**5. Absolute contraindications for breast-conserving surgery**

Only a few situations represent the absolute contraindication to BCS: inflammatory breast cancer, irrespective of NAC treatment response, inability to obtain adequate resection margins due to diffuse breast disease, and inability to deliver adjuvant breast irradiation (lack of required facilities or patient comorbidities that prevent safe irradiation delivery). Although rare nowadays, in these cases mastectomy is considered mandatory, with or without immediate or delayed breast reconstruction.

Patients' desire for radical surgery is another issue that requires consideration. It is often driven by patients' knowledge gaps and subsequent fear of disease recurrence. The surgeon's role in modifying patients' decisions is tremendous. Most of the patients can be reassured easily with the appropriate information concerning both procedures, as well as their impact on oncologic outcomes and QoL [22, 23]. A decision for mastectomy should never reflect the surgeon's desire to avoid complex oncoplastic surgery. The optimal treatment strategy must be offered to every patient and ignorance may not be an excuse for suboptimal management.

Relative and absolute contraindications for BCS are summarised in **Table 2**.


**Table 2.**

*Relative and absolute contraindications for breast conserving surgery in breast cancer management.*

### **6. Oncoplastic techniques in breast conservative surgery**

For academic purposes, the techniques of partial breast reconstruction following tumour resection can be divided into two major groups: breast volume displacement and breast volume replacement (**Figure 2**). The basic difference is in the donor area utilised for partial breast reconstruction. The resected volume can be substituted by displacement of the remaining breast parenchyma, or replaced with fat tissue harvested adjacent to the breast.

Volume displacement techniques may further be categorised into level I (simple breast tissue advancement) and level II procedures (breast tissue rearrangement); however, due to variable definitions in the literature, certain techniques can be

*Oncoplastic Breast Conservation: A Standard of Care in Modern Breast Cancer Surgical… DOI: http://dx.doi.org/10.5772/intechopen.108944*

**Figure 2.** *Oncoplastic techniques in breast conserving surgery.*

categorised in both groups. Although basic concepts originate from reconstructive surgery (advancement flaps) and aesthetic breast surgery (mastopexy and breast reduction), the adopted procedures were significantly modified and enriched with new techniques, designed for cancer surgery. Different oncoplastic breast surgery atlas recommendations, proposed by different authors, suggest a lack of standardisation in the field. Nevertheless, a multitude of techniques enables a personalised surgical approach for each patient.

Volume replacement techniques, local perforator flaps (level III) and fat grafting, both adopted from reconstructive surgery, have recently emerged as popular alternatives in partial breast reconstruction.

Clinical decision on the type of oncoplastic procedure is mainly based upon the anticipated percentage of breast volume loss and the residual breast volume [40], as well as the availability of additional donor sites, patients' preference and surgeons' skills.

Profound knowledge of breast anatomy is required for optimal performance for both ablative and reconstructive parts of all breast oncoplastic procedures. Compliance with the proposed oncoplastic planes of dissection, as well as respecting the breast as an aesthetic unit (shape, nipple position and symmetry with the contralateral breast), in addition to oncological safe tumour resection, is mandatory for the successful outcome of the oncoplastic surgery. Otherwise, it may result in higher complication rates (bleeding, skin and NAC necrosis, fat necrosis, infection), higher re-excision rates, and higher rates of local recurrence and disease progression. However, detailed breast anatomy and a description of surgical techniques are both beyond the scope of this chapter.

#### **6.1 Level 1 volume displacement (parenchymal advancement)**

Every oncoplastic breast surgery starts with skin incision planning. If the skin overlying the tumour is closed or involved, the skin incision is determined by the

tumour position. However, whenever oncology is safe, the preferred approach is the skin incision hidden in the inframammary fold (IMF), peri-areolar region or lateral mammary fold, accompanied by retro-glandular or subcutaneous access to the breast lesion and oncoplastic lumpectomy.

From the surgical perspective, oncoplastic level 1 procedures are technically the least demanding with a fast learning curve and wide applicability. It represents the optimal surgical approach for the majority of early-stage breast cancer patients. The best results are achieved for resections not exceeding 20% of the breast volume, ideally, in small- to medium-size, non-ptotic, firm, dense (BIRADS C-D) breasts. The basic concept of level 1 partial breast reconstruction relays upon single- or dual-layer mobilisation of the breast parenchyma surrounding the resected area and its closure by simple parenchymal advancement.

Nipple and areola complex (NAC) repositioning into a new breast centre may be required following extensive parenchymal advancement. However, if NAC pedicles and significant tissue rearrangement are involved, it would be more appropriate to categorise it as a level 2 procedure (**Figure 3**).

### **6.2 Level 2 volume displacement (parenchymal rearrangement)**

Except for the NAC pedicle formation, significantly extensive breast tissue rearrangement is involved in level 2 procedures. Consequently, the procedures are more complex, as compared to level 1, and a longer learning curve is required. A resection volume of over 20% of breast volume is an indication for the level 2 procedure. However, only selected patients, with ptotic, medium or large volume, fatty (BIRADS A-B) breasts are appropriate candidates for level 2 oncoplastic breast conservation.

Although mastopexy and reduction mammoplasty represent the origins of the level 2 procedures, the techniques have been significantly modified for cancer surgery. If the skin is not involved, the type of the skin incision (round block, vertical scar, inverted T) is determined by surgeons' preference, breast volume and the degree of breast ptosis. Subcutaneous lumpectomy for any tumour location can be performed

*Oncoplastic Breast Conservation: A Standard of Care in Modern Breast Cancer Surgical… DOI: http://dx.doi.org/10.5772/intechopen.108944*

**Figure 4.** *Quadrant per quadrant atlas of oncoplastic volume displacement techniques.*

through any of the above-proposed types of skin incision. However, the choice of NAC pedicle, parenchymal resection and rearrangement are influenced by the tumour location within the breast [19]. Nevertheless, if the overlying breast skin is involved, the tumour location determines the skin incision and the technique modification accordingly. For these situations, a quadrant-per-quadrant atlas of oncoplastic procedures has been proposed [41] as follows: lateral mammoplasty for the upper outer quadrant, J/L mammoplasty for the lower outer quadrant, V mammoplasty for the lower inner quadrant, batwing mastopexy for the upper inner quadrant, and superior/inferior pedicle mammoplasty for 12 and 6 o clock tumours (**Figure 4**).

For small-volume tumours in the small-to-medium volume, firm (dense), non-ptotic breasts, good results can be achieved in a single oncoplastic procedure. However, if a larger resection volume is required or the procedure is performed in hypertrophic, fatty and/or severe ptotic breasts, symmetry can only be achieved with an additional surgical procedure in the contralateral healthy breast. Following level 2 oncoplastic surgery, a symmetrisation procedure for the contralateral breast is usually required. Aesthetically pleasing results (good symmetry) can be accomplished with an equal procedure in the healthy breast at the time of cancer surgery or following adjuvant oncologic treatment(s) and an additional 6–12-month period required for breast stabilisation.

#### **6.3 Oncoplastic breast conservation for central quadrant tumours**

For central quadrant tumours, several procedures have been proposed: elliptic horizontal/vertical excision of the central portion of the breast, melon slice, round block and wedge resection. The choice of the optimal procedure depends on the breast volume and shape, as well as the breast volume required for oncological safe resection. The goal is to maintain the maximum projection site in the centre of the breast.

The proposed methods for NAC reconstruction are local skin flaps, contralateral NAC (grafting), NAC tattooing and external NAC prosthesis.
