
Oncoplastic Breast Surgery
David M. Hyams, M.D., F.A.C.S.
Breasts contribute to the classic female form and are an important part of feminine identity. They also have a significant sexual association and have been a source of both pride and insecurity for women of all ages.
Breasts are also an important site of disease. More than 260,000 new cases of breast cancer are diagnosed each year in the US, leading to more than 41,000 deaths. The intersection of cosmetics, sexual identity, and threat, make management of breast cancer complex, and important beyond simple disease control.
Surgery continues to be important in the staging and control of local disease. Significant tissue removal is still required for many patients in order to meet current guidelines for care. For individuals needing more generous resections, the outcome of standard cancer surgery may be suboptimal, leaving concavity deformities, nipple distortion, and significant size disparity compared with the remaining breast.
The use of oncologic surgical techniques, and the incorporation of plastic surgical principles (Oncoplasty), allow better cancer surgery with better cosmetic outcomes. Such techniques optimize adequacy of resection. They provide a better chance of complete tumor removal, even when disease is diffuse and subtle. The resection defects can immediately be reconstructed using local tissue rearrangement to fill in gaps. Careful planning can minimize the impact of scar while providing better operative exposure. Incisions can be made around the border of the areola, or in natural lines of tension, hiding the healed scar. Incisions may also be made in the crease under the breast, making a scar invisible when a women is standing.
In some cases, patients with larger breasts, may have a cancer resection combined with a breast reduction-type incision that will leave them with a better-shaped somewhat smaller breast mound. This approach allows optimal access to a cancer from the front and allows lymph node sampling without a separate incision in the underarm. Remaining breast tissue volume re-arranged to create and maintain a more youthful “cone” of breast tissue that is supported by a newly tailored skin envelope.

Postoperative Right Breast Radiation therapy
and Left Reduction

Postoperative Right Breast Radiation therapy
and Left Reduction
In some cases, absorbable implants, or even gel implants, can be used to replace volume loss. The absorbable implants (BioZorb), have an open architecture that allows tissue ingrowth, so that the implants are replaced by native tissue with disappearance of the implants in 2 years. Yet titanium markers in the implants are left behind useful for identifying the former tumor location. These markers optimize radiation therapy (when needed) and facilitate future mammographic followup.
Plastic surgical techniques can also be used to reconstruct a breast when mastectomy is indicated. This is most commonly done with tissue expansion, using inflatable saline expanders implanted under the skin envelope of the breast(s). These stretch the skin and surrounding tissues, allowing final reconstruction with gel implants.
For most patients, having a surgical oncologist who integrates oncoplastic surgical technique, means fewer preoperative and postoperative consultations, easier surgical scheduling, and more efficient perioperative care. Oncoplastic surgical oncology care of the breast has been shown to enhance cancer outcome, maintain or improve cosmesis, reduce the need for cancer-related re-operation, reduce the need for subsequent unplanned mastectomy, and improve patient satisfaction.
Oncoplastic breast surgery represents an ability to combine the best in oncologic breast cancer management with a plastic surgical toolbox. It is a quantum improvement in care that should be available to all breast cancer patients. Oncoplastic surgery achieves more effective cancer intervention, while maximizing form and function.