Approach Toward Oncoplastic Breast Surgery: Local (Flap) Solutions for Indian Problems

Introduction 

Oncoplastic breast surgery (OPBS) is the new normal for performing breast cancer (BC) surgery in patients who are deemed suitable for breast conservation surgery (BCS). The conventional method of BCS of leaving seroma cavities results in unacceptable deformities, especially in tumors located in the inner, central, and lower half of the breast and with large-volume resections [1]. The principles of OPBS mandate one to close the primary cavities in the breast applying sound plastic surgery principles to avoid unpredictable shrinkage of the cavity [2, 3]. The concept of OPBS was introduced in the 1990s [4, 5] in the West. In the Indian setting, when the acceptance of BCS itself is low due to an irrational fear of the recurrence of cancer, reconstructive surgery is often perceived as unsafe [6]. This, compounded with a lack of awareness among primary healthcare providers and patients about the safety of BCS, results in a higher rate of mastectomy despite available evidence [7]. This scenario is changing rapidly because of increasing awareness and better multimodality treatment.

More and more women are demanding BCS and are concerned about cosmetic outcomes. While adopting oncoplastic procedures for breast surgery, one needs to exercise caution balancing the obvious cosmetic benefits vis a vis oncological safety as the level of evidence for the safety of OPBS is low [8]. Most of the prospective/retrospective evidence comes from the West where BC presents in the early stage. In India, 40% of patients have locally advanced breast cancer. The median tumor size is around 3 cm, and 60% of EBCs are node-positive [9, 10]. In BCS, anterior resection often includes the skin, and placement of incisions distant from the primary is not advisable due to larger tumor size and proximity to the skin with a potential threat of positive anterior margin to the oncological outcome. There is overall reluctance for contralateral breast symmetrization procedures from the patients; hence, the choice of surgical procedures is restricted and has to be personalized each time as per patient choice and available expertise. The oncoplastic techniques can be used for maintaining the shape, size, and contour of the breast for preserving symmetry with some leeway on the visibility of scars. Latissimus dorsi (LD) myocutaneous flap has been traditionally used as the workhorse of partial breast reconstruction for early as well as locally advanced tumors [11]. There is a possibility of employing alternative local flaps in suitable settings.

We describe an easy-to-follow approach for OPBS more applicable in our setting using local flaps. This is based on our experience, utilizing simple yet effective plastic surgical principles which can be replicated by most breast surgeons, plastic surgeons, or general surgical oncologists across the country.

Understanding Vascularity of the Breast and Thoracic Trunk

The blood supply of the breast is predominantly from the 2nd–6th internal mammary artery perforators (60%), the lateral thoracic artery (25%), the thoraco-acromial artery, and the intercostal perforators. It is oriented in such a way that the “shell” is more robust than the “core.” The perforators emerge at consistent points from deeper vessels primarily contributing to the dermal and subdermal plexus [12] (Fig. 1a–d). This dermal-subdermal plexus is used for planning breast and local flaps for partial breast reconstruction. We discourage dual plane mobilization (i.e., subcutaneous as well as on the pectoralis major) for the fear of missing the subdermal plexus and risking the vascularity of the glandular flap (Fig. 1e). A dermo-glandular flap is more robust (Fig. 1f), and the axiality of blood flow is established by angiographic studies where the chest wall perforasomes are perpendicular to and away from the midline [13] (Fig-SI-1).

Fig. 1.

Vascular supply of the breast—a venous drainage, b arterial supply, c, d vessels running parallelly subdermally in the subcutaneous plane, e glandular flap after dual plane mobilization, f dermo-glandular flap and single plane mobilization includes the subdermal plexus (the encircled areas represent strong subdermal plexus)

Choice of Procedure in OPBS

There are various classifications of OPBS based on volume displacement and replacement procedures [14]. For practical decision-making, the 3 most important points in choosing the OPBS procedure are breast size, degree of ptosis, and breast/tumor (B/T) ratio. For a small-sized breast, a 15% defect may need replacement. Inner, central, and lower quadrants are more prone to cosmetic deformities requiring primary prevention. The other important factors are the availability of the donor site and the surgeon’s experience as depicted in the flowchart (Fig. 2).

Fig. 2.

Flowchart of important factors determining choice of OPBS procedure

The typical ladder of OPBS starts from the minimal type-1 procedures utilizing the dermo-glandular unit which is enough in most patients. This is followed by more complex plastic surgery volume replacement procedures. In patients with large, ptotic breasts who have a large defect, a reduction mammoplasty or mastopexy-based procedure is most suitable rather than a volume replacement procedure (Fig-SI-2b). The common application of local flaps is in small-to-moderate defects in moderate-sized, non-ptotic breasts. Most of these local flap designs are based on 3 basic plastic surgical principles of transposition, rotation, and advancement of tissue (Fig-SI-2a).

Type-1 Oncoplastic Procedure

In the simplest form of OPBS to obliterate the cavity, proper incision planning, parenchymal glandular mobilization preferably using a dermo-glandular unit, and closure of the cavity work effectively. Small defects comprising 10–15% of breast volume reaching the NAC, excised with a radial incision, in small-to-moderate-sized breasts are ideal candidates. The parenchyma can be mobilized in a uniplanar manner off the chest wall. Dual plane mobilization (i.e., in subcutaneous plane as well as pre-pectoral plane) generates excellent excursion/movement to fill the defect but renders the vascularity precarious, prone to fat necrosis in the early and late post-operative period. This is accentuated in fatty breasts with poor turgor in older patients. The rich dermal-subdermal plexus can be utilized, and this inclusion of the skin for dermo-glandular flaps is a trade-off between additional scars versus rich vascularity. When applied to our sociocultural context, good shape takes precedence over additional scars which are unlikely to be ever exposed.

Appropriate incision planning is essential for minimizing nipple displacement and preventing hypertrophic scars. The conventionally followed dictum of circumareolar incision in the upper half of the breast and radial incisions in the lower half is not the norm anymore. The theories popularized by Langer (incision in line with the underlying muscle) and Kraissl (incision perpendicular to the underlying muscle) are contradictory to each other and lack the effect of a biodynamic component in scarring. They also do not take into consideration the effect of age, gravity, and degree of ptosis and the effect of shape and active movements which are peculiar in the breast. Vertical excisions in the upper part are acceptable in the ptotic breast as a force of gravity will cause increased tension on a horizontal scar. On the lower half of breast, due to the high anterior–posterior curvature, horizontal excisions do work better [15]. Hence, the current practice of incision planning should concentrate on increasing tension in the line of the scar while diminishing perpendicular tension resulting in a cosmetic scar. We routinely employ radial incisions in the upper half as well as the lower half of the breast especially when skin resection is involved, followed by a simple type-1 closure demonstrating excellent long-term cosmetic results (Fig. 3a–f). The dog ear might sometimes impinge on the NAC distorting it in which case the NAC can be repositioned. Almost 50–70% of the NAC can be raised as a flap, with a semi-circumareolar incision, based on the side opposite the defect. Then, the parenchyma is sutured to obliterate the cavities and NAC repositioned, and any skin overlapping under its surface is de-epithelized (not excised as dermis provides support to the overlying NAC against sinking) (Fig. 3g–j).

Fig. 3.

Radial incision planning on all quadrants of the breast—a, b outer central, c, d upper outer, and e, f lower inner regions of the breast; g previous excision biopsy periareolar scar with tunneling, h triangular incision and en bloc resection, i primary closure of cavity with de-epithelization of circumareolar skin for NAC repositioning, and j post-operative day 14 outcome

Breast parenchymal mobilization (essentially rotation flaps of breast tissue sans skin) is often employed for a small defect when no skin over the tumor is excised and excision biopsy is done with a periareolar scar with tunneling. This is a repurposing of the Benelli mastopexy which is done for ptosis correction of small defects. Benelli first reported a round block technique (RBT) for mammoplasty in 1990 to restrict the scar to the areola [16]. Since then, Benelli’s doughnut mastopexy, popularly called RBT, is routinely employed for oncoplastic reconstruction for small defects [17]. However, extreme caution needs to be exercised when a choice is made to tunnel resection through a more cosmetic incision in invasive ductal carcinoma, and the anterior margin should not suffer at any cost, especially with the larger tumor. Also, the effect of tunneling for the excision of breast tumors may be detrimental and is not conventionally recommended.

Local Flaps for Volume Replacement

In larger defects, it is necessary to obliterate the cavity by volume replacement rather than displacement. To understand the defect, 3 things are essential. First, the absolute volume of defect in three dimensions and skin excision in both dimensions needs to be considered. The relative size of the defect as a percentage of total breast volume is next. Lastly, location of the defect with respect to the quadrant and its proximity to the nipple-areola complex (NAC) is considered. One needs to assess the donor site accurately, with a pinch and pliability test which essentially is gently pinching the skin and subcutaneous tissue to understand the available donor site volume with easy primary closure. Other characteristics of the donor site such as the thickness of the dermis, pliability, and available subcutaneous tissue should be then considered. The amount a donor site can offer with tension-free primary closure should match the defect requirement. In a large breast where volume replacement with reduction mammoplasty is planned, the donor lies within the breast. When a volume replacement with a local flap is planned, the donor site lies outside it. The lateral chest wall (between axillary lines), back (LD flap territory), and upper anterior abdominal wall (below IMF), all possible sites for local flaps based on random and/or perforator-based designs, should be subject to this assessment as per the location of the defect. Donor site variability should have a bearing on the choice of flap and its design, e.g., a deficient lower pole is a poor indication for Grisotti or Wise-pattern skin excision with an inferior dermo-glandular flap. Another example is a thin lateral chest/upper abdominal wall; any intercostal artery perforator–based flap or random pattern flap will fare poorly if there is no adequate tissue to match the defect. The majority of local flaps are based on 3 essential plastic surgical principles of rotation, transposition, and advancement of tissue (SI-2a). Choosing the appropriate flap and correct design based on a morphological match between the defect and donor is key to good cosmetic outcomes. One flap and design does not work for all defects, and individualization of the procedure is mandatory.

Rotation Flap for Lower Quadrants of the Breast

Inner quadrant, lower pole defects with excess/adequate tissue in remnant/central and lateral lower pole are the best candidates for planning rotation dermo-glandular flap. The resection is triangulated with the apex toward the NAC. The flap is designed to be based superiorly, and incision is extended just above IMF, merging in the lateral breast fold. The pliability of the breast tissue ensures that a back cut into breast tissue is not needed. The flap is elevated off the chest wall till the NAC and base of the flap up to the anterior axillary fold. A tension-free closure is then obtained in two layers. The extension into the IMF is a hidden scar and is well accepted by most patients (Fig. 4). This is also referred to as J-plasty or L-plasty [18].

Fig. 4.

Rotation dermo-glandular flap for lower inner quadrant tumor—a triangular resection of skin and tumor, b inner quadrant defect, c IMF incision and mobilization of lateral breast flap, and d pre-operative and e post-operative outcome

An alternative flap often described to be used in this location is the thoraco-epigastric (TE) flap (Fig-SI-3). The TE flap is a transposition design flap with blood supply from the perforating branches of the superior epigastric artery. It can be used for the reconstruction of defects in the lower inner part of the breast closer to IMF [19].

Wise-Pattern Closure for Lower Central Defects

The lower central quadrant of the breast is another area prone to unsightly cosmetic deformity called parrot-beaking. A one-sided rotation flap design can also be employed for the lower central area in patients with a bulky lateral pole. However, most cases would need two dermo-glandular rotation flaps, medial and lateral, developed using incisions in IMF. The inverted T-closure is again well hidden in IMF and maintains the lower pole fullness and contour (Fig-SI-4). However, one needs to rule out the need for more volume replacement necessary for a larger defect or a reduction-based procedure for a ptotic breast.

Transposition Flap for Outer Quadrant Defects

We previously published the versatile design of the transposition flap used for the reconstruction of large-volume defects of the outer half of the breast [20]. This flap is essentially a random pattern flap, based on the dermal-subdermal plexus utilizing the redundant skin and fat over the lateral chest wall. It can be effectively used to replace skin and parenchymal defects, either alone or in combination, does not have a steep learning curve unlike the perforator flaps, does not need handheld doppler devices or magnification, and can effectively save many LD flaps (Fig. 5). The video link of the technique of this flap is also available for reader perusal [20].

Fig. 5.

Long-term cosmetic outcomes of transposition flap. a, b Left breast UOQ defect—parenchyma and skin replaced—c, d right breast LOQ parenchymal defect replaced by a completely de-epithelized transposition flap from the lateral chest wall, and e, f right UOQ defect reconstructed with transposition flap in a patient with ptotic breast refusing bilateral reduction

Hatchet Design Flap

This design works best for central defects with or without areola excision, combined with upper (inferiorly based) or lower pole defect (superiorly based). Adequate bulk in the lateral chest wall (skin and fat), amenable to tension-free primary closure, is mandatory. It is a good choice in breasts not suitable for solely volume displacement procedures like Grisotti, mastopexy, or reduction mammoplasty, when only displacement is insufficient and replacement with an LD an overkill. The “hatchet design” combines elements of rotation flap and VY advancement. The two “blades” of the hatchet are de-epithelized, stacked onto each other, and filled into the defect. The “leading edge” of the hatchet, closer to the defect, is “volume displaced” into the defect. The “lagging edge” from the lateral chest wall is “volume replaced” into the primary or secondary defect (Fig. 6, Fig-SI-5).

Fig. 6.

Hatchet flap for lower central and retroareolar breast defect—a lower inner, central, and retroareolar defect; b hatchet design flap; c graphic demonstration of the two limbs of the hatchet, area to be de-epithelized marked in green; d primary closure in a single layer after de-epithelization and burying for volume; and e, f post-operative day 14 outcome

Latissimus Dorsi Workhorse Now Converted to Backup Flap

Latissimus dorsi flap provides a reliable backup flap for almost every partial breast defect. Any reduction/pexy/local perforator or random pattern flap if doubtful to succeed at the planning or execution stage should be promptly abandoned or altered. LD flap can potentially replace or add to it. It might add some time to surgery and functional morbidity, but a good cosmetic outcome is assured (Fig-SI-6).

Involvement of Radiation Oncologist in the Treatment Plan of OPBS

When the patient undergoes lumpectomy without any OPBS, it is easy to delineate the tumor bed as the scar is overlying the lump cavity defined by the seroma, base clips. However, the scar and postop changes are not surrogates of the original tumor location when a patient undergoes OPBS and hence pose problems for tumor bed (TB) localization. It has been observed that there is gross under-reporting of radiotherapy details in OPBS studies with respect to the proportion of patients receiving a boost, total dose, fractionation, and technique as well as methods of TB localization. Two-thirds of patients’ boost was forgotten as reported by Shah et al. [21]. This should be kept in mind while extrapolating Western data in our patient population since, for higher stages, a boost is almost always employed in post BCS radiotherapy planning for invasive cancer. Type-1 oncolopasty does not entail mobilization of the breast tissue out of the index quadrant; hence, it is easier to delineate TB in such cases. The main issue is with type-2 OPBS where several techniques have been described, and each technique has a different impact on the lumpectomy cavity closure, shape, and relocation either away or toward the index tumor quadrant. Depending upon the technique, lumpectomy walls can move either laterally or supero-inferiorly with sometimes absolutely no relation with the skin incisions. Hence, post type-2 OPBS, it is challenging for radiation oncologists to make sense of or track the TB changes. In such cases, discussion with the surgeon and radiologist is the key for optimal radiotherapy planning [22] (Fig-SI-7). A pre-operative CT scan, intraoperative insertion of TB clips, and post-operative CT simulation are helpful. Similar additional imaging like preop PET or postop US can be used [23].

Discussion

The BC epidemic in India must be matched by the “breast reconstruction and oncoplasty” one. The use of OPBS is an essential cornerstone for optimal BC management. The cosmetic outcome is important for social and psychological well-being and quality of life [24]. Bad cosmetic results can translate to significant depression and can have a significant negative impact on mental health especially with improved survival. However, the principles of oncological resection should not be compromised at any cost, especially in the absence of a high level of evidence for safety. Achieving an adequate oncological safe margin should be the primary aim of BCS. Placing hidden, cosmetic incisions and tunneling for cancer resection are traditionally forbidden for the larger-sized tumors that we see in our country. The most important thing is to select the technique first for oncological safety and then for better cosmesis. Larger resection volumes and skin resections are needed in our patients and may necessitate more innovative ideas of reconstruction. We need simple yet reliable and robust templates/designs/algorithms/methods of reconstruction, without the need for much technology, especially for small-to-moderate defects, which can be replicated by most surgeons across the country. We describe procedures for OPBS, based on sound basic plastic surgical principles without the need of magnification or perforator marking, which are suitable for Indian patients. Multidisciplinary team involvement with careful attention to imaging and clip placement for radiation oncology planning is mandatory for successful long-term outcome. We see immense possibilities in the future for imaging using indocyanine green dye or cross-sectional imaging for morphological and vasculature assessment of donor sites and virtual planning to make these more local flap choices easier to make and execute and hence provide more predictable outcomes. Greater acceptability of therapeutic mammoplasty and symmetrizing procedures is likely in the future. This will improve further with increasing surgeon training and confidence. Several reports generated from the Therapeutic Mammoplasty (TEAM) study protocol indicate that it is an effective OPBS procedure for breasts with large size, ptosis, presence of tumor in a superior medial quadrant, or those carrying scars from prior surgery [25]. OPBS field in India is still nascent, and there is a scarcity of plastic surgeons who can work along with breast surgeons [26]. Collaboration between resecting breast surgeons and plastic and reconstructive surgeons is the ideal way ahead along with adequate training in overlapping specialties. The value of prospectively documenting data cannot be underestimated so that one learns from the long-term technical complications of the procedure as well as the oncological outcome with respect to local recurrence, especially in the event of a lack of high-level evidence. Prospective studies for patient-reported outcome measures are underway to further confirm patient satisfaction.

Conclusion

Breast conservation with good cosmetic outcomes is mandatory in the current era. The principles of plastic and reconstructive surgery are now well integrated with BCS, yielding OPBS as a philosophy. Most patients require appropriate placement of scars or type-1 OPBS. The “local flap designs” can be employed with predictability and replicable ease in well-selected cases. They offer a set of solutions, based on robust principles which gel with our patient population, type of disease at presentation, and general level of reconstruction expertise available. The reduction mammoplasty or mastopexy-based OPBS designs or LD flaps are required in selected cases only.

Supplementary Information

Below is the link to the electronic supplementary material.

Declarations

Conflict of interest

There authors declare no competing interests.