Breast conservation therapy has become the mainstay in surgical breast oncology and is now a routine surgical technique for the treatment of early-stage cancers.1,2 Improvements in diagnostic technology and mammographic screening and increased use of preoperative local or systemic therapies have extended the indications for breast conservation therapy, with reported rates of 58 percent in the United Kingdom and 60 to 75 percent in the United States.1,2 Although breast conservation therapy has enabled a less extensive tissue resection consisting of lumpectomy with tumor-free margins followed by radiation therapy, major contour irregularities have been observed following these procedures.3,4 Several oncoplastic breast surgery techniques were introduced in an attempt to optimize the balance between the risk of local recurrence and the cosmetic outcome in breast conservation therapy.3–6 The combined plastic surgery techniques of tissue replacement or tissue rearrangement involve a wider local excision and achieve enhanced breast shape and symmetry and reduced surgical dead space.3–6
Patients with a small-volume breast and a relative large lumpectomy volume are at risk of developing severe breast deformity and breast asymmetry following breast conservation therapy, presenting a unique surgical challenge. Regional flaps can be used to replace the volume loss in small-breasted patients, but many of them are reluctant to undergo this procedure because of additional scarring and morbidity, leading them to forgo oncoplastic reconstruction altogether or to undergo mastectomy and immediate reconstruction.6 The use of a prosthetic device for volume replacement in small breasts may seem appealing, but it has been largely rejected on the basis of studies that cited high complication rates following radiation therapy.7 One such study showed that subcutaneous implant placement in the immediate setting led to high incidences of capsular contracture and other complications.8 Nevertheless, there is reason to believe that with increasing surgical expertise and improved radiation delivery methods,9 implant-based procedures in the setting of radiation therapy might have a better outcome compared with earlier experience.
Recent studies have advocated immediate implant-based reconstruction for patients receiving postmastectomy radiotherapy, especially those who may not be candidates for autologous reconstruction.10 Moreover, patients with previous breast augmentation who later undergo breast conservation therapy were reported to have good to excellent outcomes following their radiation treatment.11,12 With the growing experience and refinement in breast tissue rearrangement techniques and implant-based reconstruction coupled with modern radiation therapy methods, more consistent results may be offered to breast cancer patients with small-volume breasts who are considering breast conservation therapy by means of the oncoplastic breast augmentation technique.
The oncoplastic breast augmentation technique following a lumpectomy procedure consists of immediate local glandular tissue rearrangement and bilateral subpectoral breast augmentation with different size and projection implants to compensate for the lumpectomy-caused volume loss. This technique aims to achieve immediate correction of shape and volume before radiotherapy without the added morbidity associated with the use of autologous flaps or delayed breast conservation therapy reconstructions. In this study, we describe our experience with the oncoplastic breast augmentation approach for immediate oncoplastic reconstruction surgery in breast conservation therapy cases. The indications, advantages, and limitations of the technique and the cosmetic outcomes are discussed.
PATIENTS AND METHODS
We retrospectively reviewed all consecutive patients who underwent breast conservation therapy and immediate reconstruction by means of the oncoplastic breast augmentation technique between January of 2011 and January of 2015 at the Tel-Aviv Sourasky Medical Center and private clinic of the first author (Y.B.). After approval was obtained from the institutional review board, data on demographic characteristics, oncologic findings, hospitalization, and postoperative outcome were collected and evaluated. Oncologic information included tumor type, size, and location; axillary lymph-node surgery; and neoadjuvant chemotherapy and radiotherapy. All breast specimens were marked and weighed, and surgical margins were assessed by pathologic evaluation to determine whether the tumor had been fully excised and whether the margins were tumor free. All patients were followed-up postoperatively by the plastic and breast surgeons and by the oncologists.
Candidates for the oncoplastic breast augmentation technique were considered and discussed by the multidisciplinary breast team. Inclusion criteria included patients scheduled for breast conservation therapy who had small and nonptotic breasts (cup A to B), with relatively large tumors that could not be addressed solely by tissue rearrangement. Tumor size was smaller than 25 percent of the total breast volume and not involving the nipple-areola complex. Patients with previous breast augmentation were also candidates for this technique. Patients with distant metastasis or tumors growing into the chest wall or skin (stage T4) were excluded.
Tumor size and location, surgical scars, resection area, and axillary dissection were planned and discussed all relevant breast imaging studies were reviewed. Cosmetic outcome was determined at least 6 months after radiation therapy, and it was based on patient satisfaction and by grading from 10 independent reviewers, all of whom were plastic surgeons. Categories for outcome evaluation included breast shape, nipple position, and breast nipple symmetry. Each patient was given a score on a scale of 1 to 4 (i.e., 1 = poor, 2 = satisfactory, 3 = good, and 4 = very good). The patients graded their satisfaction on a scale of 1 to 4 (i.e., 1 = regret the decision, 2 = disappointed, 3 = satisfied, and 4 = very satisfied).
After marking, preparing, and draping the supine patient, the breast surgeon performed a wire-guided lumpectomy (Fig. 1, above, left). The incision of choice was periareolar, with an incision extension if needed. In cases that the tumor was not centrally located, the surgeon performed a radial incision over the tumor area. The tumor was removed, marked, and weighed and sent for mammographic and pathologic evaluation. Additional tissue extensions were taken from the tumor bed, and the space was marked with metal hemostatic clips (Fig. 1, above, center). After irrigation and careful hemostasis, the tumor bed was inspected and tissue approximation was performed by local tissue advancement. Further limited undermining of the breast parenchyma or the skin flaps was occasionally necessary before the glandular tissue could be approximated (Fig. 1, above, right). Care was taken to limit the tissue undermining and to approximate the tissue with minimal tension, to prevent fat necrosis. The skin was sutured (Fig. 1, below, left), and a new and separate incision was made in the inframammary fold. Then, a new and separate pocket was dissected in the subpectoral plane, taking care that there was no direct connection to the tumor bed. A subpectoral pocket was formed on the contralateral healthy breast as well. Breast implant sizers were inserted, as the larger implant with higher projection was chosen for the breast that underwent lumpectomy, to match it to the contralateral breast. The patient was then placed in a seated position for intraoperative assessment of symmetry and for further adjustments. Permanent silicone implants were selected and inserted after irrigation and hemostasis (Fig. 1, below, right). In cases of previous augmentation, the incision was made in the previous inframammary scar, old implants were removed, and a new subpectoral pocket was dissected, after partial capsulectomy. No drains were used for the breast surgery. A 7-mm Jackson-Pratt drain was placed in the axilla for patients who had undergone axillary lymph node dissection.
A total of 21 women with unilateral breast tumors underwent lumpectomy followed by oncoplastic breast augmentation technique reconstruction and contralateral subpectoral augmentation. Their mean age was 45 years (range, 23 to 63 years), and their tumor stage was in situ to stage 3. Reconstruction was performed immediately by the plastic surgeon after tumor removal by the breast surgeon. The patient’s demographic and clinical characteristics are summarized in Table 1. Eighteen patients (86 percent) had preoperative hypoplastic breasts (bra cup size A to B) and three patients had previous breast augmentations (two aesthetic and one congenital breast asymmetry). Implants in all previous augmentations were in a subglandular plane with an inframammary skin incision.
Sixteen patients (76.2 percent) had invasive carcinomas (14 invasive ductal carcinoma and two invasive lobular carcinoma), four patients (19 percent) had in situ ductal carcinoma, and one patient (4.8 percent) had borderline phyllodes tumor. Twenty patients (95.2 percent) underwent lymph node biopsy and seven of them (35 percent) underwent axillary lymph node dissection in the same operation. The lymph node procedures were performed from a separate axillary incision. Chemotherapy was given to nine patients (43 percent), five before and four after surgery. All patients received postoperative radiation therapy, which included daily fractionated doses up to a total of 45 to 50 Gy and an additional boost of 10 Gy to the primary tumor bed. Radiation treatment was initiated 6 weeks after surgery or after the last course of chemotherapy. The oncologic data are summarized in Table 2.
All 21 study patients underwent unilateral oncoplastic breast augmentation reconstruction with contralateral breast adjustment, yielding a total of 42 operated breasts. The surgical outcomes are summarized in Table 3. The duration of surgery averaged 2 hours (range, 1.5 to 3.5 hours), and hospital length of stay averaged 2.3 days (range, 1 to 5 days). The mean postoperative follow-up period was 23 months (range, 12 to 48 months). The weight range of the excised tumor was 25 to 80 g (mean, 44.5 g). The mean implant volume on the reconstructed breast was 275 cc (range, 225 to 475 cc), whereas the mean implant volume on the adjusted side was 225 cc (range, 150 to 335 cc). The mean implant volume difference (i.e., the reconstructed implant volume minus the adjusted implant volume) was 50 cc (range, 0 to 250 cc).
Three patients (14.3 percent) had tumor-positive surgical margins and required a second lumpectomy procedure. There was no violation of the implant’s subpectoral pocket. None of the patients needed a mastectomy as a second procedure because of involved margins. The postoperative complications included grade III/IV capsular contracture in five patients (23.8 percent). Three of the 21 patients (14.3 percent) had a second operation because of their capsular contracture and underwent subtotal capsulectomy and exchange of the affected implant (Table 3). Two patients (10 percent) had a breast infection: one was diagnosed with Staphylococcus aureus infection before undergoing radiation therapy and had her implant removed. The other patient’s infection was diagnosed after she underwent radiation therapy, with positive bacterial culture to Staphylococcus epidermidis. She had a salvage reconstruction by means of a latissimus dorsi myocutaneous flap and exchange of the implant.
The patients reported a high degree of satisfaction with the surgical outcome in terms of improved breast shape, volume, and position, all of which were retained after radiation therapy. Seventeen patients (81 percent) were either very satisfied or satisfied with their overall results, whereas two patients (10 percent) were disappointed and regretted having undergone the operation. The independent observers’ evaluation of the 16 patients who completed follow-up (76 percent) was that most of the patients had a very good to good surgical outcome in terms of breast shape, nipple-areola complex position, and breast symmetry (Table 4). Clinical cases are presented in Figures 2 through 4.
Lumpectomy in combination with postoperative radiation therapy (breast conservation therapy) has become the gold standard for early-stage breast cancer.13 Poor cosmetic results of breast conservation therapy have been reported in 5 to 40 percent of patients.14,15 The surgical dead space created from the lumpectomy defect with added postoperative radiation effects may sometimes lead to substantial distortions in breast shape, size, and nipple position.16 In such cases, the management of breast deformities secondary to breast conservation therapy can be challenging, particularly when operating in an irradiated field with poor tissue compliance. In contrast, immediate reconstruction (i.e., before adjuvant radiotherapy) has been shown to be oncologically safe and aesthetically beneficial.17 Options for reconstruction include tissue rearrangement (local breast tissue) or tissue replacement (autologous flaps) for surgical dead-space obliteration.18
Patients with small breasts and a relative large lumpectomy volume constitute a unique subgroup that is prone to considerable breast deformity and asymmetry, presenting a challenge for oncoplastic reconstruction. Many of these patients are offered mastectomy and immediate reconstruction, and some are offered breast conservation by means of tissue replacement techniques. The disadvantages of those options include donor-site morbidity, longer operating time, and flap failure. Also, the ensuing radiation treatment can result in fat necrosis and dermal fibrosis of the flap.18–20 For these reasons, many patients decline oncoplastic reconstruction and choose to undergo mastectomy or breast conservation therapy without reconstruction, despite the high risk for breast deformity.19
This study evaluated the efficacy of using implants as volume replacement devices in cases of breast conservation in small breasts with relative large lumpectomy defects. Although prosthetic device use for volume replacement has an obvious advantage in the setting of breast conservation therapy, it has been historically marginalized based on studies citing high complication rates following implant placement and postoperative radiation therapy.8,21,22 With the advancements in targeted breast irradiation, surgical technique, and surgical devices, however, many of the breast irradiation-induced effects on implants are on the decline.23–26 Judicious selection of the radiotherapy technique can reportedly help to improve the dose distribution and cause fewer radiation-induced side effects.24 Although radiotherapy is generally considered as being a factor that negatively influences the dynamics of breast tissues, even when an acellular dermal matrix graft is added, patients with a preserved implant-based reconstruction following radiation therapy have maintained a lower capsular contracture grade with better outcome.25 Spear et al. showed that although over one-half of patients who received radiation therapy following mastectomy and expander reconstruction had grade III/IV capsular contracture, 70 percent required only capsular modification, with preservation of the implant reconstruction during 15 months of follow-up.7 These encouraging results have paved the way for supplementary concepts of implant-based reconstruction in the setting of radiation therapy. One such example is the concept of immediate augmentation mammaplasty following breast conservation therapy and intraoperative radiotherapy that was introduced by Rietjens et al., who demonstrated success with low capsular contracture rates despite radiotherapy in their cumulative experience of 29 patients.26 In our series of immediate reconstructions preceding radiotherapy, the grade III/IV capsular contracture incidence was 23.8 percent, similar to previously published values in studies of late reconstruction following radiotherapy.22,25
The oncoplastic breast augmentation technique described in this article is suitable for patients with small, nonptotic breasts and a relative large lumpectomy who decline immediate autologous reconstruction or mastectomy. This technique aims to achieve volume compensation and maximum obliteration of the lumpectomy defect before radiotherapy. The combination of local glandular tissue rearrangement around the lumpectomy site and the subpectoral implant placement allows volume restoration of the reconstructed breast and minimizes the dead space by tightly packing the glandular tissue between the pectoralis major and the skin flaps. Furthermore, simultaneous augmentation offers immediate volume replacement and volume enhancement, adding to patient satisfaction from the oncologic procedure.
The type of implant used in our study was dependent on patient body habitus and tumor location. Round silicone implants with various projections were used in the majority of the cases (17 of 21). In cases of tall, slim patients or lower pole tumors (four patients), we used shaped implants, to match the body habitus and to fill the lower pole defect.
Subpectoral implant placement did not raise any issues regarding breast cancer surveillance, because surveillance was carried out as for any conventional subpectoral augmentation.27,28 There were no reported concerns from the radiation oncologists regarding dosimetry or targeting treatments throughout our 12- to 48-month follow-up. Moreover, because the postoperative shape and volume of the breast are generally preserved, cases of mild postirradiation asymmetry and irregularities can be treated with minor adjustments to the contralateral nonradiated breast or by ancillary fat grafting to the irradiated breast.
Local recurrence is an important consideration in oncoplastic surgery.29 In our series, three patients (13 percent) had tumor-positive surgical margins that required a second lumpectomy procedure. The reexcision was performed through the lumpectomy incision and the defect was reconstructed with local tissue rearrangement, with no need for implant exchange because there was no violation of the implant’s subpectoral pocket. None of the patients needed a completion mastectomy because of involved margins. However, for cases in which a mastectomy is required, all options are feasible (e.g., nipple-sparing or skin-sparing mastectomy, depending on the oncologic assessment). For implant-based reconstruction, the subpectoral pocket is reused, with acellular dermal matrix graft to support the lower pole.
Postoperative complications of capsular contracture and infection among the current study patients were comparable to published data on implant-based reconstruction with postoperative radiation therapy.22,25,26 Two patients had breast infections, and both had tumors in the lower pole of the breast, in proximity to the subpectoral pocket. One patient’s infection appeared before radiation treatment, requiring removal of the implant to prevent delay in treatment. The other patient’s infection was diagnosed following radiation therapy, requiring a salvage procedure with a latissimus dorsi myocutaneous flap and exchange of the implant. The lumpectomy and implant pockets were found to be connected in both of those revision procedures. In the future, for cases of lower pole breast tumors, we plan to use an acellular dermal matrix graft to reinforce the lower pole of the breast and to improve the separation between the implant and the lumpectomy pockets when we perform the oncoplastic breast augmentation technique.
Five patients had significant capsular contracture, and three of them underwent a capsulectomy and exchange of the implant after radiation therapy. There was no recurrence of capsular contracture in any of the revised cases. We recommend that all patients undergoing the oncoplastic breast augmentation technique should receive a detailed explanation about the wide range of radiation effects on the breast (i.e., from negligible to severe capsular contracture). Currently, we have no way to predict which patient will do well after radiation therapy. Nevertheless, our overall outcome results show high patient satisfaction and high independent reviewers’ scores. None of the patients that had revision surgery because of capsular contracture regretted undergoing the oncoplastic breast augmentation technique, and all were very satisfied with the outcome.
There are several limitations associated with the oncoplastic breast augmentation technique. One is that it is limited to patients with small, nonptotic breasts whose tumors take up less than 25 percent of the breast volume and do not involve the nipple-areola complex. Nipple position and skin contracture are unpredictable after radiation therapy in ptotic breasts, therefore excluding those cases as well. Finally, patient satisfaction might be biased because of a prior desire for larger and fuller breasts.
The oncoplastic breast augmentation technique helps achieve the adjustment of shape and volume in small-breasted patients before radiotherapy, without the added morbidity associated with the use of regional autologous flaps or late reconstructions. Careful patient selection, coordinated planning with the breast surgeon, and meticulous intraoperative management are the keys to a favorable surgical outcome of the oncoplastic breast augmentation technique, as expressed by high patient and surgeon satisfaction rates.
1. Jeevan R, Cromwell DA, Browne JP, et al. Findings of a national comparative audit of mastectomy and breast reconstruction surgery in England. J Plast Reconstr Aesthet Surg. 2014;67:1333–1344.
2. Katipamula R, Degnim AC, Hoskin T, et al. Trends in mastectomy rates at the Mayo Clinic Rochester: Effect of surgical year and preoperative magnetic resonance imaging. J Clin Oncol. 2009;27:4082–4088.
3. Berry MG, Fitoussi AD, Curnier A, Couturaud B, Salmon RJ. Oncoplastic breast surgery: A review and systematic approach. J Plast Reconstr Aesthet Surg. 2010;63:1233–1243.
4. Hill-Kayser CE, Vachani C, Hampshire MK, Di Lullo GA, Metz JM. Cosmetic outcomes and complications reported by patients having undergone breast-conserving treatment. Int J Radiat Oncol Biol Phys. 2012;83:839–844.
5. Nahabedian MY, Patel KM, Kaminsky AJ, Cocilovo C, Miraliakbari R. Biplanar oncoplastic surgery: A novel approach to breast conservation for small and medium sized breasts. Plast Reconstr Surg. 2013;132:1081–1084.
6. Krishnan L, Stanton AL, Collins CA, Liston VE, Jewell WR. Form or function? Part 2. Objective cosmetic and functional correlates of quality of life in women treated with breast-conserving surgical procedures and radiotherapy. Cancer 2001;91:2282–2287.
7. Spear SL, Seruya M, Rao SS, et al. Two-stage prosthetic breast reconstruction using AlloDerm including outcomes of different timings of radiotherapy. Plast Reconstr Surg. 2012;130:1–9.
8. Thomas PR, Ford HT, Gazet JC. Use of silicone implants after wide local excision of the breast. Br J Surg. 1993;80:868–870.
9. Speers C, Zhao S, Liu M, et al. Development and validation of a novel radiosensitivity signature in human breast cancer. Clin Cancer Res. 2014;64:135–152.
10. Cordeiro PG, Pusic AL, Disa JJ, McCormick B, VanZee K. Irradiation after immediate tissue expander/implant breast reconstruction: Outcomes, complications, aesthetic results, and satisfaction among 156 patients. Plast Reconstr Surg. 2004;113:877–881.
11. Victor SJ, Brown DM, Horwitz EM, et al. Treatment outcome with radiation therapy after breast augmentation or reconstruction in patients with primary breast carcinoma. Cancer 1998;82:1303–1309.
12. De Lorenzi F, Lohsiriwat V, Barbieri B, et al. Immediate breast reconstruction with prostheses after conservative treatment plus intraoperative radiotherapy: Long term esthetic and oncological outcomes. Breast 2012;21:374–379.
13. Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347:1227–1232.
14. Rietjens M, Urban CA, Rey PC, et al. Long-term oncological results of breast conservative treatment with oncoplastic surgery. Breast 2007;16:387–395.
15. Clough KB, Lewis JS, Couturaud B, Fitoussi A, Nos C, Falcou MC. Oncoplastic techniques allow extensive resections for breast-conserving therapy of breast carcinomas. Ann Surg. 2003;237:26–34.
16. Losken A, Hamdi M. Partial breast reconstruction: Current perspectives. Plast Reconstr Surg. 2009;124:722–736.
17. Baildam AD. Oncoplastic surgery of the breast. Br J Surg. 2002;89:532–533.
18. Anderson BO, Masetti R, Silverstein MJ. Oncoplastic approaches to partial mastectomy: An overview of volume-displacement techniques. Lancet Oncol. 2005;6:145–157.
19. Harcourt DM, Rumsey NJ, Ambler NR, et al. The psychological effect of mastectomy with or without breast reconstruction: A prospective, multicenter study. Plast Reconstr Surg. 2003;111:1060–1068.
20. Losken A, Styblo TM, Carlson GW, Jones GE, Amerson BJ. Management algorithm and outcome evaluation of partial mastectomy defects treated using reduction or mastopexy techniques. Ann Plast Surg. 2007;59:235–242.
21. Spear SL, Majidian A. Immediate breast reconstruction in two stages using textured, integrated-valve tissue expanders and breast implants: A retrospective review of 171 consecutive breast reconstructions from 1989 to 1996. Plast Reconstr Surg. 1998;101:53–63.
22. Spear SL, Baker JL Jr. Classification of capsular contracture after prosthetic breast reconstruction. Plast Reconstr Surg. 1995;96:1119–1123; discussion 1124.
23. Jagsi R. Progress and controversies: Radiation therapy for invasive breast cancer. CA Cancer J Clin. 2014;64:135–152.
24. Anderson PR, Hanlon AL, Fowble BL, McNeeley SW, Freedman GM. Low complication rates are achievable after postmastectomy breast reconstruction and radiation therapy. Int J Radiat Oncol Biol Phys. 2004;59:1080–1087.
25. Nahabedian MY. AlloDerm performance in the setting of prosthetic breast surgery, infection, and irradiation. Plast Reconstr Surg. 2009;124:1743–1753.
26. Rietjens M, De Lorenzi F, Veronesi P, et al. Breast conservative treatment in association with implant augmentation and intraoperative radiotherapy. J Plast Reconstr Aesthet Surg. 2006;59:532–535.
27. Cochrane RA, Valasiadou P, Wilson AR, Al-Ghazal SK, Macmillan RD. Cosmesis and satisfaction after breast-conserving surgery correlates with the percentage of breast volume excised. Br J Surg. 2003;90:1505–1509.
28. Eklund GW, Busby RC, Miller SH, Job JS. Improved imaging of the augmented breast. AJR Am J Roentgenol. 1988;151:469–473.
©2017American Society of Plastic Surgeons
29. Masetti R, Di Leone A, Franceschini G, et al. Oncoplastic techniques in the conservative surgical treatment of breast cancer: An overview. Breast J. 2006;12(Suppl 2):S174–S180.