Breast Conserving Surgery – General
Breast conserving surgery causes minimal gland disruption especially if combined with immediate glandular reshaping. However, the subsequent effect of radiotherapy can lead to significant distortion of the remaining breast. The skin and underlying soft tissues of the irradiated area becomes edematous, less vascular and scarred, with a tight, woody appearance. Fibrosis also occurs in the underlying muscles and remaining breast tissue, which eventually shrinks to some degree.
There is a change in both the shape and volume of the breast, which many patients find unacceptable. Although surgery to an irradiated breast is not recommended, the deformity can be so marked that reconstructive surgery, with the addition of well-vascularized tissue from outside the irradiated area, may be necessary.
Since the Milan trials of the early 1970’s there has been a trend towards breast conserving surgery. Modern breast reconstructive techniques were not available at that time and breast conservation was an attractive alternative to the radical or modified radical mastectomy. Unfortunately over the years, this over-enthusiasm with breast conservation has led to many substandard or poor aesthetic results. While the results can be excellent in patients with large breasts, many small breasted, thin women survive their cancer only to be faced with significant post-radiation fibrosis, glandular retraction and nipple-areolar distortion. In particular, wide excisions, of between one-third and one-half of the gland, lead to a poor outcome. Some very good results can still be achieved with breast conservation therapy but patient selection is critical.
The relationship between body mass index, breast size and tumor size is extremely important. Good results can only be obtained, without resorting to local or distant flaps, implants or other tissues (i.e. lipofilling), if less than 1/8 of the total breast gland is resected and primary closure of the defect performed. Neo-adjuvant chemotherapy can also assist in reducing the preoperative tumor size and increasing the number of suitable candidates for breast conserving surgery.
As ablative breast surgeons began to realise that the aesthetics of the breast were important to a woman after her breast cancer treatment, there was a move towards narrower excision margins. Unsurprisingly this resulted in a higher re-excision rate. Without plastic surgical support, it can be difficult to balance excising enough tissue around a tumour to obtain acceptable oncologic margins, with simultaneously preserving the natural shape of the breast. This is particularly true when one considers the challenge of predicting the long-term effect of post-lumpectomy radiotherapy.
Within plastic surgery we possess the reconstructive tools that allow the replacement of total or partial mastectomy defects. We can rearrange the breast gland or introduce new tissue into the resection cavity at the time of the ablative surgery to minimize the severity of contour changes. The availability of plastic surgeons as part of the breast conservation team gives the oncologic surgeon flexibility to pursue wider resection margins without concerns about unacceptable aesthetic results and therefore reduces the re-excision rate. With modern reconstructive procedures we can now provide the same oncologic safety but offer even better breast conserving surgery (BCS). The presence of a plastic surgeon in the breast clinic can therefore influence the way in which an oncologic (ablative) surgeon decides to treat breast cancer.
The wide range of BCS defects encountered by a plastic surgeon is the result of a number of variables including the orientation of the skin incision, the pre-operative breast size, the percentage of breast parenchyma resected, the location of that resection, the intensity and method of delivery of radiotherapy and a patient’s response to radiotherapy.
In both breast conserving surgery and a mastectomy, the orientation of the skin incisions are of the utmost importance. In the upper quadrants, circumferential incisions, in or parallel to, the circumference of the areola are recommended, to limit their confines to the area covered by a bra. In the lower quadrants radial incisions are acceptable. In later corrections these scars can be used to further adjust, reduce or lift the breast. The radial incisions can also be combined with a horizontal incision in the inframammary crease (fig. 1).
Different reconstructive options are available, depending on the breast volume deficiency following resection or the effects of radiotherapy (table I).
|Breast volume deficiency||Reconstructive Option|
|< 1/8||direct closure, local glandular flap or lipofilling|
|> 1/8 and < 3/8||loco-regional soft tissue flap from the flank or back, lipofilling|
|> 3/8||skin sparing mastectomy and reconstruction with a distant free flap|
An explanation of the different options:
- Direct closure: if the remaining breast gland is supple and well vascularized, simple tissue advancement can be used to fill small defects.
- Local glandular flaps: small pieces of breast tissue, particularly from the bottom edge of the gland, can be transposed to correct minor defects or contour irregularities. It is a relatively short, simple procedure that leaves inconspicuous scars. This technique is also frequently used to perform a simultaneous lift or reduction of the affected breast (fig.2). Local random patterned flaps often have wound healing problems because of the widespread radiation changes. Sometimes it is therefore necessary to introduce regional or distant, well vascularized, healthy tissue.
- Loco-regional soft tissue flaps from the flank or back: if some of the outer quadrant of the breast has been removed, this defect can be filled by moving tissue from the back or flank.
- Distant free flaps: skin and subcutaneous fat can be transferred from the abdomen or, less commonly, the buttock to reconstruct an entire breast.
- If the shape of the irradiated breast is acceptable but there is a volume difference between the two sides, another option is to adjust the normal breast. This can range from a simple breast lift to a breast reduction.
It is important to realise that the reconstructive options after breast conserving surgery are not limited to loco-regional flaps or lipofilling. For women with small breasts, those facing wide local excisions or for women considering risk-reducing surgery, a skin-sparing mastectomy with primary reconstruction may also be an option, providing no adjuvant radiotherapy is required. A recent study has shown that in selected cases (women with small tumors who are also good candidates for BCS) a skin-sparing mastectomy with primary autologous breast reconstruction achieved significantly better aesthetic results, in comparison to a similar group of patients undergoing pre-operative chemotherapy, breast conserving surgery and radiotherapy.
It is difficult to reach defects in the upper-medial quadrant of the breast with loco-regional flaps and this area is also hard to reconstruct when skin has been resected. If the defect is not suitable for lipofilling, one could consider a skin sparing mastectomy and primary autologous breast reconstruction, which also reduces the long-term oncological risks,
Timing of partial breast reconstruction
Unfortunately with breast conserving surgery, we have seen suboptimal aesthetic results following immediate flap reconstruction and radiotherapy. The other disadvantages of immediate partial autologous reconstruction include the risk of positive resection margins and the logistical difficulty of organising these cases in the days or weeks following a breast cancer diagnosis.
Every woman who undergoes immediate partial reconstruction with a loco-regional flap and encounters positive section margins, early recurrence or flap fibrosis due to the effects of radiotherapy, has already lost one reconstructive option. Once again, patient selection is the key.
We offer immediate partial reconstruction with glandular remodelling or breast reduction to patients with defects of less than 1/8 of the gland. For resections of greater than 3/8, a skin-sparing mastectomy and immediate reconstruction with either an implant or autologous tissue is indicated. Offering immediate reconstruction to patients with resections between 1/8 and 3/8 is debatable and we prefer to delay the final reconstruction until 6 months after the completion of radiotherapy. Meanwhile, the shape of the breast can be improved by re-draping of the remaining gland, filling the cavity with saline or a temporary implant, or just accepting the temporary deformity. Adopting this strategy preserves our reconstructive options and we have therefore not burnt any bridges.
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