Management of nipple-areolar complex
Common complications and their management
Differentiating from standard lumpectomy and mastectomy
Importance of oncological safety alongside aesthetic outcomes.
Clinical Pearls:
Always prioritize oncological safety
achieve clear margins first
Consider contralateral symmetrization early in the planning process
Meticulous technique for flap viability is critical
Patient selection and realistic expectations are paramount for satisfaction
Communication between surgeon, oncologist, and pathologist is vital.
Common Mistakes:
Inadequate margin clearance
Compromising vascularity to flaps
Poor planning of nipple-areolar complex transposition
Underestimating tissue redundancy in macromastia
Neglecting contralateral symmetrization leading to significant asymmetry
Failing to adequately counsel patients on potential complications and long-term follow-up.