Overview
Definition:
Oncoplastic breast reconstruction is a surgical approach that integrates oncological tumor removal with plastic surgery techniques to achieve optimal aesthetic outcomes following breast cancer surgery
Level I reconstruction typically refers to simpler, less complex techniques, often involving local tissue rearrangement or minor augmentation, suitable for smaller defects or less extensive resections.
Epidemiology:
Breast cancer incidence is significant globally and in India
The demand for breast conservation surgery (BCS) and subsequent reconstruction is rising, driven by patient preference and improved oncological outcomes
Oncoplastic techniques are becoming increasingly integrated into standard breast cancer management protocols.
Clinical Significance:
Oncoplastic reconstruction is crucial for improving the quality of life and body image for breast cancer survivors
It allows for wider margins in tumor excision while minimizing cosmetic deformities, thereby enhancing patient satisfaction and adherence to adjuvant therapies
Understanding Level I techniques is foundational for residents aiming to offer breast-conserving options effectively.
Indications
Oncological Indications:
Tumor excision requiring significant tissue removal but amenable to preservation of the breast mound
Tumors located in positions where standard lumpectomy would result in unacceptable deformity
Patients seeking to maintain breast symmetry and shape post-BCS.
Cosmetic Considerations:
Desire to avoid mastectomy or to achieve a better aesthetic result compared to conventional lumpectomy
Patients with ptotic or macromastic breasts may benefit from therapeutic mammoplasty components within oncoplastic reconstruction.
Patient Selection:
Good general health for surgery
Realistic expectations regarding outcomes
Absence of contraindications to oncological resection or reconstructive techniques
Multidisciplinary team discussion to confirm suitability.
Preoperative Preparation
Preoperative Assessment:
Detailed history and physical examination, including breast size, shape, ptosis, and tumor characteristics
Mammography, ultrasound, and potentially MRI for tumor staging and assessment of breast volume
Photography for baseline documentation and planning.
Oncological Planning:
Clear demarcation of tumor margins
Discussion with pathologist regarding specimen orientation
Decision on the extent of resection based on tumor size, location, and oncological safety
Multidisciplinary tumor board review.
Reconstructive Planning:
Selection of appropriate Level I technique based on defect size and location
Assessment of available local tissue for rearrangement
Planning for potential contralateral symmetrization if required
Informed consent covering risks, benefits, and alternatives.
Level I Reconstructive Techniques
Local Tissue Rearrangement:
Involves reshaping existing breast tissue to fill the defect after tumor excision
Examples include: Wise pattern reduction mammoplasty (inverted T scar) or vertical scar techniques adapted for oncological resection
Often used for central or inferior tumors.
Therapeutic Mammoplasty:
A reduction mammoplasty performed on the affected breast concurrently with tumor resection, designed to excise the tumor while reshaping the breast
Can address asymmetry due to ptosis or macromastia
The contralateral breast may require reduction or mastopexy for symmetry.
Advancement Flaps:
Simple flaps created from adjacent breast tissue, such as superior or inferior dermal flaps, to cover the defect
These are typically minor reconstructions for small to moderate defects, aiming to provide immediate volume and shape.
Mesh Augmentation:
In specific cases, a small defect might be augmented with synthetic or biological mesh to provide structural support and fill volume, particularly when local tissue is insufficient
This is less common in standard Level I but can be an adjunct.
Surgical Procedure Steps
Tumor Excision:
Careful excision of the tumor with adequate oncological margins
Specimen orientation for pathological assessment is critical
Haemostasis is meticulously achieved.
Defect Management:
Assessment of the resulting defect size and shape
Decision on the reconstructive technique based on preoperative planning and intraoperative findings.
Tissue Mobilization And Rearrangement:
Mobilization of local breast tissue or flap creation as per the chosen technique
Undermining of skin flaps to allow for movement and closure without tension
The breast parenchyma is then reshaped and repositioned to fill the defect and reconstruct the breast mound.
Closure And Drains:
Layered closure of subcutaneous tissues and skin
Placement of drains if indicated to manage seroma formation
Application of dressings and surgical bra.
Postoperative Care
Wound Care:
Regular dressing changes
Monitoring for signs of infection, dehiscence, or flap necrosis
Management of drains, including timing of removal based on output.
Pain Management:
Adequate analgesia, typically with oral or intravenous analgesics
Consideration of nerve blocks for enhanced pain control.
Monitoring For Complications:
Close observation for hematoma, seroma, infection, and flap viability
Assessment of breast shape and symmetry
Patient education on activity restrictions and self-care.
Follow Up Schedule:
Early postoperative visit within 1-2 weeks
Subsequent follow-up based on oncological and reconstructive needs, including adjuvant therapy planning and long-term surveillance for recurrence.
Complications
Early Complications:
Hematoma
Seroma
Wound infection
Skin necrosis or flap compromise
Asymmetry
Pain.
Late Complications:
Cheloid or hypertrophic scarring
Loss of sensation
Persistent asymmetry
Breast contour irregularities
Impact on future mammographic screening interpretation.
Prevention Strategies:
Meticulous surgical technique
Careful haemostasis
Appropriate use of drains
Gentle tissue handling
Adequate patient selection
Prophylactic antibiotics where indicated
Appropriate garment support postoperatively.
Key Points
Exam Focus:
Level I oncoplastic techniques are primarily about tissue rearrangement and reshaping for smaller defects following breast conservation surgery
Key Level I procedures include therapeutic mammoplasty and local flaps
Understanding the indications and limitations of each is vital.
Clinical Pearls:
Always consider contralateral symmetrization early in planning, even for Level I reconstruction, to achieve the best aesthetic result
Adequate undermining of skin flaps is crucial for tension-free closure and flap survival
Patient selection and realistic expectations are paramount.
Common Mistakes:
Underestimating the defect size, leading to inadequate tissue rearrangement
Insufficient undermining of flaps
Over-reliance on mesh for volume without adequate native tissue
Failing to plan for contralateral symmetry, resulting in significant asymmetry.