Oncoplastic surgery is the ability to use plastic surgical techniques to achieve better cancer outcomes. Of nearly equal importance, oncoplastic surgery provides an opportunity to maintain, or even enhance, natural appearance and contour.

Because we are oncology surgeons first, and not cosmetic plastic surgeons, we focus primarily on the cancer procedure and the cancer outcome. By using approaches, incisions, and reconstructive techniques developed in the world of plastic surgery, we can actually do better oncologic surgery.

Patients often think that the smallest incision is the best. And, while this may be true in some general surgical procedures, it is not necessarily true in oncologic breast surgery. What is more important is the location of incisions, the orientation of incisions, and the exposure that allows the most successful operation.

When we perform a breast resection through a W-shaped incision, most commonly used for breast reductions or lifts, we are able to elevate flaps of skin that give us remarkable exposure to the front, the sides, and the bottom of tumors we are resecting. It is a little like opening the hood of a car to work on its engine, rather than trying to do the work through only a small access panel.

Using these techniques, we can often remove large blocks of tissue, completely containing a target tumor, without the contour deformity that would result from a standard linear incision. This increases the healthy margin around a resected tumor and may reduce local recurrence.

Data from a large North American study, published in the New England Journal of Medicine in 2004, and updated in 2013, have shown that survival and distant recurrence is not adversely impacted when radiation therapy is omitted from patients over age 70 who have smaller hormone responsive breast cancers. This partly reflects a better tumor biology in an older population and partly recognizes that such individuals have other competing risks which may overtake their cancer risk.

However, these patients do have a slightly higher risk of local recurrence of their breast cancer. This represented an absolute difference of only 8% between those who did, and those who did not receive radiation. Again, this recurrence risk had no demonstrable impact on survival.

Eligibility for this study required only a clear margin of resection, which may have been as little as a millimeter or less. As most recurrences after lumpectomy occur in the same quadrant as the original tumor, it is likely that the low risk of local recurrence without radiation therapy, might be minimized with better surgical margins. Oncoplastic surgical technique optimizes this opportunity.

In patients with non-invasive cancer (DCIS), gene expression profiling can identify individuals in whom risk of invasive local recurrence is low. Large prospective studies have never demonstrated a survival value to radiation therapy for in-situ disease; it makes sense to avoid such treatment in low-risk individuals.

Having a low-risk gene expression risk profile from the original biopsy specimen facilitates planning. A more aggressive local resection using oncoplastic technique may completely remove in-situ disease, achieve wider margins, and permit avoidance of radiation therapy. Conversely, individuals with a high-risk gene expression profile, may have an average recurrence risk of 20%, extending up to 27%, even after radiation therapy. When considered with other risk factors, some of these patients may entertain more aggressive surgical approaches, including planned skin and nipple-sparing mastectomy with immediate reconstruction.

Breast cancer management with oncoplastic surgery may lead to better cancer and cosmetic outcomes. Oncoplastic breast surgery may also help appropriately selected individuals avoid unnecessary additional treatments like radiation therapy. Dr. Hyams can help you understand your best choices, providing you with an optimized journey back to better