Oncoplastic Breast Reduction Technique and Outcomes: An Evolution over 20 Years

Losken, Albert M.D.; Hart, Alexandra M. M.D.; Broecker, Justine S. B.S.; Styblo, Toncred M. M.D.; Carlson, Grant W. M.D.

Plastic & Reconstructive Surgery: April 2017 - Volume 139 - Issue 4 - p 824e–833e
doi: 10.1097/PRS.0000000000003226
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Background: Reduction mammaplasty at the time of lumpectomy is a good option in women with breast cancer and macromastia. We critically evaluated refinements and outcomes of this technique.

Methods: A prospectively maintained database was reviewed of all women with breast cancer who received lumpectomy and reduction mammaplasty at our institution from 1994 to 2015. Patients’ demographics were reviewed. Preoperative and postoperative patient satisfaction (BREAST-Q) was determined. Comparisons were made between early and recent cases.

Results: There were 353 patients included. Average age was 54 (range, 21 to 80 years), with the largest number having stage I disease [n = 107 of 246 (43.5 percent)]. Average lumpectomy specimen was 207 g (range, 11.6 to 1954 g) and total reduction weight averaged 545 g (range, 21 to 4102 g). Tumor size averaged 2.02 cm (range, 0.00 to 15.60 cm). The positive margin rate was 6.2 percent (n = 22). Completion mastectomy rate was 9.9 percent (n = 35). Overall complication rate was 16 percent. The recurrence rate was 5.2 percent (n = 10 of 192) at a mean follow-up of 2 years (range, 2 months to 15 years). Resection weights greater than 1000 g were associated with having a positive margin (16.7 percent versus 5.0 percent; p = 0.016), and tended to be associated with having a completion mastectomy (p = 0.069). Positive margin and completion mastectomy rates have been lower in the past 10 years. Over 1 year postoperatively, women reported increased self-confidence (p = 0.020), feelings of attractiveness (p = 0.085), emotional health (p = 0.037), and satisfaction with sex life (p = 0.092).

Conclusions: The oncoplastic reduction technique is effective and results in improved patient-reported outcomes. Resections over 1000 g are associated with a higher incidence of positive margins and may increase the risk for completion mastectomy. Outcomes have improved with experience and refinement in technique.

This and Related “Classic” Articles Appear on Prsjournal.Com for Journal Club Discussions.

Atlanta, Ga.

From the Emory Division of Surgical Oncology.

Received for publication July 27, 2016; accepted September 16, 2016.

Presented at the 2016 Meeting of the Southeastern Society of Plastic and Reconstructive Surgeons, in Orlando, Florida, June 11 through 15, 2016.

Disclosure: Dr. Losken is a speaker for RTI. There are no other potential conflicts to report.

Albert Losken, M.D., Emory Division of Plastic and Reconstructive Surgery, 550 Peachtree Street, Suite 9000, Atlanta, Ga. 30345, alosken@emory.edu

Article Outline

The concept of performing partial breast reconstruction at the time of tumor resection for women with breast cancer who wish to undergo breast conservation therapy continues to gain acceptance and popularity. This is particularly true for the oncoplastic reduction approach because of its many documented benefits for women with breast cancer and macromastia.1–3

The oncoplastic reduction approach is not a new concept and has continued to broaden acceptance from breast surgeons and plastic surgeons alike. The initiation of this approach was met with some early resistance by breast cancer surgeons who were concerned about the oncologic safety of manipulating the breast architecture and the potential to impact radiation therapy, recurrence, or surveillance. As our collective experience has grown, we have continued to demonstrate safety equivalence in areas of surgical margins, patient selection, outcomes, and surveillance compared with breast conservation therapy alone. We are only now starting to report larger series in the literature with longer follow-up so that we can draw valid conclusions on variables such as recurrence and refinements in technique. The number of publications on the topic continues to rise, and we are now discussing different related topics such as patient-reported outcomes, intraoperative radiation therapy, extreme oncoplastic techniques, autoaugmentation reduction techniques, longer term oncologic safety, margins, and surveillance.4–8

The purpose of this review was to evaluate indications and outcomes in our large series of oncoplastic reduction mammaplasties in women with breast cancer. The use of patient-reported outcomes measures will help us draw conclusions from the patient’s perspective. Having followed patients over a 20-year period will also allow us to compare outcomes over time and discuss refinements in technique and approach to possibly improve outcomes.

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PATIENTS AND METHODS

All patients from 1994 to 2015 who underwent partial mastectomy and immediate partial breast reconstruction using reduction mammaplasty at Emory University hospitals were included in this series. Approval from the Institutional Review Board of Emory University Hospital was obtained. Data were collected from a prospectively maintained database and electronic medical records and recorded in a Microsoft Excel database (Microsoft Corp., Redmond, Wash.). Patients were typically treated by a team approach with an extirpative surgeon and a reconstructive surgeon. The indications were determined by tumor size and location, tumor size–to–breast size ratio, breast size, potential for deformity, and the need for a generous resection. All patients underwent glandular manipulation with either a mastopexy or reduction technique. The type of reduction pattern and pedicle technique was dependent on the breast size and location of the tumor. Local or distant flap reconstructions of the lumpectomy defect were not included in this series. Patients were submitted for neoadjuvant or adjuvant chemotherapy, hormone therapy, and radiation therapy according to our institutional protocol.

Surgical, oncologic, radiologic, and pathologic records were analyzed for follow-up to determine outcomes. Patients were followed up every 6 months for screening mammography for the first 2 years, and then annually. Recurrences were determined by clinical examination, radiologic tests, and/or pathologic assessment. Major complications were those that required readmission or unplanned reoperation.

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Demographics and Outcomes

Patient demographics queried included diagnosis, stage, risk factors, and procedural data points (e.g., type of procedure, reduction technique, weight of specimen). Outcome variables included complications, margin status, the need for revision surgery or completion mastectomy, and tumor recurrence. More recently, data regarding patient-reported outcomes and satisfaction were collected using a validated survey (BREAST-Q), which was given preoperatively and then at least 1 year postoperatively. A total scale score was then calculated through the QScore scoring software. This ranged from 0 to 100, with a higher score correlating with greater satisfaction.9

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Comparisons

1. Outcomes: Outcomes including positive margin, completion mastectomy, local recurrence, complications, and patient satisfaction were evaluated to determine what risk factors were associated with these outcomes.

2. Period: A comparison was made between two time points to determine whether the outcomes improved over the course of the series. An arbitrary time point of 2010 was used as the cutoff and comparisons were made between 101 patients before 2015 and 192 patients after 2010.

Pearson chi-square and Fisher’s exact tests were used for all categorical data comparisons as appropriate. The t test and analysis of variance were used for continuous data comparisons. Continuous variables were described as mean ± SD. Multivariate logistic regression adapted adjusted for clinical characteristics (i.e., body mass index, smoking, indication for reconstruction) and postoperative complications (i.e., infection, seroma, infra mammary fold problems, capsular contracture, mechanical shift, bottoming-out, rippling, and wound problems) using a logistic regression model. A value of p < 0.05 was considered statistically significant for all comparisons. Adjusted odds ratios and 95 percent confidence intervals were reported for the multivariate results. Statistical analyses were performed using IBM SPSS Version 23.0 (IBM Corp., Armonk, N.Y.).

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RESULTS

Demographics

A total of 353 patients who underwent an oncoplastic reduction had sufficient data to be included in the series. The average age was 54 years (range, 21 to 80 years), with the majority having a body mass index greater than 30.0 kg/m2 [n = 219 (62.3 percent)]. The average body mass index was 33.7 kg/m2 (range, 19.6 to 60 kg/m2). The majority of patients on final pathologic evaluation had infiltrating ductal or lobular carcinoma [n = 215 (60.9 percent)]. Stage I disease was the most common [n = 107 (43.5 percent)] (Table 1) and wire localization was required in 260 (73.4 percent) (Fig. 1). Ninety-three percent of patients with breast cancer had postoperative irradiation.

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Intraoperative Details

The majority of patients had an axillary procedure [sentinel node biopsy, n = 222 (62.9 percent); axillary node dissection, n = 30 (8.5 percent)] at the time of tumor removal (Table 1). The average lumpectomy specimen weighed 207 g (range, 11.6 to 1954 g) and total reduction weight averaged 545 g (range, 21 to 4102 g). The average contralateral specimen weighed 586 g (range, 0 to 3217 g). The ipsilateral and contralateral pedicle types are shown in Table 2. Tumor size averaged 2.02 cm (range, 0.00 to 15.60 cm). The positive margin rate was 6.2 percent (n = 22) and the average distance to the closest margin was 0.51 cm (range, 0.00 to 5.0 cm).

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Univariate Analysis

Total resection weight greater than 1000 g was associated with having a positive margin (27.3 percent versus 9.1 percent; p = 0.016) and with having a completion mastectomy (p < 0.0001). Patients with larger biopsy size, larger tumor size (>2.00 cm), and estrogen receptor positivity were more likely to have positive margins (Table 3). Patients with in situ disease on final pathologic evaluation had a 10.3 percent positive margin rate (eight of 78) compared with 6.0 percent for those with invasive disease (13 of 215). There was no difference in the incidence of complications between the patients with positive or negative margins.

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Multivariate Analysis

Multivariate logistic regression analysis revealed that tumor size greater than 2.00 cm (OR, 4.896; 95 percent CI, 1.286 to 18.648) and total ipsilateral specimen weight of greater than 1000 g (OR, 4.638; 95 percent CI, 1.260 to 17.079) were associated with positive margins (Table 4).

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Completion Mastectomy

Completion mastectomy occurred in 35 patients (9.9 percent). The diagnosis in those 35 patients who required completion mastectomy was ductal carcinoma in situ (40 percent), invasive ductal carcinoma (40 percent), and other (20 percent). On univariate analysis, as expected, having a positive margin was associated with having a completion mastectomy (p < 0.0001). In the multivariate model, completion mastectomy was associated with a lower body mass index (OR, 0.864; 95 percent CI, 0.753 to 0.992) and ipsilateral specimen weight greater than 1000 g (OR, 3.518; 95 percent CI, 1.149 to 10.771) (Table 5). The type of reconstructive procedure performed at the time of completion mastectomy was noted in the 28 patients: transverse rectus abdominis musculocutaneous/deep inferior epigastric perforator flap in 15 (53 percent), latissimus flap with implant in 10 (36 percent), and tissue expander/implant in three (11 percent).

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Complications

The overall complication rate was 16.4 percent, with the majority of those being minor and on the ipsilateral breast (Table 6). There was no significant difference in overall complications on univariate analysis; however, patients with a body mass index greater than 30 kg/m2 had a significantly higher incidence of delayed wound healing [28 of 219 (12.5 percent) versus six of 134 (4.5 percent); p = 0.009). On multivariate analysis, having a complication was not associated with any other comorbidities, having positive margins, or completion mastectomy. The unplanned reoperation rate for complications was 4.2 percent (n = 15 patients). Long-term revision surgery for symmetry in those patients who did not have a completion mastectomy occurred in 4 percent (12 of 318).

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Recurrence

The recurrence rate was 5.2 percent (n = 10 of 192) at a mean follow-up of 2 years (range, 2 months to 15 years). On logistic regression analysis, preoperative chemotherapy was associated with a risk for recurrence (OR, 4.350; 95 percent CI, 1.230 to 15.383).

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Time Comparison

When the outcomes were compared in 101 patients (1994 to 2010) with 192 patients after 2011 to 2015, the positive margin rate (8 percent versus 5 percent; p = 0.256) and completion mastectomy rate were lower in the recent cohort (8.2 percent versus 13.2 percent; p = 0.138) but not significantly so. Lumpectomy weight, tumor size, and stage were similar between the two groups.

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Patient Satisfaction

Over 1 year postoperatively, women reported increased emotional health (from 3.73 to 4.18; p = 0.019), body acceptance (from 3.41 to 4.50; p = 0.050), feelings of attractiveness (from 3.07 to 3.88; p = 0.064), satisfaction with how their breasts looked unclothed (from 2.53 to 3.38; p = 0.075), and satisfaction with sex life (from 3.16 to 3.48; p = 0.068). Raw data are listed in Table 7. There were no decreases in their overall satisfaction.

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DISCUSSION

The landscape for oncoplastic reduction mammaplasty continues to evolve as we improve techniques, broaden patient indications, and continue to strive for improved outcomes.10 Oncoplastic surgery in how it pertains to breast conservation therapy is a topic that generally stimulates interest, but has been slow to be fully adopted by many breast and plastic surgeons alike. A recent article from Canada cited lack of training, access to plastic surgeons, and poor reimbursement as barriers to the adoption of these techniques in that country.11 We recently also demonstrated that although oncoplastic surgery was of interest to breast surgeons and plastic surgeons and that there was general agreement as to the benefits, there was disparity in terms of delivery likely because of the system-based inadequacies in the United States.12 Both groups agreed that the aesthetic benefits were the driving force, that margin involvement was a major concern, and that resection and complex partial reconstructions were best performed using the team approach. It was also concluded that future adoption of these techniques should rely on increased training and increased awareness of these procedures. Larger oncoplastic series with longer follow-up like this one will help determine and demonstrate safety and efficacy. Our series is one of the largest, focusing on oncoplastic reduction techniques, which have gained popularity faster in the United States compared with flap reconstruction of partial mastectomy defects. Provided that the patient is a candidate for breast conservation therapy and there is sufficient breast parenchyma left following tumor resection, the breast can be shaped using the oncoplastic technique (Fig. 2).

There has been increased interest in this topic, with the number of articles in the literature rising. A recent systematic review on oncoplastic surgery demonstrated that local recurrence was found to be approximately 7 percent; positive margins, 14 percent; and good cosmesis, 86 percent.13 They did also conclude, however, that current evidence supporting these techniques is based on poorly designed and underpowered studies. Another systematic review looked at 6011 patients who had oncoplastic breast conserving surgery. Of the patients reviewed, 81 percent had T1 and T2 disease, with invasive ductal carcinoma being the most common histopathologic condition. Positive margins were reported at 10.8 percent; completion mastectomy, 6.2 percent; overall survival, 95 percent; and local recurrence, 3.2 percent.14 Our larger single-center series demonstrated similar results.

The majority of patients in our series had ductal carcinoma in situ or stage I disease. We have previously shown that young patients with ductal carcinoma in situ had a 25 percent risk of having a completion mastectomy after oncoplastic reduction because of margin involvement.15 In this series, almost 50 percent of patients with high-grade comedo ductal carcinoma in situ required completion mastectomy, and many of these were younger patients. Stricter patient selection needs to be in place for these patients when selecting oncoplastic breast-conserving surgery to minimize positive margins. We have also shown that performing an oncoplastic reduction following neoadjuvant chemotherapy in high-risk patients is as safe and effective as breast-conserving surgery alone in these patients, which is consistent with other reports in the literature.16 We continue to see reports of series where oncoplastic reductions have been used in higher risk patients, and sometimes referred to as extreme oncoplasty, which allows breast conservation therapy in patients with large (>5 cm multifocal) tumors who otherwise would have needed a mastectomy.7,17 These techniques have also now been described with intraoperative radiation therapy with good results from a cosmetic and oncologic perspective.18,19 The patients in this series underwent immediate reconstructions because this is the preferred approach at our institution. We have shown in prior studies that the complication rates are significantly lower when reduction techniques are performed before radiation therapy (21 percent) compared with after radiation therapy in a delayed fashion (57 percent),20 which has also been demonstrated by other authors.21

The concern for positive margins has always been one of the cited drawbacks to this approach. This is true despite many studies demonstrating positive margins being significantly lower with the oncoplastic approach compared with breast-conserving surgery alone. Our overall positive margin rate was 6.2 percent and associated with larger tumors, larger resections, ductal carcinoma in situ disease, and estrogen receptor positivity. When significant resections (>1000 g) are required even with the oncoplastic approach, perhaps these patients are better served with a mastectomy. Clough et al. found that, despite the ability to generously resect using oncoplastic reduction, large tumors were more likely to have positive margins.22 It is incredibly important to consider tumor size when planning these procedures. We recently evaluated margin control following oncoplastic reduction and breast conservation therapy alone and found a benefit to the oncoplastic approach with a lower positive margin rate (12 percent versus 20 percent).23 In this series, patients in the oncoplastic group had wider free surgical margins, required fewer reexcisions, and went on to completion mastectomy less often. This is likely related to the generous resection that often accompanies oncoplastic resections. Another report demonstrated a 30 percent reexcision rate following oncoplastic breast-conserving surgery and found this to be more common in overweight patients that had tumor multifocality and the presence of microcalcifications.24 Other reports have similarly shown a significant reduction in mastectomy rate and reexcision when oncoplastic techniques are added to breast-conserving surgery.25 Although we have shown that positive margins are easily managed with either reexcision or completion mastectomy, if patients are at high risk or there is a concern about margin status, the oncoplastic reduction can be delayed until confirmation of clear margins. The vast majority of positive margins in our series are managed by completion mastectomy because if margins are positive following the generous, often greater than 200-g tumor resection, tumor biology might suggest that these patients are better managed with completion mastectomy. All reconstructive options are still available following oncoplastic reduction and likely easier now that the breasts have been reduced.

Despite the margin advantage of this approach, there is still no demonstrable oncologic advantage over breast conservation therapy alone. Longer follow-up is now available, with one series of 82 patients at an average of 10-year follow-up having a local recurrence rate of 8.7 percent.26 Their overall survival rate was 82 percent and similar to the previously reported 10-year survival rate of 75 percent for the National Cancer Institute study27 and 65 percent for the European Organization for Research and Treatment of Cancer study.28 Another study with an average follow-up of 7.2 years demonstrated a local recurrence rate of 6.7 percent.29 The overall survival with the oncoplastic patients was equivalent to the breast conservation therapy–only patients. Our follow-up in the full series is less than 5 years, making any conclusions on recurrence limited. We have previously shown that breast recurrence tends to occur at the primary tumor site, stressing the importance of directed radiation therapy to that area.30 Given concerns of tissue rearrangement with the reduction technique, it is important to clip the cavity or tumor bed for directed postoperative irradiation and postoperative surveillance. In addition, it is also important to mark the pathologic specimens if additional tissue is removed from around the tumor cavity. True comparisons are difficult when it comes to recurrence and survival. To draw true conclusions, studies performed with standardized patient cohorts and follow-up will need to be performed. Furthermore, there is disagreement in what to compare these oncoplastic procedures to: breast conservation therapy alone or mastectomy. Mansell et al. suggested that because of similar histopathologic results, the oncoplastic cohorts need to be compared to mastectomy patients when it comes to oncologic outcomes.31

The complication rate of oncoplastic reduction remains low. Although complications do exist, they are often managed with conservative treatment and do not delay initiation of adjuvant treatment. Studies have shown fewer complications in obese women and women with macromastia following oncoplastic reduction compared with mastectomy and immediate reconstruction.32,33 Tong et al. demonstrated fewer complications requiring additional surgery (3.8 percent versus 28 percent) and fewer complications delaying adjuvant therapy (0.8 percent versus 14 percent) in the oncoplastic group for obese patients.33 In a previous report, we have similarly shown in patients with macromastia a lower breast complication rate (22 percent versus 47 percent), shorter hospital stay (0.8 days versus 3.5 days), and fewer trips to the operating room (1.2 versus 2.7) in the oncoplastic group.32 The complication benefits compared to mastectomy are significant, and those compared to breast conservation therapy alone are acceptable. The usual patient selections, technique adjustments, and anticipation for radiation fibrosis will minimize complications and the need for additional operations. The ipsilateral side is often left approximately 10 percent larger in anticipation for radiation fibrosis, and this will reduce the need for revisions in the long term. Revision for symmetry is often possible on the contralateral side and was performed in 4 percent in our series.

In terms of patient-reported outcomes and satisfaction, the oncoplastic reduction technique has been shown to fare favorably compared with breast conservation therapy alone and compared with mastectomy and reconstruction for women with macromastia.34 Although we often at best wish to preserve satisfaction and quality of life when performing breast reconstruction, this approach does often show improvement. Likely because of the benefit to reduction mammaplasty, these patients in our series reported improvement in body acceptance, feelings of attractiveness, satisfaction with how their breasts appeared unclothed, and satisfaction with sex life. Their improvement in emotional health is likely attributable to the breast cancer being managed and behind them. Veiga et al. showed a positive impact on quality of life and self-esteem when comparing patients who had oncoplastic surgery compared with breast conservation therapy alone.35 Hart et al. have similarly shown that oncoplastic reduction patients reported an unexpected increase in their ability to wear sexually provocative clothing and in their partners’ perception of them as womanly.34 Although not typically a driving force behind the selection of the oncoplastic reduction for women with macromastia and breast cancer, the quality-of-life improvements are definite benefits to this technique.

Our technique and patient selection have changed slightly over the years. Despite now having this technique as an option in women with higher stage breast cancer and in women with smaller breasts, we have shown a small reduction in positive margin rate and completion mastectomy weight over time. In women with smaller breasts, and in larger tumors in upper outer or medial locations, we have been using autoaugmentation flaps to fill the defect after a generous resection. These autoaugmentation flaps are either as extended primary pedicles or the addition of a secondary pedicle. These refinements in technique will further broaden the indications for this approach in patients and minimize the potential for secondary deformities following radiation therapy. Another concern occasionally raised is the potential impact reduction mammaplasty might have on cancer surveillance. We previously reported that mammographic stabilization in oncoplastic reduction patients was slightly longer than breast conservation therapy alone, but that the sensitivity and overall mammographic findings were similar.36 Dolan et al. found an increased need for ultrasound and subsequent biopsies likely related to fat necrosis.37 Others found no increased incidence of mammographic abnormalities or unnecessary biopsies despite substantial tissue rearrangement in oncoplastic patients.38 It is important that all members of the multidisciplinary team communicate well to understand what was done and minimize unnecessary biopsies. It is also important to ensure that all glandular and skin flaps are as vascularized as possible, not only to better tolerate radiation therapy but also to minimize potential for fat necrosis.

As our collective experience with these techniques grows,39,40 we continue to find additional benefits to oncoplastic reduction techniques and refine our procedures to minimize complications and improve cosmetic and oncologic results. It will likely be an approach that, through exposure to and education of breast surgeons and plastic surgeons, will continue to gain popularity and acceptance for the management of women with breast cancer.

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