**2.1. Wide local excision (WLE)**

Simple excision of the tumour with reasonable margins forms the basis for lumpectomy or wide local excision (WLE) and is appropriate for majority of screen-detected in situ or invasive cancer. Traditional approach of scar placement over the tumour site, without adequate mobilisation of skin or approximation of breast parenchyma and leaving the cavity to fill with seroma, was responsible for poor cosmetic outcomes in the past [10]. Volume of excision relative to breast size, location of the tumour and re-excision surgery are independent risk factors for poor cosmesis (**Figure 1**).

In a recent clinical study correlating resection volumes and tumour location with clinical photographs of patients 2 years after completing radiotherapy, was assessed by a panel and scored. Despite the small sample size, there was significant variation in the cosmetic results between oncoplastic surgeon and general breast surgeons (**Figures 2** and **3**) [11].

Oncoplastic breast surgery involves careful preoperative planning with dedicated breast radiologists in the MDT to confirm adequate clearance of the tumour from the overlying skin.

**Figure 1.** Poor cosmetic results from breast conserving surgery.

The term oncoplastic breast surgery (OPBS) was first coined by Werner Audretsch in the 1980s, to describe rearrangement of breast tissue to fill the defect following a partial mastectomy and recreate the breast shape, with emphasis on cosmesis. Over the last three decades, oncoplastic breast surgery has been established globally to encompass the 'quadrant-per-quadrant' approach to breast conservation advocated by Krishna Clough [4] and the Nottingham algorithm for therapeutic mammoplasty, championed by Douglas Macmillan and Stephen McCulley [5]. Introduction of biological mesh or acellular dermal matrix (ADM) in the mid-1990s defined another watershed period with increasing mastectomy rates and immediate reconstruction. Steven Kronowitz from the MD Anderson Cancer Center in Texas, USA, introduced the concept immediate-delayed reconstruction in 2002 to help women avoid the

Today, women diagnosed with a new breast cancer are offered a range of treatment options within a multidisciplinary setting [7]. Breast cancer surgery is no longer a two-operation discipline, based on cancer dimension relative to breast size or patient choice of mastectomy versus breast conservation. An oncoplastic approach to modern management of breast cancer involves careful preoperative planning with other specialists such as radiologists, pathologists and oncologists. A comprehensive breast assessment to determine the optimal breast conservation techniques is essential with emphasis on scar placement. All patients undergoing mastectomy should have a discussion around reconstruction options, where appropriate. Good communication skills and additional time during consultation, helps safeguard patient's understanding of complex discussions around treatment. Early involvement of clinical psychologists in selected cases can help anxious patients and exclude underlying mental health concerns. Heightened anxiety at the time of diagnosis could impact decision-making and alter clinical management, with potential for decision-regret after completing treatment. Welltrained and dedicated breast care nurses are indispensable in a modern surgical breast unit [8]. Providing well designed and simple information leaflets to read outside the stressful environment of the doctor's office, can help patients navigate the complexity of the decision-making process. These combined efforts serve to demystify the various treatment options, empower

trauma of mastectomy after waking up from surgery [6].

10 Breast Cancer and Surgery

women with the concept of 'patient choice' and ensure informed consent.

of breast cancer, with emphasis on implant-based reconstruction.

**2. Oncoplastic breast surgery**

**2.1. Wide local excision (WLE)**

This chapter aims to present aspects of modern oncoplastic surgical approach in the treatment

Breast conserving surgery, often referred to as lumpectomy or wide local excision (WLE), is the standard treatment for the majority of early invasive and in situ breast cancer [9]. Screening programs have been established for over 60 years with early detection of small and non-palpable cancers, allowing smaller resection volumes and avoiding the need for mastectomy in most women.

Simple excision of the tumour with reasonable margins forms the basis for lumpectomy or wide local excision (WLE) and is appropriate for majority of screen-detected in situ or

**Figure 2.** Clinical study results poor cosmetic outcome.

This allows aesthetically placed scars which could be remote from the tumour site and avoids disfiguring scars across the breast mound. Mobilisation and approximation of the breast parenchyma after removal of the tumour can help avoid unsightly tethering of the skin to the underlying muscle following radiotherapy (**Figure 4**). These simple measures can help ensure good cosmesis for patients whilst obtaining oncological clearance of the tumour. Almost all cases of wide local excision (WLE) are achievable via a circumareolar approach, which heals well with minimal scarring on the breast mound (**Figure 4**).

*2.2.1. Benelli/round-block mammoplasty*

*2.2.2. Therapeutic mammoplasty (TM)*

**Figure 5.** Pre-op MRI demonstrating tumour and silicone leak.

the volume of resection and the size of the patient's breasts.

same incision and redundant skin excised using the Benelli technique.

similar approach with good postoperative symmetry (**Figures 6** and **7**).

The Benelli or round-block mammoplasty is a versatile technique used to excise tumours from various quadrants in the breast and reposition the nipple in the desired location at the end of the procedure [12]. This is essentially a variation of the *tennis racquet technique*, but without the 'handle'. The tennis racquet is a useful option if the skin overlying the tumour needs to excised and prevents the nipple from being tethered towards the index quadrant after radiotherapy and accentuating the asymmetry compared to the contralateral breast. The Benelli mammoplasty can also be used to reduce the skin envelope if required, depending on

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Use of bilateral *round-block/Benelli mammoplasty* is illustrated in this 70-year-old patient with aged silicone implants and a new symptomatic LEFT breast cancer. The implants were more than 35 years old with MRI evidence of intra- and extracapsular rupture and silicone leakage (**Figure 5**). The tumour located in the LEFT breast at 6:00/50 mm from the nipple was excised with safe margins. Capsulectomy and removal of the aged implant was achieved through the

MRI proven ruptured aged silicone implant in the opposite breast was also removed via a

Adjuvant radiotherapy in large breasted women after WLE can be difficult due to the volume of breast tissue, degree of ptosis and in some cases need to be delivered with the patient prone. *Therapeutic mammoplasty* (TM) combines breast reduction surgery and WLE to provide an opportunity for these women to achieve the desired smaller breasts, as part of their cancer treatment [13]. More importantly, breast reduction surgery after previous radiotherapy increases the risk of wound related complications and should only be undertaken by experienced plastic and oncoplastic breast surgeons. For women with large breasts, TM allows large excision volumes with excellent margins, beyond the conventional threshold for simple

#### **2.2. Volume displacement techniques**

A number of *volume displacement* and *volume replacement* techniques in a *quadrant-per-quadrant approach* to treating breast cancer, have been described by Clough [4]. Careful assessment of the breast size, shape and density combined with preoperative estimation of resection volumes, helps determine the optimal choice of procedure. Two of the commonly used volume displacement techniques, Benelli (round block) and therapeutic mammoplasty, are discussed below.

**Figure 3.** Clinical study results good cosmetic outcome.

**Figure 4.** Wide local excision using circumareolar incision.

#### *2.2.1. Benelli/round-block mammoplasty*

This allows aesthetically placed scars which could be remote from the tumour site and avoids disfiguring scars across the breast mound. Mobilisation and approximation of the breast parenchyma after removal of the tumour can help avoid unsightly tethering of the skin to the underlying muscle following radiotherapy (**Figure 4**). These simple measures can help ensure good cosmesis for patients whilst obtaining oncological clearance of the tumour. Almost all cases of wide local excision (WLE) are achievable via a circumareolar approach, which heals

A number of *volume displacement* and *volume replacement* techniques in a *quadrant-per-quadrant approach* to treating breast cancer, have been described by Clough [4]. Careful assessment of the breast size, shape and density combined with preoperative estimation of resection volumes, helps determine the optimal choice of procedure. Two of the commonly used volume displacement techniques, Benelli (round block) and therapeutic mammoplasty, are discussed below.

well with minimal scarring on the breast mound (**Figure 4**).

**2.2. Volume displacement techniques**

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**Figure 4.** Wide local excision using circumareolar incision.

**Figure 3.** Clinical study results good cosmetic outcome.

The Benelli or round-block mammoplasty is a versatile technique used to excise tumours from various quadrants in the breast and reposition the nipple in the desired location at the end of the procedure [12]. This is essentially a variation of the *tennis racquet technique*, but without the 'handle'. The tennis racquet is a useful option if the skin overlying the tumour needs to excised and prevents the nipple from being tethered towards the index quadrant after radiotherapy and accentuating the asymmetry compared to the contralateral breast. The Benelli mammoplasty can also be used to reduce the skin envelope if required, depending on the volume of resection and the size of the patient's breasts.

Use of bilateral *round-block/Benelli mammoplasty* is illustrated in this 70-year-old patient with aged silicone implants and a new symptomatic LEFT breast cancer. The implants were more than 35 years old with MRI evidence of intra- and extracapsular rupture and silicone leakage (**Figure 5**). The tumour located in the LEFT breast at 6:00/50 mm from the nipple was excised with safe margins. Capsulectomy and removal of the aged implant was achieved through the same incision and redundant skin excised using the Benelli technique.

MRI proven ruptured aged silicone implant in the opposite breast was also removed via a similar approach with good postoperative symmetry (**Figures 6** and **7**).

#### *2.2.2. Therapeutic mammoplasty (TM)*

Adjuvant radiotherapy in large breasted women after WLE can be difficult due to the volume of breast tissue, degree of ptosis and in some cases need to be delivered with the patient prone. *Therapeutic mammoplasty* (TM) combines breast reduction surgery and WLE to provide an opportunity for these women to achieve the desired smaller breasts, as part of their cancer treatment [13]. More importantly, breast reduction surgery after previous radiotherapy increases the risk of wound related complications and should only be undertaken by experienced plastic and oncoplastic breast surgeons. For women with large breasts, TM allows large excision volumes with excellent margins, beyond the conventional threshold for simple

**Figure 5.** Pre-op MRI demonstrating tumour and silicone leak.

**Figure 6.** Pre-op capsular contracture and Benelli mammaplasty.

WLE. Secondary pedicles of tissue which are usually excised as part of breast reduction surgery are used to fill the WLE defect. Recovery from surgery is similar to simple mastectomy without any delay in adjuvant therapy (**Figures 8** and **9**).

provides a better alternative to mastectomy for these patients and avoids large and heavy external prosthesis to match the contralateral normal breast [14]. In this example, an 83-yearold lady with large ptotic J-cup sized breasts presented with symptomatic 45 mm RIGHT breast cancer @12:00, with associated 110 mm of suspicious calcification extending to the

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Bracketed hook-wire was used preoperatively to mark the extent of calcification to ensure safe margins and confirmed on final histology (**Figure 11**). Despite the extensive nature of surgery,

nipple (**Figure 10**).

**Figure 8.** Pre-op therapeutic mammaplasty.

**Figure 9.** Post-op therapeutic mammaplasty.

The nipple-areolar complex (NAC) can be sacrificed in older patients to minimise the risk of nipple necrosis and wound complications. The NAC may also need to be removed when the tumour is located close to the nipple to ensure oncological safe margins. TM in this setting Oncoplastic Breast Surgery in the Treatment of Breast Cancer http://dx.doi.org/10.5772/intechopen.77955 15

**Figure 8.** Pre-op therapeutic mammaplasty.

**Figure 9.** Post-op therapeutic mammaplasty.

WLE. Secondary pedicles of tissue which are usually excised as part of breast reduction surgery are used to fill the WLE defect. Recovery from surgery is similar to simple mastectomy

The nipple-areolar complex (NAC) can be sacrificed in older patients to minimise the risk of nipple necrosis and wound complications. The NAC may also need to be removed when the tumour is located close to the nipple to ensure oncological safe margins. TM in this setting

without any delay in adjuvant therapy (**Figures 8** and **9**).

**Figure 6.** Pre-op capsular contracture and Benelli mammaplasty.

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**Figure 7.** Post-op round block mammaplasty.

provides a better alternative to mastectomy for these patients and avoids large and heavy external prosthesis to match the contralateral normal breast [14]. In this example, an 83-yearold lady with large ptotic J-cup sized breasts presented with symptomatic 45 mm RIGHT breast cancer @12:00, with associated 110 mm of suspicious calcification extending to the nipple (**Figure 10**).

Bracketed hook-wire was used preoperatively to mark the extent of calcification to ensure safe margins and confirmed on final histology (**Figure 11**). Despite the extensive nature of surgery,

(SAAP) and thoracodorsal artery perforator (T-DAP) flaps have been described to fill large defects created by WLE. Mini-LD flaps should be avoided in this setting and the latissimus dorsi muscle preserved as salvage tissue cover for complex locally advanced and recurrent disease, for lower pole support instead of mesh or as definitive reconstruction option following mastectomy.

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The original pedicled perforator flaps described by Mustafa Hamdi in 1984 included thoracodorsal artery perforator (T-DAP), intercostal artery perforator (ICAP), serratus anterior

*2.3.1. Autologous adipo-dermal perforator flaps*

**Figure 12.** Post-op TM sacrificing the NAC.

**Figure 13.** Pre-op marking of L-TAP and Li-CAP vessels with USS Doppler.

**Figure 10.** Pre-op hook-wire and markings for TM.

**Figure 11.** Bracketed hook-wire.

TM confers a high degree of patient satisfaction, without any delay in adjuvant treatment or significant morbidity; even in older patients (**Figure 12**). Well-trained breast care nurses are essential for preoperative patient education and managing complex wounds after surgery.

## **2.3. Volume replacement techniques**

Several volume replacement techniques, such as mini-latissimus dorsi (LD), lateral thoracic artery perforator (L-TAP), intercostal artery perforators (I-CAP), serratus anterior artery perforator (SAAP) and thoracodorsal artery perforator (T-DAP) flaps have been described to fill large defects created by WLE. Mini-LD flaps should be avoided in this setting and the latissimus dorsi muscle preserved as salvage tissue cover for complex locally advanced and recurrent disease, for lower pole support instead of mesh or as definitive reconstruction option following mastectomy.

#### *2.3.1. Autologous adipo-dermal perforator flaps*

The original pedicled perforator flaps described by Mustafa Hamdi in 1984 included thoracodorsal artery perforator (T-DAP), intercostal artery perforator (ICAP), serratus anterior

**Figure 12.** Post-op TM sacrificing the NAC.

TM confers a high degree of patient satisfaction, without any delay in adjuvant treatment or significant morbidity; even in older patients (**Figure 12**). Well-trained breast care nurses are essential for preoperative patient education and managing complex wounds after surgery.

Several volume replacement techniques, such as mini-latissimus dorsi (LD), lateral thoracic artery perforator (L-TAP), intercostal artery perforators (I-CAP), serratus anterior artery perforator

**2.3. Volume replacement techniques**

**Figure 11.** Bracketed hook-wire.

**Figure 10.** Pre-op hook-wire and markings for TM.

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**Figure 13.** Pre-op marking of L-TAP and Li-CAP vessels with USS Doppler.

artery perforator (SAAP) and superior epigastric artery perforator (SEAP) flaps for immediate or delayed partial breast reconstruction or as adjuncts to implant reconstruction [15]. These versatile perforator flaps can be used to fill parenchymal defects in almost any quadrant of the breast. This technique allows large excision volumes to ensure good resection margins and the size of the flap can be adjusted to achieve good cosmesis.

The length of the scar is variable depending on the volume required for replacement and is mostly hidden within the bra, with less donor site morbidity compared to traditional LD flap (**Figure 15**). These autologous perforator flaps are robust and appear to tolerate radiation therapy without significant volume loss. They serve as ideal volume replacement options for high-risk patients such as diabetics, smokers and older patients, without compromising flap

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Two-stage procedure is recommended by the Nottingham group, particularly if the extent of disease is unclear on diagnostic imaging. WLE and axillary surgery is completed as the first stage and the cavity filled with water to keep the cavity patent. Once the histology confirms adequate margins, patients can undergo the second stage to recruit the perforator flap (**Figures 16** and **17**). If the pathology demonstrates more extensive disease than originally

viability.

**Figure 16.** After first stage WLE cavity filled with water.

**Figure 17.** Post-op photo after volume replacement with Li-CAP.

The Li-CAP and T-DAP vessels are marked preoperatively with handheld Doppler's or USS colour Doppler mode prior to skin incision (**Figure 13**). These flaps utilise the skin and subcutaneous fat in the lateral chest wall and are raised on small and consistent perforator vessels (**Figure 14**).

**Figure 14.** Perforator vessels for Li-CAP flap.

**Figure 15.** Lateral scar after volume replacement with Li-CAP flap.

The length of the scar is variable depending on the volume required for replacement and is mostly hidden within the bra, with less donor site morbidity compared to traditional LD flap (**Figure 15**). These autologous perforator flaps are robust and appear to tolerate radiation therapy without significant volume loss. They serve as ideal volume replacement options for high-risk patients such as diabetics, smokers and older patients, without compromising flap viability.

Two-stage procedure is recommended by the Nottingham group, particularly if the extent of disease is unclear on diagnostic imaging. WLE and axillary surgery is completed as the first stage and the cavity filled with water to keep the cavity patent. Once the histology confirms adequate margins, patients can undergo the second stage to recruit the perforator flap (**Figures 16** and **17**). If the pathology demonstrates more extensive disease than originally

**Figure 16.** After first stage WLE cavity filled with water.

artery perforator (SAAP) and superior epigastric artery perforator (SEAP) flaps for immediate or delayed partial breast reconstruction or as adjuncts to implant reconstruction [15]. These versatile perforator flaps can be used to fill parenchymal defects in almost any quadrant of the breast. This technique allows large excision volumes to ensure good resection margins and

The Li-CAP and T-DAP vessels are marked preoperatively with handheld Doppler's or USS colour Doppler mode prior to skin incision (**Figure 13**). These flaps utilise the skin and subcutaneous fat in the lateral chest wall and are raised on small and consistent perforator vessels (**Figure 14**).

the size of the flap can be adjusted to achieve good cosmesis.

**Figure 14.** Perforator vessels for Li-CAP flap.

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**Figure 15.** Lateral scar after volume replacement with Li-CAP flap.

**Figure 17.** Post-op photo after volume replacement with Li-CAP.

anticipated, patients could be offered re-excision of margins or conversion to mastectomy. A two-stage procedure helps avoid wasting a good flap in the initial stage and serves as a bridge to definitive surgery.

The chest wall perforator flaps (L-TAP and Li-CAP) can also be used as complete autologous flap reconstruction following mastectomy and was first described by Losken and Hamdi in 2009 [19, 20]. This is a safe reconstruction option in the high-risk candidates, such as smokers, raised BMI, diabetics, or in patients where implant or complex autologous reconstructions are relatively contraindicated due to post-operative radiotherapy

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**Figure 19.** Right mastectomy with immediate LD flap and left mastectomy with implant reconstruction.

**Figure 20.** Pre-op marking bilateral mastectomy following neoadjuvant chemotherapy.

(**Figures 20** and **21**).
