Oncoplastic surgery combines the plastic surgery technique of a breast reduction with lumpectomy surgery to give you a better cosmetic outcome after the cancer is removed.

You can think of an oncoplastic operation as a doing a breast reduction operation and including the cancer in the area to be removed while moving the remaining tissue into position to create a normal but more compact breasts mound.

There are many different oncoplastic approaches available to reshape the breast after removing the cancer and in our unit, almost every lumpectomy will have some local tissue transposition to prevent a permanent defect.

Oncoplastic surgery techniques also include reconstruction after mastectomy, but for the purposes of this document, we will limit the discuss to breast conservation surgery.

Our Surgical team were one of the first in South Africa to incorporate oncoplastic techniques into breast cancer surgery.

What is oncoplastic lumpectomy?

The two main options for breast cancer surgery are lumpectomy and mastectomy. Breast reconstruction is routinely offered with mastectomy, but you might not know that oncoplastic surgery could be a reconstructive option if you’re eligible for lumpectomy.

Traditional lumpectomy vs. oncoplastic surgery: What’s the difference?

Lumpectomy — also called partial mastectomy or breast-conserving surgery — removes the breast cancer and a rim of healthy tissue called a margin, preserving most of the breast. The surgeon then closes the incision. Initially fluid fills the space left behind, but later a defect may remain in the operation area.  If the cancer is small and you have a large or mid-sized breast, you should still have an excellent cosmetic result. But with larger tumours in smaller breasts, some women are not completely satisfied with their appearance after traditional lumpectomy. 

In some cases, a divot or dent forms and causes visible indentation in the breast, a tight scar, or distortions in the nipple’s appearance. Radiation often worsens the cosmetic effect on the breast by affecting the size and shape. A breast that looked fine on the operating table might not look the same as time passes.

Oncoplastic lumpectomy combines plastic surgery techniques with lumpectomy to both remove the cancer and reconstruct and reshape the breast. It can be useful for achieving a better cosmetic outcome , especially  in those who have:

• smaller breasts, where removing even a small tumour is likely to have a visible impact
• breast cancer in an especially visible place, such as high on the chest wall, on the inner portion of the breast, or close to the nipple
• mid- to large-sized breasts and the need to have a large amount of tissue (20% to 50%) removed from the affected breast
• chemotherapy before surgery (called neoadjuvant chemotherapy) that shrinks the cancer enough to make lumpectomy possible
• pre-existing issues with their breasts, such as excessive sagging (ptosis), very large size (macromastia), or obvious lack of symmetry (balance), which could be addressed at the same time the cancer is removed

Oncoplastic lumpectomy is not a good option for inflammatory breast cancer or for cancers that are so widespread they can’t be completely removed with a good aesthetic result. The procedure also may not be possible if there are multiple tumours throughout the breast, unless the breast is quite large and the tumours clustered together.

Oncoplastic lumpectomy techniques

There are many different approaches to oncoplastic lumpectomy. Simple oncoplastic techniques (Level 1)  are routinely used in out unit. We will focus on the more advanced procedures (Level 2)

With all of these approaches, the surgeon pays attention to the position of the nipple and areola, adjusting its location as needed while maintaining its blood supply. In Some cases, removal of the nipple may be required.

Volume reduction with breast lift (mastopexy): The surgeon removes the section of the breast that contains the cancer and then performs a breast lift. This procedure can address sagging breasts (ptosis) or excess skin. To make the breasts symmetrical, the surgeon can also perform a breast lift on the other side.

Significant breast reduction (reduction mammaplasty): If a woman has very large breasts, the surgeon can remove the cancer and a larger amount of surrounding tissue as part of a breast reduction. The surgeon would also reduce the size of the other breast to match.

Volume replacement using nearby tissue flaps: Flaps of tissue from the side of the body (near the breast) or the upper back can be moved into the breast area while still attached to their blood supply (this is called a pedicle flap). The surgeon may use flaps if there is not enough nearby tissue to fill in space left behind after the lumpectomy (in a smaller-breasted woman, for example) or if a woman wants to maintain her breast size.

Volume replacement with fat grafting: This is typically used after you complete radiation therapy  to fill in areas of the breast where volume is needed or to ensure better symmetry.

All these  procedures require a a team approach between the cancer surgeon and plastic surgeon working together simultaneously. Our surgical team is well versed in all of these techniques.

Other things to know about oncoplastic lumpectomy

Just as with a regular lumpectomy, the cancer is sent for pathology testing to the lab to ensure complete removal. Oncoplastic operations reduces the risk of requiring further operations for residual cancer. Tiny metal clips will be left to mark the cancer bed. These clips ensure that, even after the breast tissue is rearranged, your oncologist will still be able to see the cancer’s original location. This is helpful for planning radiation treatments and for future breast cancer screenings. 

Sometimes, we may perform oncoplastic surgery on the cancerous breast and then wait a few months to a year after radiation before performing surgery on the healthy breast to bring it into balance, if needed. That’s because it can be hard to predict what effect radiation therapy might have on the breast. In general, we prefer to operate on both breasts at once.

Making decisions about oncoplastic lumpectomy

It is understandable to want the cancer out as quickly as possible. But it may be worth taking time to enquire about oncoplastic surgery. The planning will be a little bit longer, but there would be no risk to your health or the cancer risk. Most Medical Aids will cover this type of surgery as it is seen as reconstructive and not cosmetic.

Your personal preferences

• Some people would like the simplest, shortest procedure and are not as concerned about having a smaller or lifted breast. For them a simple lumpectomy might be sufficient.
• If you have ever considered a breast reduction of breast lift, an oncoplastic lumpectomy might be a good option for you.

Advantages of oncoplastic lumpectomy

Oncoplastic lumpectomy offers a number of advantages:

• The surgeon pays attention to the shape and appearance of the breast.
• Since you keep much of your natural breast tissue, your breasts usually retain feeling. Although there may be some changes in sensation, you avoid the numbness that is common with full mastectomy and breast reconstruction (if you chose to have reconstruction).
• The surgeon often can remove more tissue than with lumpectomy alone, which is more likely to result in clean margins.
• It gives you and your surgeon the opportunity to address issues such as sagging, excess skin, very large breasts, and/or asymmetry.
• For larger-breasted women who undergo a breast reduction as part of oncoplastic surgery, having less breast tissue may lower the risk of the cancer coming back (called recurrence) and makes future screenings easier.
• In some cases, the surgery can be done in one day as an outpatient procedure.

Disadvantages of oncoplastic lumpectomy

• You may likely still need to have radiation therapy.
• Radiation treatments can affect the size and shape of the breast. Your surgeon may try to account for this change during oncoplastic surgery, but there may be a need for additional procedures (such as fat grafting) to balance the breasts.
• The incisions are usually larger than with traditional lumpectomy. Those scars do fade over time, though.
• The recovery time is longer than it would be with traditional lumpectomy.
• As with traditional lumpectomy, there is a small chance of positive margins, but your surgeon won’t know for certain until the pathology report comes back a few days later. With positive margins, you would need additional surgery to remove more tissue (re-excision) or, possibly, the entire breast (mastectomy).
• There are not many surgical teams like ours with the with the training and expertise needed to perform oncoplastic operations.