Modern Breast Conservative Surgery
In our blog on lumpectomy vs mastectomy we mentioned that one of the limitations of lumpectomy is having a large tumour in a relatively small breast, particularly in the upper inner or lower parts of the breast. With the use of modern breast conservative techniques that we are going to discuss in this blog, your surgeon will be able to offer you breast conservative therapy for larger tumours without aesthetic compromise.
The use of modern breast conservative techniques (also called oncoplastic breast conservative surgery) has been gradually popularised in the UK and some European countries since early 2000. Australian breast surgeons have picked up modern breast conservative techniques at various speeds, more avidly in some states than the others. Using oncoplastic techniques the surgeon can perform larger lumpectomies in cosmetically concerned areas of the breast and still maintain a good aesthetic outcome. In fact when mammoplasty (lift/reduction) techniques are used the aesthetic outcome is often better than the original breast!
Before we discuss these techniques, it is worthwhile to have a look at a few poor cosmetic outcomes after lumpectomy so that you understand why oncoplastic techniques are employed in the first place. It is important to note that correcting a poor cosmetic outcome after breast conservative therapy is extremely difficult! This is due to the effect of adjuvant radiotherapy on wound healing. Once radiotherapy is delivered to the breast, it affects blood supply to the skin and breast tissue, hindering healing following subsequent corrective surgeries. The challenge is that a poor cosmetic outcome after lumpectomy often doesn’t manifest until after radiotherapy! Immediately after the surgery the cavity created by lumpectomy is filled up with ‘seroma’ (fluid oozed out of the vessels). This will create a nice contour even though there is a lumpectomy defect left behind in the breast. Once radiotherapy is delivered the lumpectomy cavity will contract, leaving a contour defect on the breast (Picture 1). In many cases the contracture of the lumpectomy defect following radiotherapy will pull on the surrounding breast tissue causing deviation of the nipple towards the cavity (Picture 2). The degree of these changes depends on various treatment as well as patient factors, and rather difficult to predict. Therefore, the best treatment for a poor cosmetic outcome after lumpectomy is to prevent it in the first place!
Picture 1. Lumpectomy was done through a small incision on top of the tumour in the right breast. What appeared to be a very nice and small scar right after surgery, turned to an obvious indentation after radiotherapy. This is very difficult to fix, often requiring multiple sessions of fat grafting with unpredictable outcome.
Picture 2. Left: “Bird beak” deformity following lumpectomy and radiotherapy for a lower pole right breast cancer without closure of the cavity. Contracture of the cavity has caused downward deviation of the nipple. Right: Extreme distortion of the left breast with nipple deviation following a large lumpectomy through a small lateral incision. Extensive reconstructive surgery will be required to improve this deformity.
Irrespective of the exact technique used, there are two overarching oncoplastic principles that must be considered when doing a wide local excision (lumpectomy) for cancer:
Thoughtful incision (scar) placement
Filling the breast defect created by lumpectomy
1. Thoughtful incision placement
a. Scar contracture: All wounds will contract during healing. This is a very important point to consider in breast surgery. A poorly placed scar may pull the nipple causing breast distortion (Picture 2, Right).
b. Social area of the breast: The upper inner part of the breast forms the cleavage area and is likely to show in a low-cut dress (Picture 3). The entire upper part of the breast may be on view when wearing a décolleté. Of course as fashion designers become more and more creative, they leave less and less safe areas for us breast surgeons!
Picture 3. Social area of the breast: The upper inner part of the breast is often shown in a low-cut dress. However, as fashion designers become more and more creative, less and less of the breast remains safe for us breast surgeons to hide our scars!
c. Facilitate future procedure in case of positive margin(s): as mentioned in our previous blog on lumpectomy vs mastectomy, there is 10-15% chance of having a positive or close margin when doing a lumpectomy in which case a second operation may be necessary. The initial incision should always be placed in a way that lends itself well to a second procedure which could be a re-excision of margin followed by an oncoplastic procedure to fill in the resultant defect or a mastectomy.
d. Camouflaged scars: There are certain anatomical landmarks in the breast that can be used to hide a scar. These are periareolar area (around the pigmented skin surrounding the nipple), inframammary fold (lower boundary of the breast), and lateral mammary fold (outer boundary of the breast). When possible, scars should be placed in one of these areas.
e. Avoid incisions on top of the lesion: As a general rule a scar placed right on top of the cancer away from one of the areas mentioned above will result in a contour defect (Picture 1). Even if the cancer is too far from one of the above camouflaged areas, it is best to place the scar somewhere in between the above landmarks and the lesion so that a skin flap is raised allowing for closure of the defect caused by the lumpectomy without an overlying scar.
2. Filling the defect created by lumpectomy
As mentioned above, although the defect created by lumpectomy is initially filled by seroma (fluid oozed out of the vessels) and is visually unnoticeable, after radiotherapy and with wound contracture as part of natural wound healing a contour defect may form in the breast. The best way to avoid this is to fill in the defect created by lumpectomy at the time of initial surgery.
If the defect is relatively small and there is good amount of remaining breast tissue (often in case of a small cancer in the lateral part of the breast) the surrounding breast tissue can be mobilised and brought into the defect and suture closed with minimal additional surgery. However if the defect is large, a modern breast conservative technique must be employed to fill it. Oncoplastic breast conservative techniques allow filling of the lumpectomy defect by one of the two main ways:
Redistributing breast tissue from other quadrants of the breast (volume distribution)
Bringing new tissue into the breast from outside of the breast (volume replacement)
2.1. Volume distribution
This is most commonly done through so called ‘therapeutic mammoplasty’ which is essentially a combination of lumpectomy and breast reduction or lift procedure. Imagine a woman with a relatively large breast presenting with a cancer that is located in the lower part of her breast. This is the part that is usually removed during breast reduction. Therefore, it is possible to do the lumpectomy as part of a breast reduction procedure and reduce and lift the breast at the same time. This will cover the lumpectomy defect and produce an aesthetically pleasing outcome.
In a more complex scenario, the lump is not located where it would have been usually removed during a breast reduction procedure, but the surgeon is able to mobilise the breast tissue in a way that can reach and fill the lumpectomy defect while lifting the breast (Picture 4).
Picture 4. Therapeutic mammoplasty, photos were taken before operation (top) and 6 months after surgery and radiotherapy (bottom): A large cancer in the upper outer part of the left breast (the hatched area) was removed along with breast reduction. The lower pole breast tissue was shifted to fill in the lumpectomy defect. A symmetry procedure on the right side was planned following completion of adjuvant therapy.
In yet another scenario, if the breast is relatively small but saggy, a breast reduction may not feasible. However, a breast lift can be done at the same time as lumpectomy (therapeutic mastopexy). In this scenario the surgeon takes advantage of the droopiness in the breast to lift up the breast tissue and fill in the defect created by the lumpectomy (Picture 5).
Picture 5: Therapeutic mastopexy, photos were taken before operation (left) and 6 months after surgery and radiotherapy (right): A lumpectomy through a periareolar scar was performed at the first operation. A re-excision procedure was required to achieve clear margins. This was combined with a mastopexy to lift the breast and fill in the defect created in the upper pole following margin re-excision. A contralateral symmetry procedure can be performed if desired.
The good news is that all these breast reduction and lift procedures that are done in the setting of breast cancer attract Medicare rebate as they are not considered cosmetic. In addition, the symmetry procedure on the contralateral side (opposite to the cancer side) is also rebatable through Medicare either done at the same time or down the track.
2.1.a. Indications for therapeutic mammoplasty
1. Allow closure of the lumpectomy cavity by displacing breast tissue as discussed above.
Picture 6: Right breast lymphoedema following lumpectomy, axillary lymph node dissection and radiotherapy. Despite compliance with her lymphoedema therapy sessions, she is feeling miserable with her chronic symptoms and is requesting a mastectomy! A breast reduction at the time of lumpectomy (therapeutic mammoplasty) could have prevented this condition.
2. Facilitate radiotherapy for a large pendulous breast: When a woman with very large pendulous breasts presents with breast cancer and is undergoing lumpectomy, breast reduction at the same time should be offered, irrespective of the cancer size. This is to facilitate radiotherapy to the breast and reduce its complications. There is good evidence that radiotherapy to a very large breast can be associated with dose inhomogeneity, skin toxicity, and lymphoedema of the breast (specially in cases undergoing complete removal of the armpit lymph nodes, i.e. axillary dissection). Breast reduction prior to radiotherapy can reduce these complications. Breast lymphoedema is a debilitating chronic condition that is extremely hard to treat (Picture 6).
3. Patient desire: If a woman who desires a breast lift/reduction receives a diagnosis of breast cancer and is a candidate for breast conservative therapy (lumpectomy and radiotherapy), she should be offered lift/reduction at the time of her cancer surgery. This is because breast reduction/lift is contraindicated after radiotherapy due to the effect of radiotherapy on wound healing, as discussed in our blog on lumpectomy vs mastectomy. Therefore, when I see a woman with breast cancer one of my standard questions is ‘how much do you like the current size and shape of your breasts?’ If she has always wanted her breast enhanced, this is the time to do it!
2.1.b. The cons of therapeutic mammoplasty
1. Wound healing issues: There is no surprise that the more complex the procedure is, the higher chance of complications will be. For example, the so called “T-Junction” after breast reduction surgery is particularly prone to wound healing issues. Although this is often managed simply by a slightly more prolonged dressing care, very rarely it may delay radiotherapy with potentially untoward effects on cancer care. Patient selection is a very important part of decision making when it comes to these more complex procedures. A well trained oncoplastic breast surgeon will be able to adjust their technique based on particular patient’s risk factors and offer the safest procedure with the best possible aesthetic and oncological outcome.
2. Fat necrosis: Some degree of fat necrosis is an inevitable part of every breast surgery. The breast is composed of glandular tissue with a variable amount of fat interspersed between the glandular tissues, together hold on the chest wall with a complex ligamentous network. The proportion of fat vs the glandular tissue determines (radiological) breast density with an inverse relationship. In other words, the higher the fat proportion, the less dense is the breast. While the glandular tissue is often well-vascularised, the blood supply to the fat is often minimal and therefore the fat is susceptible to necrosis (tissue death) following breast surgery. The more the breast tissue is mobilised (moved off the chest wall and or the skin) the higher the chance of fat necrosis will be. While small amount of fat necrosis is inconsequential and often unnoticed, a large area of fat necrosis may present as a hard lump, contour defect, and/or a radiological abnormality that mimics breast cancer. While fat necrosis has been reported in up to 16% of cases following therapeutic mammoplasty in the best hands, symptomatic fat necrosis is a relatively rare event.
3. Need for contralateral symmetry procedure: Assuming the breasts were almost symmetrical prior to surgery, some degree of asymmetry will be expected following therapeutic mammoplasty on the cancer side. In some cases the resultant asymmetry is minimal and no contralateral (opposite side) surgery is required. When significant reduction or lift is done however, a contralateral breast procedure will be required to match it with the cancer side. This can be done either at the same or later time (Picture 7). If the woman does not wish surgery on the contralateral breast, therapeutic mammoplasty is not a good option and she should consider other advanced breast conservative techniques such as a perforator flap to fill in the defect resulting from a large lumpectomy.
Picture 7: Symmetrising reduction of the contralateral breast: Therapeutic mammoplasty was done for right breast cancer a year prior. Preoperative photo (top right) and 2 weeks after symmetrising left breast reduction (top left and bottom).
4. Limited use in women with small non-ptotic (non-droopy) breasts: As therapeutic mammoplasty is based on reducing the breast tissue and lifting the breast, its use in women with small breasts with no ptosis (sagginess) is limited. Again perforator flaps are very good options for such breasts.
2.2. Volume replacement
As mentioned above with volume replacement techniques new tissue is brought into the breast to fill in the lumpectomy defect. Using these techniques, the surgeon is able to do large lumpectomies without changing the current breast shape and size. Essentially the removed breast tissue is replaced with a new tissue that is imported into the breast from nearby structures.
Volume replacement is most commonly done using so called ‘perforator flaps’. A flap is essentially the medical term used for a piece of tissue that is moved from its original location in the body to another location and is kept alive by its own blood supply. They are called perforator flaps as the blood vessel supplying the flap (which is often only composed of skin and fat) perforates through the underlying muscle to supply the flap. They are often named based on the name of the blood vessel that supply them, e.g., LICAP flap for lateral intercostal artery perforator flap (Picture 8).
Picture 8: LICAP flap: This flap is the most common perforator flap used for partial breast reconstruction following lumpectomy for a large breast cancer. A 5cm area of DCIS in the lateral part of the left breast is marked with two wires. A LICAP flap is marked to allow filling of the lumpectomy defect. The perforator vessels supplying the flap are mapped (black crosses) before surgery (left). Photos taken 10 days following surgery (middle and right). The scar is well hidden in the lateral mammary fold.
Perforator flaps have revolutionised reconstructive surgery throughout entire body. These flaps have become possible through in-depth understanding of blood supply of the skin. By mapping the perforating blood vessels, the reconstructive surgeon is able to raise and move reliable flaps almost anywhere in the body. We owe this detailed understanding to extensive anatomical studies carried out in the last half a century. Perhaps you will be proud to know that a substantial part of these studies were done right here at the Plastic and Reconstructive Surgery Lab of Professor Ian Taylor at the University of Melbourne. I cannot overemphasise how grateful I am for having the opportunity to do three years of research under Professor Taylor’s supervision who, with no doubt, had a fundamental role in shaping of my professional surgical career.
2.2.a. The advantages of perforator flaps
1. Robust flaps that can be done in the presence of almost any patient comorbidities: The blood supply of these flaps is very robust so that they can be done even in smokers and diabetics where the use of some types of therapeutic mammoplasty is risky.
2. No need for contralateral symmetry procedure: As opposed to therapeutic mammoplasty, perforator flaps aim to keep the shape and size of the breast the way they are and therefore contralateral (opposite side) matching surgery is often not required. So if a woman is currently happy with their breast, perforator flaps are often better option that therapeutic mammoplasty to fill in large lumpectomy defects.
3. Can be done for small breasts with no ptosis (droopiness): Perforator flaps are very useful in women with very small A-B cup breasts without sagginess as the use of therapeutic mammoplasty in these women is limited.
2.2.b. The disadvantages of perforator flaps
1. Creating scar outside the breast: When perforator flaps are raised scarring may extend outside the breast boundaries depending on the size and type of the flap required. However in most cases the scar can be hidden within the breast boundary. For example a LICAP flap scar can be hidden in the lateral mammary fold (outer boundary of the breast, Picture 8), and an AICAP flap scar can be hidden in the inframammary fold (lower boundary of the breast, Picture 9).
Picture 9: AICAP flap: This flap is ideal for lower pole tumours. Top: Preoperative photos with a large right breast cancer at 7 o’clock associated with skin tethering. Bottom: Six months following right breast lumpectomy and AICAP flap followed by adjuvant radiotherapy. The scar is well hidden in the inframammary fold.
2. Donor site morbidities (complications): Occasionally there may be problem with wound healing at the donor site (the site the flap is raised from). Also occasionally seroma (fluid oozed out of the vessels) may accumulate at the donor site and may require needle drainage after surgery.
3. Flap failure: Although perforator flaps generally have very robust blood supply, the vessels may kink, form a clot within, or get damaged during flap raise and transfer which leads to flap necrosis (death). This will often cause a very noticeable deformity to the breast specially following radiotherapy.
4. Postoperative pain: Patients often experience pain at the donor site as well the breast itself. This is often managed with simple analgesia and breakthrough opioid pain killers. You will stay one night in the hospital which gives your doctor and the nursing staff enough time to assess your individual pain threshold before discharge.
5. Burning the bridge for future reconstruction: For example a LICAP flap may compromise future latissimus dorsi (LD) flap reconstruction in case you have a positive margin after lumpectomy and need mastectomy and reconstruction. This should be carefully considered by both the patient and the surgeon before making the final decision. An extra consulting session for a well-informed decision prior to surgery is a time well-spent!
Closing comments
We have come a long way since the days of maiming breast surgery in the name of cancer cure! Recent advancements in oncology have translated into a long life-expectancy for our patients and therefore quality of life after breast cancer has become as important as cancer cure itself. Yet still I regularly see patients with disfigured breasts after their breast cancer treatment! While most of these women are very grateful to their original team for being cancer-free, they are rightfully looking to get their quality of life, sense of well-being, and their body image back. However, as mentioned at the start of this blog, due to the hindering effects of radiotherapy on wound healing, the best treatment for poor cosmesis after breast conservative therapy is to prevent it in the first place! I was most shocked to see that in the current patient information page by the American Cancer Society, having an indentation in the breast following lumpectomy is considered an expected outcome (Picture 10)! While I do inform my patients that they may occasionally get an indentation in their breast following their lumpectomy, I would consider that an aesthetic failure and not a norm!
Picture 10: Extract from the current patient information page on lumpectomy from the American Cancer Society. I was surprised to see that patients are still informed that a breast indentation following lumpectomy is an often-expected outcome! In my opinion this is an aesthetic failure that should be avoided by a good surgical planning and technique and should only be considered as a rare but possible complication after lumpectomy. https://www.cancer.org/cancer/breast-cancer/treatment/surgery-for-breast-cancer/breast-conserving-surgery-lumpectomy.html
In summary in my opinion a good breast conservative surgery is a surgery that is considerate to what we leave women to live with for the rest of their lives! Modern breast conservative techniques are invaluable recent addition to our armamentarium in treating breast cancer and should be an integral part of training programs for our future breast cancer surgeons. A thorough and detailed patient assessment is crucial in deciding on the type of surgery, which considers individual patient’s wishes and desires, oncological risks, and background comorbidities.