Oncoplastic surgery of the breast combines the optimal breast cancer treatment with simultaneous tissue rearrangement to improve cosmesis. In Part 1 of this series (March 2017, page 11), we discussed the increased use and safety of oncoplastic procedures as well as the skills associated with oncoplastic surgery.
There is a spectrum of degrees of complexity in oncoplastic surgical procedures. For that reason, it is useful to conceptualize 4 skill levels of oncoplastic surgery (OPS) used for breast cancer. Most surgeons will be satisfied with level 1 and level 2 skill training—that is, procedures that primarily involve the ipsilateral breast when 20% or less of the breast has been removed. This training is within the grasp of the general surgeon, because most of the procedures use techniques they have already mastered for other breast surgical procedures.
Some level 2 skills, along with all level 3 and 4 skills, involve major reconstructive procedures and the achievement of contralateral symmetry, which is important to most patients. Often, even an OPS-trained surgeon will partner with a plastic surgeon to offer these more advanced procedures.
A description of the 4 skill levels of OPS was presented in a consensus position by a multidisciplinary panel led by Gail Lebovic, MD, convened at the 2010 American Society of Breast Disease (ASBD) Annual Symposium and a similar panel that met at the Senologic International Society (SIS) World Congress in 2012. You will note that many of the foundational skills include the concepts of the aesthetic approach to breast surgery. OPS is not a list of procedures but a comprehensive approach to the patient and her clinical and aesthetic desires
Risk assessment using a multidisciplinary model: The OPS process begins with a comprehensive preoperative assessment to ensure that patients who might benefit from this approach are eligible for it. Eligible patients fall into two groups: The first group consists of those who have been diagnosed with breast cancer and need wide excision or mastectomy, and the second group includes those without cancer but who desire a prophylactic procedure because of a strong family history of the disease, positive BRCA or other genetic test results, or other high-risk factors. Various members of a multidisciplinary team besides the surgeon may need to be consulted to complete the assessment, including the medical oncologist, genetics counselor, radiation oncologist, radiologist, pathologist and plastic surgeon. By the end of this evaluation, eligible patients will be identified, and the group of OPS procedures to help them will be defined.
Aesthetic principles, evaluation, and techniques: As we noted in Part 1 of this series, one vital goal in OPS is to anticipate potential aesthetic issues created by the surgery and address them in the surgical planning stage. Once the surgery is completed, it may not be possible to easily correct aesthetic problems created by the resection. For instance, surgical excision in the inferior breast will often cause the nipple to deviate downward. To the extent this can be anticipated, a remedial strategy should be included in the plan at the time of surgery to avoid a second follow-up procedure.
Just as important, the plan should include strategies that incorporate the patient’s specific cosmetic goals for surgery, as determined by forthright discussions with her surgeon. At this stage of OPS training, the surgeon learns to ask questions such as: How important is the appearance of your breasts to you after surgery? Have you ever thought of changing the size or appearance of your breasts? If surgery leaves your breast somewhat smaller than the other one but otherwise leaves the contour the same, is that OK with you or do we need to address it? The patient’s answers to such questions will help determine how the surgeon plans the incision, whether to include a reduction to the contralateral breast, add tissue to the ipsilateral breast, move the nipple, and so on.
Comprehensive surgical plan: Diagnosis, treatment, adjuvant therapy, follow-up, etc: The surgical plan is designed with both oncologic and aesthetic goals in mind. Essentially, 3 factors must be considered when devising the plan. First, achieve optimal cancer control with wide cancer-free margins. Second, prevent local recurrence of the disease including use of adjuvant modalities (radiation, etc). This becomes more important in multifocal disease. Third, preserve the breast’s original shape and appearance as much as possible; or if the patient requests it, improve that appearance with a lift, reduction, etc. This third goal underscores the need to know the patient’s overall satisfaction with her breasts as they are preoperatively.
Aesthetic approach to incisions and resection: Although an incision may be small and not very conspicuous, those factors alone are not enough to be an oncoplastic incision. The location, length and direction of the incision is a major decision after the operative plan is conceived. The location allows access to the entire OPS plan including flap development. But the incision also considers appearance based on how the breast looks when the patient is standing up—the position in which she will normally observe herself in a mirror. A common error in breast surgery is to open and close the patient while supine and never check how the patient will look when standing. In addition, incision planning must take into account how to access the tissue that will need to be rearranged to meet the patient’s more specific aesthetic goals. For example, a round block incision that is 360 degrees around the nipple provides excellent access to many areas of the breast while maintaining cosmesis. All of this planning is done during open discussion with the patient, including soliciting her input. It is vital that her concerns and desires be considered at every point in the planning, so she knows what to expect in her postsurgical appearance and will not be disappointed. Setting appropriate expectations in the OPS planning phase leads to a satisfied patient more often.
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Large resections with breast conservation: Conventional lumpectomies often may produce disappointing cosmetic results. Here is a common scenario: The surgeon excises the tumor and then sutures the skin and subcutaneous tissue back together. A seroma then forms in the space created by the tumor removal, and both surgeon and patient are happy. Then the patient has radiation therapy, and 2 months later the breast looks markedly different. Once the seroma absorbs, typically during the postsurgical radiation period, the lumpectomy cavity partially collapses, creating a substantial indentation in the breast’s contour and causing dissatisfaction all around. The surgeon blames the radiation and the radiation oncologist blames the surgery.
In level 1 OPS training, surgeons learn to avoid this scenario by rotating or advancing other breast tissue to fill the space left by the tumor excision. This tissue rotation or advancement normally is performed during the same surgery that excises the cancer. This aspect of oncoplastic surgery also may improve reexcision rates.1 Oncoplastic surgeons do not worry as much about minimizing the cancer margins because they are going to fill that space with rotated tissue. Thus, they often obtain a larger resection than a surgeon performing a standard lumpectomy, yielding less positive margins and reexcisions (Table 2).
Partial breast reconstruction with local tissue flaps: This technique involves dissection of local tissue in acceptable planes and rotating it into what would otherwise be a surgical deformity. This is a technique that draws on skills and expertise that every surgeon already possesses to achieve cosmetically pleasing results with breast cancer surgery.
Accurate marking of the tumor bed for radiation planning and follow-up: After tissue advancement or rotation flap, the original lumpectomy cavity may be difficult to identify for the radiation oncologist. Targeting boost radiation or partial breast irradiation may be inaccurate when targeting the residual seroma, which may include some or all of the mobilized noncancerous tissue. Although seroma targeting is a standard approach for radiation treatment, that concept was established prior to the wide use of oncoplastic procedures. With larger seromas associated with OPS, the targeted treatment volume may be much larger than the original lumpectomy cavity. This directly relates to the overall radiation dose and secondary fibrosis and scarring. Targeting the true lumpectomy cavity and not the rearranged tissue will optimize the radiation to the proper target, reduce total treatment volumes, and avoid radiation to mobilized noncancerous tissues. In addition, potential candidates for partial breast irradiation may be excluded unnecessarily when targeting the seroma created by OPS rather than focusing on the true lumpectomy cavity.
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Bioabsorbable 3-D implant marks the lumpectomy cavity.
Traditional methods of marking the lumpectomy cavity with clips may be inaccurate as the breast heals and clips may migrate.8 A novel method to target the lumpectomy cavity includes a 3-D implant,9 discussed in Part 1. The implant provides a marker that moves with the breast, and its 3-D structure can be targeted from any direction by the radiation oncologist. One can avoid treating the seroma that extends into oncoplastic areas and only target the lumpectomy cavity, making targeting more efficient. In regard to oncoplastic closures, the 3-D implant may act as a bridge to close the lumpectomy cavity, allowing surgeons to mobilize less breast tissue to fill the gap. The implant also provides a scaffolding for tissue ingrowth.9
Level 2 Skills
Perform skin/nipple–sparing mastectomy: This app-roach, which technically encompasses sparing of the areola as well as the breast skin and nipple, also draws on the general surgeon’s existing skill set. The skills involved include a) creating even and viable flaps with the existing breast skin; b) maintaining the viability of the nipple and areola by ensuring that they will have adequate blood supply (avoiding cautery near the base of the nipple); and c) strategically placing the incision so that it balances oncologic and aesthetic considerations while also giving the surgeon access to the entire breast. Once the mastectomy portion is completed, the reconstruction within the new skin envelope may be performed by the plastic surgeon, or less often by an advanced-level OPS surgeon.
Perform breast reduction with or without nipple transfer: Breast cancers often occur at the inferior breast, providing an ideal opportunity to use the Wise pattern incision that may remove the tumor as well as provide a positive oncoplastic result. Surgeons should learn the skin markings of a Wise pattern to incorporate the incision routinely for lower central breast cancers. With this approach, tumors can be removed with adequate margins while resembling a breast lift or mammoplasty. Level 2 skills of de-epithelializing superior skin and moving the nipple superiorly are useful to compensate for the tissue lost inferiorly, which draws the nipple downward. Most surgeons wish to master level 1 skills before they tackle level 2.
Perform mastopexy for cancer resection or symmetry: Breast surgeons would be wise to ask their patients before they operate whether symmetry is important to them and whether they had thought previously of changing the shape or lifting their breasts. If so, attention to the other breast should be considered. Approaching the opposite breast for a cosmetic procedure has been considered purely in the realm of the plastic surgeon. Yet, general surgeons don’t think twice about performing a bilateral mastectomy for a unilateral cancer if the patient clearly requests that procedure. Removing the opposite breast for symmetry at the request of the patient is the most extensive version of an aesthetic procedure for contralateral symmetry. Performing a Wise pattern lower pole resection and raising the nipple on the cancer side verifies that the surgeon has the technical ability to perform the procedure. When the ipsilateral cancer resection uses OPS techniques to remove the cancer and reconstruct the breast, it is not much of a leap to perform a similar OPS procedure on the opposite breast to achieve symmetry. The difference is not related to surgical skills or technique but rather the reason for the procedure. The OPS surgeon should be able to use their skills on either breast.
The Oncoplastic Surgeon’s Relationship With a Plastic Surgeon
We will avoid talking about level 3 (implants) and level 4 (flaps) as these are almost always performed by or together with a plastic surgeon. Therefore, a general surgeon who wants to offer the full range of OPS options to his or her patients needs to partner with a plastic surgeon in their region.
Most surgeons reading this article probably have an existing relationship with one or more plastic surgeons if they perform breast surgery. Yet there are many examples of plastic surgeons being unavailable due to local geography or lack of interest or time to perform breast reconstruction at the same time as mastectomy. In some communities, plastic surgeons suggest that the general surgeon perform the breast lumpectomy or mastectomy, and later the plastic surgeon will do the reconstruction at a second procedure. Although waiting for the final pathology result of margins is valuable, most often a mastectomy will have negative margins, and it is more difficult for the patient to undergo two operations when it can be performed safely in a single operation.
For breast surgeons who do not already have a relationship with a plastic surgeon, here are some tips about initiating and maintaining that relationship:
Identify plastic surgeons who have an interest in breast surgery. Plastic surgeons are not compensated as highly for oncoplastic breast surgery for the amount of time and effort it takes, as they are for many of their other procedures. So identifying a plastic surgeon to approach about partnering for immediate reconstructive procedures should be those who have shown an interest in breast reconstruction. You can identify these professionals via word of mouth or professional reputation.
Demonstrate your interest in breast reconstruction. Surgeons involved with plastic surgeons in a mastectomy-plus-reconstruction procedure often leave the operating room at the completion of the mastectomy; then the plastic surgeon takes over. If you are working with a plastic surgeon on one of these cases, ask to stay during the reconstruction phase to observe the plastic surgeon at work. Observing how the plastic surgeon plans, measures and executes tissue reorientation is educational and consistent with classic surgical education (“see one, do one, teach one”).
Refer appropriate cases to your plastic surgeon colleague. Most surgeons performing OPS procedures experience incremental accumulation of skills over time. Initial use of OPS may be limited to a few level 1 procedures (sidebar). Over time and with repeated courses, most surgeons gradually expand their abilities and comfort with these procedures and may approach the opposite breast. From the standpoint of both professional integrity and maintaining a good relationship with your plastic surgeon partner, it is important to recognize your limitations and refer the OPS procedures that are beyond your expertise and comfort zone to your plastic surgeon colleague.
OPS and Hospital Policies
As stressed in Part 1 of this article, it is increasingly important for any surgeon who performs breast cancer surgery or has an interest in doing so to receive OPS training. Ultimately, although the general surgeon may take pointers from their plastic surgeon, the bulk of OPS knowledge will come from hands-on courses and practice. Once you have taken the course(s) and started using level 1 procedures, you may establish a series of procedures in which you have performed and dictated oncoplastic rearrangements and Wise pattern approaches. These types of procedures are within a surgeon’s skill set and privileges.
As one’s skills and experience increase, some surgeons have requested formal privileges whereas others gradually increase their skill set from rearrangements to moving the nipple to reduction patterns with nipple advancement to contralateral symmetry procedures. The stepwise increase in your own skills, your results, your dictated reports and perhaps proctoring will allow you to gradually incorporate new skills and new techniques that will benefit your patients.
When a patient asks you, “Do you do oncoplastic surgery?” that is the time when you will know that you are surgically current because you can answer “yes,” or have a deficit in your surgical skills if you answer “no.” More women are learning it is possible to have their tumor safely removed and still preserve their appearance. If you are unable to offer those options in your practice, you will lose patients to surgeons who can.
Nonetheless, taking a hands-on OPS course is the first step. Like any new procedure (sentinel nodes, laparoscopic procedures), one needs documentation of education and hands-on exposure.
The Future of OPS
It is simple to predict some short-term developments in OPS because many of these changes already have been set in motion, and others are just logical outgrowths of OPS’ present status. Here’s what is seen coming around the corner.
Incorporation of OPS into mainstream surgical training: Although some breast fellowships include OPS training, it is likely to be an expected part of breast fellowships in the future. Due to the costs of a cadaver lab to learn OPS, an educational grant provided scholarships for several breast fellows at a recent School of Oncoplastic Surgery training course. One would expect that general surgery training eventually will include entry-level oncoplastic procedures in the training as these procedures become an integral part of breast surgery.
Expansion of the literature: With OPS being performed in more hospitals, new studies will be published about OPS safety and efficacy, although the literature already has a sturdy foundation.
Recognition by credentialing committees that oncoplastic procedures are part of breast cancer surgery: For many reasons, plastic surgeons are less available for breast reconstructive procedures, which limits their availability nationwide. Meanwhile, patient demand for OPS is growing. This creates a potential logjam, but it will probably become less of an issue as aesthetic outcomes are recognized and measured by quality systems. Hospital credentialing committees likely will recognize that breast cancer surgery has evolved and become more liberal about approving surgeons to perform OPS.
New technology: Right now, the 3-D bioabsorbable implant is the leading novel technology assisting with enhancement of the lumpectomy defect. There are already a variety of mastectomy reconstructive choices and new implants. As OPS joins the mainstream, other helpful technologies are likely to emerge for both lumpectomy and mastectomy patients.
OPS certification: The School of Oncoplastic Surgery (discussed in Part 1) has provided a Certificate in Oncoplastic Surgery verifying education with hands-on experience. This is associated with a list of procedures and lab time. Over time, other training programs here and abroad have developed, or will develop, their own certifications.
OPS will be part of the mainstream in breast cancer surgery, because it is already well on its way to that status. Breast cancer patients deserve the excellent results that OPS can deliver. We look forward to the day when patients can expect them.
References
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Ann Surg Oncol. 2016;23(10):3190-3198.
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Ann Surg. 2012;255(6):1151-1157.
Breast J. 2013;19(1):56-63.
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Dr. Kaufman is asociate clinical professor of surgery at the University of Washington, in Seattle, past chairman of the National Accreditation Program for Breast Centers (NAPBC), past president of the National Consortium of Breast Centers (NCBC), sole American representative on the European Commission’s Initiative on Breast Cancer (ECIBC), and Medical Director of the Bellingham Regional Breast Center in Bellingham, Washington.
Disclosure: Dr. Kaufman reported past speaker/consultant fees from the American Society of Breast Surgeons; the School of Oncoplastic Surgery; Focal Therapeutics, Inc; Medical Tactile, Inc; and Sanarus Technologies.
The Landscape Today and Some Predictions About the Future
Anthony Beisler, MD, whom we met in Part 1 of this article, is a general surgeon who practices at Mary Rutan Hospital in Bellefontaine, Ohio. As the surgeon who is doing most of the breast cancer surgery in his area, he practices level 1 oncoplastic surgery (OPS) methods that he learned in 2016.
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Anthony Beisler, MD
“I realized I could start with some basic OPS methods soon after my course. Now I’m considering higher-level techniques as my feedback has been positive,” he said.
Dr. Beisler plans to continue advancing in his knowledge and practice of OPS. As he heads down that road, he is seeing issues that general surgeons typically see when they expand their range of skills.
This is a major reason that Dr. Beisler advocates repeating basic OPS courses such as the one he took from the School of Oncoplastic Surgery in 2016. By focusing on different techniques each time, he will be taking advantage of the rich course content in a way that advances his competency step-by-step.
“The key is incremental implementation. It’s more comfortable for the hospital, and it’s more comfortable for me,” he said.
Dr. Beisler is permitted by his credentialing committee to practice basic level 1 OPS approaches, such as round block technique and tissue rearrangement, that are based in practices already familiar to general surgeons. To go beyond those—for example, to perform a reduction mammoplasty on the contralateral breast—his committee likely would require him to be proctored by a plastic surgeon.
He believes that a certification in OPS like the one being developed by the School of Oncoplastic Surgery will ease the process of demonstrating OPS competencies to credentialing committees. OPS certification demonstrates that recipients have attained verified levels of OPS knowledge and have gained proctored, hands-on experience in the lab.
The entry-level techniques are not much of a reach for general surgeons, Dr. Beisler said. “When I got my first training last year, I literally felt confident enough with what I learned in the tissue lab to be able to take it and do it the next day.”