Breast cancer: oncoplasty and new surgical techniques

By Cristiano Antonino On Oct 31, 2022

Let’s talk about breast cancer. Breast cancer is the most frequently diagnosed neoplasm in women: about 1 malignant tumour in every 3 (30%)

Breast cancer, knowing the disease

In order to initiate an appropriate therapeutic programme, even pre-surgery, it is not enough to know the result of the cytological examination, which only informs us whether the cells are healthy or not, but it is necessary to carefully evaluate the histological examination, which, as I often tell my patients, allows us to better understand the characteristics of the tumour, a bit like name, surname, address and postcode.

Oncoplastic breast surgery: what it is for

To use the word ‘demolition’ for the surgical treatment of the breast today is incorrect.

In fact, today’s approach to surgery is oncoplastic and has the following objectives

to obtain as much local control of the disease as possible
to use the techniques of aesthetic plastic surgery
to provide an optimal aesthetic result,
to meet the patient’s values and wishes.

Oncoplasty is, therefore, a new way of thinking and working that means approaching the tumour problem not as a single aspect, but as a complex of situations, to be managed as best as possible to meet an optimal result defined in advance, thanks also to multidisciplinary work.

Breast cancer, the techniques of breast oncology surgery

Speaking of breast oncological surgery, the most commonly used modern techniques at present are several:

Quadrantectomy;
Mastectomy;
Skin reducing mastectomy (SSM).

Quadrantectomy

Quadrantectomy is a conservative surgical procedure that consists of removing a quadrant of breast tissue in which, in addition to the neoplasm, a margin of healthy tissue is also removed, thus offering the possibility of radically removing the tumour while preserving a normal breast appearance.

To achieve this, it is often necessary to ‘reshape’ the breast using techniques derived from cosmetic surgery.

Mastectomy

Mastectomy is the surgical removal of the breast that, in the collective imagination, is now the demolition operation par excellence.

The specialist points out, however, that radical mastectomies (e.g. using the Patey or Madden technique), in which the breast is removed entirely together with a portion of skin that includes the areola and nipple, are rarely used today, and in any case reconstruction with implants or flaps is also possible for these.

Conservative mastectomy

Today, the majority of mastectomies have a conservative approach, hence the term ‘conservative mastectomy’, a term now commonly used worldwide, which Dr Nava first coined in a 2009 publication.

Conservative mastectomy always involves the radical removal of the mammary gland.

NAC (Nipple-areola compex-sparing) conservative mastectomy, if the skin envelope of the breast and the areola-nipple complex can be spared;
SKIN-sparing conservative mastectomy, if only the breast skin envelope can be preserved, but not the areola-nipple complex.

This type of technique allows for an optimal reconstruction, with implants, that is closer to a ‘normal’ breast in shape and size.

Skin reducing mastectomy (SSM)

Skin Reducing Mastectomy is a technique devised by Dr. Nava, published by him in 2006 and oncologically validated in 2011.

Suitable for medium to large breasts with a certain degree of ptosis (sagging), in SSM the tumour is removed by making the same incisions as in reduction mammaplasty used in cosmetic surgery.

This technique offers the possibility of immediate reconstruction with prostheses, bearing in mind, however, that the decision parameters must always be taken into account.

On the basis of what procedure is chosen in the case of breast cancer?

The surgical course is built around the woman, with a choice shared between the doctor and the patient, who must be clearly and completely informed about the entire surgical and therapeutic course, and with recourse, if necessary, also to psychological counselling.

A number of parameters are to be assessed in the decision-making process:

risk of recurrence of the neoplasm, derived from an analysis of the biological characteristics of the tumour as well as the patient’s
anatomy, shape and volume of the breast;
anatomical characteristics of the patient’s body;
quality and quantity of adipose tissue;
possible need for other therapies such as radiotherapy;
risk of post-operative complications;
the patient’s expectations, also in relation to the perception of the disease and her own image.

Breast cancer reconstruction

When conditions permit, the general trend today is to carry out reconstruction already during the tumour removal operation, so that the patient leaves the operating theatre without the mutilation of the mastectomy.

In some cases, however, for various reasons, mainly related to the patient’s own choices, it may be appropriate to postpone the reconstructive phase to a later date.

Breast reconstruction can take place using

expanders
prosthetic implants
flaps
lipofilling
hybrid reconstruction.

Let us look at these techniques in detail.

Expanders

When it is not possible to implant breast implants directly during neoplasm removal surgery, expanders can be inserted.

These are temporary implants filled with saline solution that gradually and regularly increase in volume to

stretch the breast tissues in view of the future application of permanent implants;
fill the skin envelope and allow lipofilling before being replaced by permanent implants.

Prosthetic implants

In order to be able to plan the reconstructive course in the best possible way, the doctor emphasises how it is necessary to view a mammogram before the operation, so as to assess how much fat thickness between the skin and the mammary gland corresponds to in the patient and to establish where to place the implants.

These can be implanted above the pectoral muscle, when the fat tissue between the skin and the gland removed with the mastectomy is thick enough to guarantee protection of the prosthesis and therefore a good cosmetic result.

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Sometimes it is necessary to cover the prosthesis with a ‘mesh’, synthetic or biological, which becomes mandatory in the case of post-surgical radiotherapy.

Prosthetic implants can be made with

dual plane technique: when the adipose tissue is of medium thickness, the ‘dual plane’ technique, the same used in cosmetic surgery, is recommended. The pectoral muscle covers the upper ⅔ of the prosthesis, while the lower third is covered by a ‘mesh’, synthetic or biological;
2-stage technique: when fat tissue is lacking, it is preferable to resort to the placement of a temporary expander, always inserted in relation to the thickness of the fat. Before removing it, 2 or more lipofilling will be performed to improve the final result, as the adipose tissue makes the breast warmer and softer.

Reconstruction with flaps

Reconstruction with flaps involves shaping the new breast with the use of

pedicled flaps, i.e. flaps that rotate from one side of the body to reconstruct the breast, with or without implants;
free flaps, which require microsurgery and are taken from the same or other areas of the patient’s body, such as the abdomen and back.

Lipofilling

If the removal of the tumour has not resulted in a particularly large removal of breast tissue, reconstruction with lipofilling, i.e. autologous transplantation of the patient’s own adipose tissue (fat), can be used to optimise the shape and naturalness of the breast.

This technique is also used in the aesthetic field, to give more volume to the patient’s breasts.

Hybrid breast reconstruction

The hybrid reconstructive technique, published by Dr Nava in 2015, is based, as the word itself implies, on the fusion of several reconstructive techniques: the use of implants, adipose tissue and mesh (synthetic or biological), with the aim of getting closer and closer to a natural breast.

The evolution of breast cancer surgery

Over the last few decades, breast cancer surgery has evolved towards a global approach not only aimed at preserving as much as possible, but also implementing a ‘tailor-made’ therapy, which varies from patient to patient, thanks to integrated protocols involving tailor-made surgical, but also radiotherapeutic, chemotherapeutic and hormonal treatments.

This also creates a synergy between different specialists, including:

senologist;
plastic surgeon;
medical oncologist;
radiologist;
radiotherapist;
pathologist;
psychologist;
geneticist;
physiatrist/physiotherapist.

In addition, the figure of the oncoplastic breast surgeon has become highly specialised and capable of mastering all reconstructive techniques with up-to-date expertise in oncology and reconstruction.

Even if for some reason the surgeon is unable to perform all the techniques in the field, he or she must at least be familiar with them and make the patient aware of them so that she can make an informed choice.

Lipofilling: towards the future

Today, studies are turning to the attempt to replace breast implants with autogenous adipose tissue alone, thanks to 3D photocopy technology with which scaffolds of the shape and size of the removed breast are constructed.

The scaffold is a 3D scaffold of resorbable material, which is inserted into the mastectomy cavity where it encourages the lipofilling fat cells to take root, resulting in a breast entirely reconstructed with adipose tissue.

Not all patients, however, have sufficient adipose tissue for the procedure, so advances in other techniques such as the hybrid technique will continue.

Breast cancer, let’s not forget prevention

At the end of the day, it must still be remembered that self-examination and breast screening programmes are the only way to do prevention as, unfortunately, breast neoplasms are asymptomatic in their early stages.

The stages in which, however, we also know, that by intervening correctly with appropriate treatment, we can achieve a 90% cure rate.

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