Oncoplastic Surgery

Overview

Oncoplastic surgery is an essential component of all breast cancer procedures. The utilization of an aesthetic approach for breast conservation or mastectomy expands the number of options available for women with breast cancer, cyst or other benign breast diseases. It should be the accepted standard of care. Although various operational procedures are documented, an organized strategy to identifying acceptable approaches is required.

The goal of an oncoplastic treatment is to minimize aesthetic harm to the breast by removing surgical cavities that cause distortion; hence, the words parenchymal redistribution or parenchymal replacement have been employed.

 

What is Oncoplastic Surgery?

It is never easy to go through breast cancer therapy. It might be reassuring to know that there are options available to help you look and feel your best following breast cancer surgery.

Oncoplastic surgery, also known as oncoplasty, is a novel procedure that combines the most recent advances in plastic surgery with breast surgical oncology. Your tumor is removed in one treatment, and your remaining breast tissue is reshaped to give you a more natural breast look and symmetry.

Breast indentations and unevenness can arise after traditional breast cancer surgery. Oncoplasty addresses the major influence on body image and self-esteem that this can have by eliminating cancer cells as fully as other forms of breast cancer surgery while attaining the greatest possible look.

You can feel good about your therapy and how you'll appear when it's over.

 

How Oncoplastic Surgery Works?

Oncoplastic surgery is typically performed in conjunction with a lumpectomy. To begin, the tumor, a small amount of surrounding tissue, and potentially part of the neighbouring lymph nodes will be removed by the surgeon. The plastic surgeon will then do a bilateral breast reduction or breast lift to make the two breasts symmetrical.

The breast cancer surgery and plastic surgery operations are conducted sequentially. This has various advantages:

• Only one surgical session is required.
• Allows for the removal of more tissue, which is useful for larger tumors.
• It makes producing symmetrical breasts easier.
• Performed prior to radiation therapy, which assists patients in avoiding potential risks associated with exposing surgical incisions to radiation.

 

Indications of Oncoplastic Surgery

Breast-conservation surgery (BCS) has been proven to be a safe alternative for the majority of women with early breast cancer. In reality, in patients with Stage I or II breast cancer, the 5-year survival of BCS with radiation is not statistically different from mastectomy alone. These surgeries are often quadrantectomy and lumpectomy. A broad excision, encompassing skin and underlying muscular fascia, is frequently performed during quadrantectomy. The goal of a lumpectomy is to remove the tumor with no skin resection and with negative surgical margins.

Despite the fact that most BCS abnormalities may be handled with primary closure, the cosmetic outcome is uncertain and usually results in an undesirable result. In reality, between 10% to 30% of patients who have BCS are dissatisfied with the cosmetic outcome. The primary causes are associated with tumor excision, which can result in asymmetry, retraction, and volume alterations in the breast. Furthermore, radiation might have a deleterious impact on the native breast. The major clinical features include alterations in skin pigmentation, telangiectasia, and skin fibrosis. Local radiation produces fibrosis and retraction in glandular tissue.

Oncoplastic techniques have recently received more attention since the rapid use of plastic breast surgery methods allows for a broader local excision while still attaining the aims of enhanced breast form and symmetry. Indeed, current oncoplastic breast surgery combines oncologic and plastic surgery concepts to provide oncologically sound and aesthetically acceptable outcomes. Thus, by using personalized approaches, the surgeon guarantees that oncologic principles are not threatened while addressing the patient's cosmetic demands.

Oncoplastic methods, in general, are associated with volume displacement or replacement operations, and may involve contra-lateral breast surgery. Local flaps, latissimus dorsi myocutaneous flap, and reduction mammaplasty methods are the most widely used surgeries. Furthermore, the oncoplastic approach may begin at the moment of BCS (immediate), weeks later (delayed-immediate), or months to years afterwards (delayed).

Despite the fact that there is no consensus on the optimum procedure, the criteria are decided by the surgeon's experience and the extent of the defect in comparison to the remaining breast size. The key advantages of the approach used should be reliability, little interference with oncologic treatment, and long-term outcomes. All of these objectives are unlikely to be met by a single approach, and each technique has advantages and limits.

 

Contraindications of Oncoplastic Surgery

Absolute contraindications, which are reasons why the procedure absolutely cannot be done, include:

1. Pregnancy: Pregnancy is a major contraindication to breast irradiation. In rare circumstances, breast-conserving surgery during the third trimester and radiation treatment after birth may be possible.
2. Primary tumors: Two or more primary tumors in different quadrants of the breast, or microcalcifications that seem malignant.
3. Previous breast irradiation: A history of earlier therapeutic breast irradiation that would need re-treatment at an extremely high total dose.
4. Persistent positive margins: Persistent positive margins despite acceptable surgical attempts: the significance of a single focally positive microscopic margin warrants additional investigation and may not be an absolute contraindication.
5. Inflammatory breast cancer.
6. Diffuse or indeterminate micro-calcifications on mammography.

Relative contraindications are instances in which the patient is at a higher risk of consequences, which may be balanced by other factors, such as the patient's benefit. The following are relative contraindications:

1. Previous radiation treatment for the breast.
2. Scleroderma, Sjogren Syndrome, Lupus, and Rheumatoid arthritis are examples of connective tissue diseases that may increase the risk of radiation damage.
3. Very big tumor size in comparison to breast volume.

 

What are the Benefits of Oncoplastic Surgery?

While fighting breast cancer and restoring your health are your main priorities, changes in your looks following breast cancer surgery can have a substantial influence on your entire well-being. Oncoplastic surgery addresses the physical, emotional, and psychological elements of breast cancer surgery, resulting in the following benefits: 

1. Complete cancer removal with the best possible cosmetic outcome:

Oncoplastic surgery eliminates all malignant cells while maintaining a nice, natural-looking breast form. Oncoplasty is a new alternative for women who would otherwise need a mastectomy since even bigger tumors can be removed while maintaining your breast. Furthermore, radiation therapy, if required, can make lumpectomy indentations or deformities more difficult to cure afterwards. Before radiation therapy begins, your breast reconstruction is completed with oncoplasty.

 

2. A single surgery with a shorter recovery time:

Oncoplastic surgery combines tumor removal with rapid rebuilding utilizing your own residual breast tissue in a single procedure. It is frequently performed as an outpatient treatment, allowing you to go home the same day and have a simpler, quicker recovery period. And having only one operation implies minimal scars.

 

3. The breast will look more natural:

Scars are often practically invisible after oncoplastic surgery, and your nipple stays intact, resulting in a natural appearance with little or no loss of feeling. Instead than waiting months between cancer removal and reconstructive surgery, you feel "normal" almost immediately.

 

4. Reshaping of non-cancerous breast can be done at the same time so your breasts are symmetrical:

Because tissue is removed during cancer surgery, your breast shrinks. As a result, your breasts may differ in size or form. You can opt to have your non-cancerous breast lowered and elevated at the same time during oncoplastic surgery, so both breasts seem even and natural.

 

Oncoplastic Options

Oncoplastic procedures vary based on the features of the malignancy, the patient's health and physique, and the intended goal. Some of the most frequent are:

1. Local Advancement Flap:

During a typical lumpectomy, a tumor and a tiny part of the surrounding tissue are excised. However, depending on the size and location of the tumor, this might distort the breast.

Instead, a local advancement flap lets surgeons to use the tissue that remains after removing a tumor to rebuild the natural look of the breast. There are no more indentations or defects.

 

2. Bilateral Breast Reduction:

When only one breast is removed after a lumpectomy, its size and shape might be altered. A bilateral breast reduction addresses this issue by reshaping the opposite breast as well.

This approach offers various advantages. A bigger quantity of tissue is removed when operating on the opposite breast. This can be useful if the tumor is huge and more tissue is needed. Modifying the opposite breast will also assist to improve the symmetry of both breasts.

During the procedure:

The method utilized to lower the size of your breasts might differ. The technique might include:

• Incision-based surgery.
• Liposuction can be used to remove extra fat from your breasts.

Typically, the surgeon will:

• Incisions are made around the areola and down each breast.
• Excess breast tissue, fat, and skin are removed to minimize the size of each breast.
• Repositions the nipple and areola and reshapes the breast

The nipple and areola:

• Typically, they stay linked to the breast.
• If your breasts are exceptionally large, they may need to be removed and then reattached at a higher location as a skin graft.
• Although your surgeon will make every effort to achieve symmetry between your breasts, some variance in breast size and form may occur. The areola's size may also be lowered. Your incision scars may decrease over time, but they will never be totally gone.

 

3. Bilateral Breast Lift (Mastopexy):

A bilateral breast lift, often known as a mastopexy, is a less invasive method of bilateral breast reduction. This is a fantastic choice for women who do not want to drastically alter the form of their breasts.

Rather than removing a considerable quantity of tissue from both breasts, just the original excision is eliminated (as well as a comparable amount on the other breast). Additional cosmetic procedures, such as nipple relocation, can be used to assist the breasts become more symmetrical.

Your breast lift will take place at a hospital, an outpatient surgery facility, or the doctor's own operating room. Before the operation, you will meet with the anesthesiologist, surgeon, and nursing staff.

The surgeon will note the exact location of your nipple. After that, you'll be taken to the operating room for general anesthesia or sedation.

The surgeon will remove excess skin and raise your breast tissue into place. If you have implants, the surgeon will insert them before closing and bandaging your breasts. For the next 24 to 48 hours, you may have small drains in your breasts.

Your surgeon will remove all of your sutures in 2 to 3 weeks. The breast's size and form will continue to improve over time.

There may be minor symmetry deviations between the two breasts. If this is the case, your plastic surgeon will do a little touch-up operation to assist reposition the nipple as needed. Minor changes can be made later.

During your recovery, it is critical to limit your activities as instructed by your surgeon and to report any side effects or difficulties as soon as possible. Infection is a possibility with every operation. Permanent loss of feeling in the nipples or breast skin is extremely unusual after breast reduction surgery.

 

4. Skin-Sparing Mastectomy:

Skin-sparing mastectomies are safe for most individuals, but they are not suggested if you are not having immediate breast reconstruction since the residual skin may fold and contract.

It is also not advised if you have tumor cells near to your skin or if your malignancy affects your skin. If you have inflammatory breast cancer, for example, a skin-sparing mastectomy is not an option.

A mastectomy may be required for people with advanced-stage breast cancer. If this is the case, a skin-sparing mastectomy can assist the patient in preserving the appearance of the breast.

The skin of the breast, including the nipple and areola, is removed during this treatment. The breast tissue is then removed through the same incision. The excised skin, nipple, and areola will then be used to restore the breast. This helps them to keep the breast's natural shape and look.

Because a skin-sparing mastectomy removes less skin than a traditional mastectomy, you may be concerned that your breast cancer may recur. Several studies, however, have found that skin-sparing mastectomies do not increase the chance of recurrence.

 

Oncoplastic Surgery Recovery Time

You may be able to have the operation performed as an outpatient, or you may be required to stay in the hospital overnight. It is typical to have discomfort and numbness in the area surrounding your breasts and armpits. You will be shown how to care for the wounds at home, which bras to use, how to use drains, and how to recognize indications of infection.

The whole recovery time is around 6 weeks. Some people, however, feel better sooner and can return to work after 3-4 weeks.

 

Possible Problems With Oncoplastic Surgery

Problems immediately after surgery:

• Blood clots: 

Following surgery, you are at risk of developing blood clots in your legs (DVT).  A blood clot in your lungs (PE) is also a possibility.

Your nurses will get you up as quickly as possible following your procedure to prevent blood clots. They encourage you to get up and walk about or perform your leg exercises.

To assist lower the danger of blood clots, you may be given anticoagulant injections before, during, and after surgery. If you require this, your surgeon will discuss it with you beforehand.

 

• Wound infection:

Infection is a risk in each surgical procedure. You will need to relax and take medication if you get an infection following breast reconstruction. This usually clears up the illness in a week or so.

Infection symptoms include:

1. a temperature of above 37.5C or below 36C.
2. redness around the breast.    
3. fluid seeping from the wound (discharge).
4. feeling cold or shivery. 
5. feeling generally unwell.

 

• Fluid under the wound (seroma):

It is typical for the region to release fluid following any operation. You may need to insert two or more drains into the incision to drain the fluid. Drains are often long, thin tubes connected to vacuum bottles. Even if you have drains, fluid can gather behind the incision and cause swelling. This is known as a seroma. If blood collects, it is called a hematoma.

Sometimes the fluid is absorbed by the body and the swelling subsides on its own. If the fluid does not go away after a few days, your surgeon or breast care nurse will use a tiny needle and syringe to remove it.

If you've had an implant reconstruction and the fluid continues to build up, the implant may need to be removed and replaced later.

Seroma was once fairly prevalent following flap restoration from the back. However, surgeons have refined their skills, making it considerably less common.

 

• Flap failure:

The biggest concern with body tissue reconstruction is that the tissue flap utilized to create the new breast may die. This is considerably less likely with a flap that remains linked to its original blood supply (a pedicled flap).

TRAM and DIEP flaps must be detached and then rejoined to a fresh blood supply. Some persons may experience flap blood supply issues in the first 48 hours following surgery when using these approaches. If this occurs, you will need to return to the operating room as soon as possible to try to save the flap.

About three out of every hundred flaps (about three percent) fail entirely, and the cells in the whole flap die.If this happens, you will need to have surgery to remove the flap.

 

• Loss of sensitivity:

Your reconstructed breast will feel different and have less feeling than your other breast. You may have numbness or pins and needles following surgery. The sensation may improve with time, but it may not for some people.

If your flap fails entirely and must be removed, you will need to recuperate completely from the procedure. Typically, you must wait 6 to 12 months before attempting reconstruction again.

 

Longer term problems with implant reconstruction:

There can be problems after implant surgery, whether you have tissue expansion or the implant put in directly.

• Hardening and changing shape of the implant

The greatest long-term issue following implant surgery is the formation of a fibrous coating surrounding the implant. Silicone is not dangerous, yet it is strange to the body. The body's natural reaction is to create a fibrous capsule around it.

The capsule might shrink and compress the implant over time. This is referred to as capsular contracture by doctors. It causes the breast to become painful and rigid, as well as changing its contour. If the form changes significantly, the implant may need to be removed and replaced.

 

• Leakage of the implant fluid:

Many women are concerned about the implant leaking. The risk is substantially lower with newer types of implants. However, if you have a serious injury or blow to the breast, you may experience leaking.

Minor bumps and bangs, as well as plane travel, will not produce a leak. If the implant leaks, the lymph glands beneath your arm may enlarge.

If you detect a bulge or lump, if the breast is uncomfortable, or if the contour of the breast changes, call your doctor or a breast care nurse. If the implant has leaked, it will need to be removed and replaced.

 

• Unequal breasts:

Your repaired breast may no longer match the other one over time. This might occur if you lose weight or if the implant shifts. In this case, surgery is frequently performed to try to find a better fit. It is not always possible to make the breasts identical on both sides. However, your surgeon may be able to make them more equal.

If your weight changes, you may need to undergo surgery on your other breast. Alternatively, the surgeon might swap out the breast implant with a bigger or smaller one.

 

Conclusion

Oncoplastic breast surgery combines standard breast cancer surgery procedures with the aesthetic benefits of plastic surgery. The objective is to eliminate cancer while minimizing the negative side effects of surgery, allowing patients to rehabilitate physically and emotionally.

There are several oncoplastic procedures available, based on the features of the malignancy, the patient's health and physique, and the intended outcome. Local Advancement Flap, Bilateral Breast Reduction, Bilateral Breast Lift (Mastopexy), and Skin-Sparing Mastectomy are some of the most frequent.