Dr. Renee Hanrahan 14/11/2016

22nd OAGS Annual Meeting ‐ Nov.5‐16 1

Oncoplastic Breast Surgery

OAGS 2016Dr Renee HanrahanGeneral SurgeonOncologic and Reconstructive Breast Surgeon

Disclosures

Newfoundlander

Objectives

Define Oncoplastic SurgeryDescribe the underlying principles of Oncoplastic

surgeryDiscuss an approach to appropriate patient and

procedure selectionOncoplastic Tool BoxDiscuss aesthetic mastectomies

What is Oncoplastic Surgery

1.Flowers, rainbows and pink stuff.2.Never heard of it.3.Not safe.4.Combination of ablative and plastic surgery

techniques in breast cancer treatment.

Definition and Principles

First described by Audretsch in 1998. Originating out of Europe.

The technical convergence of oncologic (ablative) surgery and aesthetic breast surgery.

Consideration of aesthetic outcomes and survivorship. Main principles;

Complete excision of tumor with clear marginsImmediate reshaping/remodeling of breast tissueConsideration of contralateral symmetry

Aesthetic Outcomes

The single most important determinant of aesthetic outcome in breast surgery is the percentage of tissue removed from the breast.

Studies have shown that if anything greater than 20% of the breast volume is being excised, it will result in a deformity.

Some areas of the breast are easier to reconstruct than others.

lower poleupper inner/cleavage

Oncoplastic surgery provides options for closure.

Dr. Renee Hanrahan 14/11/2016

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One of the most dangerous phrases in medicine…..

“This is the way we have always done it.”Principles

Cancer comes firstMultidisciplinary approachPatient InvolvementPatient selection Incision selectionGood technique

Oncologic Principles

Oncologic safetyMilan 2007London 2012UK 2013

no long term follow up

Larger specimens and increased exposure.Re excision vs completion mastectomy for positive

margin. Location of scar and radiation planning.

Multidisciplinary Approach

Patient Plastic surgeon Radiology Pathology Radiation OncologyMedical Oncology

Patient Centered Care

Do they want it?Do they need it?Is it safe for them?Anxiety vs PleasedLevel of expectation

They are sisters, not twins.

Patient Selection

All patients – even if a radial incision utilize the multilayer closure, parenchymal mobilization, good hemostasis…..

No significant risk for surgical complications – eg. DM, smoker, GA risks.

Contralateral breast – immediate or delayed and normal imaging.

Appropriateness for breast conserving therapy – when to consider a mastectomy +/- reconstruction.

Pre op imaging – try to avoid the need for re-excision.

Dr. Renee Hanrahan 14/11/2016

22nd OAGS Annual Meeting ‐ Nov.5‐16 3

Algorithm

Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated with postmastectomy radiation therapy.Peled AW, Sbitany H, Foster RD, Esserman LJBreast J. 2014 May-Jun; 20(3):302-7.

Incision SelectionFour factors

1. breast size/density2. nipple location/ptosis3. Tumor size4. Tumor location

Anatomic Considerations

My Personal Favorites Benelli / Donut / circumareolar

Inframammary / Horizontal / Smile

Racket / Lateral or medial mammoplasty

Dr. Renee Hanrahan 14/11/2016

22nd OAGS Annual Meeting ‐ Nov.5‐16 4

Case Presentation

Very young 72 yo with palpable left breast cancer, clinically node negative.

Previous reductionOn exam

tumor at 3 o’clock position skin dimplingmoderate breast size, described as a “C” cupgrade 2 ptosis

Partial mastectomy with Racket closure,SLN Bx and balancing mastopexy

Post op 2 weeks 55 yo female with Locally Advanced Breast Cancer

Presented with large central mass, nipple involvement.

1 node positive

Triple negative receptor status

Genetically negative

Treated with Neoadjuvant chemotherapy

Central Lumpectomy

Dr. Renee Hanrahan 14/11/2016

22nd OAGS Annual Meeting ‐ Nov.5‐16 5

Paget’s Disease Nipple Reconstruction

Provides symmetry

Hide scars

Appear more natural

3-D tattooing

Benefits

Decreased breast volume, better tolerated adjuvant radiation

Decreased re-excision rates 2-3% vs. 5-15%

Improvement in patient reported outcomesImproved self esteem Decreased mental health issues post treatment>80% would do it again40% of sBCT patients seek reparative surgery

Complications Surgical

15 – 30%Hematoma, fat necrosis, skin flap necrosis/wound issues, nipple

areola loss/sensation

Delay to adjuvant therapiesSurveillance mammo and scarring

OncologicPositive marginRecurrenceTreatment is same as sBCT, completion mastectomy

Local Experience 239 case over 2009 – 2015

12 re-excision 2 completion mastectomy 1 local recurrence 0 deaths

3 evacuation of hematoma 28 wound infections, 1 nipple areola loss

Dr. Renee Hanrahan 14/11/2016

22nd OAGS Annual Meeting ‐ Nov.5‐16 6

Tips of the Trade

Markings – do them standing before you go into the room.Orientation – place stitches prior to removal of the specimen. Clips – Radiation Oncologist love them. Close the defect – avoid dimpling/delayed contracting. Use drains.Considerations for the contralateral breast

Weight specimen Radiation effects Make the cut – a smaller scar is not always better, but double

layer closure.

Tools

Closure3 layered

Defect – raise parenchymal flaps in the subcutaneous spaces. 2-0 vicrylDeep Dermal – spreads tension, 3-0 monocrylSub Q – will use staples in the inframammary fold.Nipple – folds will flatten, make up of difference, 4-0 PDS sutureRescue stitch – 4 -0 plain

3 Layered Closure

Nipple Areolar Closure Billing Tips

Do the work

History and Physical

Operative Header

Dictation

Balancing procedures

RH1

Slide 36

RH1 Renee Hanrahan, 07/06/2015

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Training

Amount of training depends on what you want to incorporate into your practice.

Local plastic surgeonProvincial training programs International courses/electives

Residents and Fellows

Aesthetic Mastectomy Skin sparing, nipple sparing are felt to be oncological

safe as long as margin is clear.

Only appropriate in the case of immediate reconstruction or within a vey short time period to delayed reconstruction (weeks).

Considerations for mastectomy;Keep incision low, inframammary to areola, low

lying ellipseV-Y advancement flap, for lateral dog earInverted T

SummaryThese techniques leave patients with minimal

deformities without compromising oncologic safety.

ASBS consensus conference July 2015 recommended that “ the utilization of oncoplastic surgery should be considered, (along with other factors) in optimization of lumpectomy surgery”.

Simple techniques can be employed in any general surgeons OR but more complex approaches require specific training.

45 yo female with LABC (6 cm) triple negative breast cancer. Genetic testing negative, Node negative.Which of the following would be your option for treatment?

1. Modified Radical Mastectomy2. Neoadjuvant chemotherapy followed by oBCT

and SLN Bx3. sBCT and SLN Bx4. Mastectomy and SLN Bx +/- reconstruction

Questions