Oncoplastic surgery: extending the limits of breast conservation.

The majority of patients presenting with early breast cancer are suitable for breast conservation. Patient expectation of the highest levels of aesthetic outcome can now be met by the oncoplastic skills of specialist breast surgeons. The time for repair of the volume deficit created by cancer resection is at the time of the primary operation. Gone are the days when surgeons simply left the cavity to fill the haematoma or seroma. The therapeutic changes and resulting contracture following radiotherapy potentially result in a volume defect and retraction that is difficult to correct in the secondary setting. This primary repair can be achieved by utilising adjacent breast tissue using a non-axial blood supply and in its most simple form consists of an advancement or rotation flap of glandular parenchyma. More formalised methods of volume displacement include the central round block repair, the Grisotti flap and various modifications of standard breast-reduction techniques.

Volume replacement involves the transposition of tissue from distant sites. The most common form is the utilisation of the latissimus muscle. Variants of the procedure are described, utilising part of the muscle as a mini-flap and myosubcutaneous flaps to minimise donor site morbidity and scarring. A major disadvantage of volume replacement procedures is the need for a donor site and the increased time to recovery that may follow from harvesting autologous tissue. Volume displacement and replacement techniques are discussed by Benson and Absar in the first feature article of this issue. Macmillan et al. share their experiences from the Nottingham Breast Unit and their pioneering work in this field in the second article.

It is often assumed that breast-conservation surgery enhances patient satisfaction and quality of life. Evaluation of outcome measures and the tools available for assessing these parameters are often subjective and complex. Objective or semi-quantitative measurements such as breast retraction analyses, photographic assessment or panel scores do not necessarily translate readily into patient perception. The issues surrounding attempts to standardise and hence facilitate comparison of quality-of-life measures in the context of breast conservation is addressed by Potter and Winters in the final article of this issue.

Breast cancer survival following modern multimodal treatment for early breast cancer is associated with improved outcome. The importance of good local control by optimum surgery and radiation therapy is essential. Loco-regional failure can be minimised by wide margins followed by appropriate adjuvant therapy, and oncoplastic surgery techniques extend the limits of breast conservation to a new dimension. In the longer term, after patients have recovered from their cancer treatment, the aesthetic form of their conserved breast serves as the principal reminder of their cancer diagnosis and future prognosis on a daily basis. As surgeons, we have an opportunity to optimise the aesthetic outcome with skilled oncoplastic breast-conservation surgery.

Gerald Gui

Academic Surgery (Breast Unit), The Royal Marsden NHS Trust, London, UK