Table 1.
Complexity-based classification of oncological, oncoplastic and delayed reconstructive procedures in ablative (A) and breast-conserving (B) breast cancer-related surgery.
| A. Ablative surgical procedures | |
|---|---|
| 1. | Simple ablative breast cancer surgery |
| Modified radical mastectomy or excision of a local recurrence after ablation (without reconstruction) | |
| 2. | Complex ablative breast cancer surgery |
| Radical mastectomy or excision of a local recurrence after ablation (with removal of pectoral muscles and without reconstruction) | |
| 3. | Oncoplastic ablative surgical procedures for breast cancer treatment with prosthetic reconstruction, or reconstruction after ablation |
| a. | Modified radical mastectomy with immediate prosthetic reconstruction |
| 1. | Modified radical mastectomy with immediate placement of a tissue expander |
| 2. | Modified radical mastectomy with immediate placement of a permanent implant |
| b. | Skin-sparing mastectomy with immediate prosthetic reconstruction |
| 1. | Skin-sparing mastectomy (SSM) and immediate placement of an implant |
| 2. | Nipple-sparing mastectomy (NSM) and immediate placement of an implant |
| c. | Delayed prosthetic reconstruction after mastectomy |
| 1. | Delayed reconstruction after mastectomy: placement of a tissue expander |
| 2. | Delayed reconstruction after mastectomy: placement of a permanent implant |
| d. | Implant-related procedures after implant reconstruction |
| 1. | Tissue expander removal and placement of a permanent implant |
| 2. | Implant exchange and breast remodelling in capsular contracture |
| 4. | Complex oncoplastic ablative breast cancer surgery involving defect repair with local flaps or free skin grafts (also in extensive chest wall recurrence) |
| 1. | Transposition flaps (e.g. the thoracoepigastric flap) |
| 2. | Rotation flaps |
| 3. | Local advancement flaps |
| 4. | Free skin transplants (e.g. a mesh graft) |
| 5. | Complex oncoplastic ablative breast cancer surgery with reconstruction or defect repair using distant pedicled flaps (also in extensive chest wall recurrence) |
| a. | Conventional latissimus dorsi (LD) flaps (surgical or endoscopic harvest) |
| 1. | Conventional LD flap without or with an implant for immediate breast reconstruction as part of ablative surgery (modified radical mastectomy, SSM, NSM) |
| 2. | Conventional LD flap (usually without an implant) for repair of chest wall defects |
| 3. | Conventional LD flap without or with an implant for delayed breast reconstruction after ablative surgery |
| 4. | Conventional LD flap without or with an implant for autologous reconstruction or combined autologous and alloplastic reconstruction in prosthesis-related complications |
| b. | Extended latissimus dorsi (LD) flaps |
| 1. | Extended LD flap for immediate breast reconstruction as part of ablative surgery (modified radical mastectomy, SSM, NSM) |
| 2. | Extended LD flap for repair of chest wall defects |
| 3. | Extended LD flap for delayed breast reconstruction after ablative surgery |
| 4. | Extended LD flap for conversion to autologous reconstruction in prosthesis-related complications |
| c. | Transverse rectus abdominis (TRAM) flaps |
| 1. | TRAM flap for immediate breast reconstruction as part of ablative surgery (modified radical mastectomy, SSM, NSM) |
| 2. | TRAM flap for repair of chest wall defects |
| 3. | TRAM flap for delayed breast reconstruction after ablative surgery |
| 4. | TRAM flap for conversion to autologous reconstruction in prosthesis-related complications |
| 6. | Complex oncoplastic ablative breast cancer surgery involving reconstruction or defect repair using free flaps with microvascular anastomosis (e.g. DIEP, SIEA, SGAP or free TRAM flaps) (also in extensive chest wall recurrence) |
| 1. | Free flap for immediate breast reconstruction as part of ablative surgery (modified radical mastectomy, SSM, NSM) |
| 2. | Free flap for repair of chest wall defects |
| 3. | Free flap for delayed breast reconstruction after ablative surgery |
| 4. | Free flap for conversion to autologous reconstruction in prosthesis-related complications |
| B. Breast-conserving surgical procedures | |
| 1. | Simple breast-conserving cancer surgery |
| (histologically complete tumour excision, performed as a "wide excision" up to quadrantectomy with defect repair involving only direct apposition without mobilisation of glandular tissue or skin flaps) | |
| 2. | Complex breast-conserving cancer surgery |
| (additional intramammary reconstruction of the mammary gland by mobilisation of subcutaneous or epifascial glandular lobes and, if necessary, mobilisation of the skin envelope for defect repair of ≤ 25% of the area of the breast) | |
| 3. | Oncoplastic breast-conserving surgery |
| (additional intramammary reconstruction of the mammary gland by mobilisation of subcutaneous or epifascial glandular lobes and, if necessary, mobilisation of the skin envelope for defect repair of > 25% of the area of the breast) | |
| 4. | Complex oncoplastic breast-conserving surgery |
| a. | Tumour-adapted mastopexy (breast lift) without additional removal of healthy breast tissue |
| (selection of skin incision pattern depending on amount of excess skin and desired scar pattern, i.e. purely circumareolar, vertical, segmental or "inverted T") | |
| 1. | Central pedicles |
| 2. | Inferior-central pedicles |
| 3. | Cranial pedicles |
| 4. | Modified B mammoplasty |
| 5. | Free nipple transfer |
| b. | Tumour resection with defect repair using local flaps without or with skin replacement |
| 1. | Transposition flaps (e.g. the thoracoepigastric flap) |
| 2. | Rotation flaps |
| 5. | Complex oncoplastic breast-conserving surgery with additional resection (reduction) of mammary gland tissue – Tumour-adapted reduction mammoplasty |
| (selection of skin incision pattern depending on amount of excess skin and desired scar pattern, i.e. purely circumareolar, vertical, segmental or "inverted T") | |
| 1. | Central pedicles |
| 2. | Inferior-central pedicles |
| 3. | Cranial pedicles |
| 4. | Free nipple transfer |
| 6. | Complex oncoplastic breast-conserving surgery involving defect repair using distant pedicled flaps |
| a. | Tumour resection with partial volume replacement using an endoscopically harvested latissimus dorsi flap |
| b. | Tumour and skin resection with partial volume and skin replacement using a latissimus dorsi flap with a skin island |
| c. | Tumour and, if required, skin resection with partial volume replacement and, if indicated, skin replacement using a pedicled TRAM flap |
| d. | Tumour excision and, if indicated, skin resection with partial volume replacement and, if indicated, skin replacement using free flaps with microvascular anastomosis (e.g. DIEP, SIEA or SGAP flaps) |