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Oncoplastic Surgery of
the Breast

Second Edition

Edited by

Maurice Y. Nahabedian, MD, FACS

Professor
Department of Plastic Surgery
Virginia Commonwealth University - Inova Branch
Falls Church, VA, USA

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Preface
I am proud to introduce the second edition of Oncoplas-
tic Surgery of the Breast. It has been 10 years since the first
edition. As the field of oncoplastic surgery continues to
evolve with new concepts and strategies being introduced
every year, it is important for surgeons around the world to
remain current. The safety and efficacy of oncoplastic breast
surgery has clearly been demonstrated as patient outcomes
have continued to improve and patient satisfaction has con-
tinued to soar. This second edition has made every effort to
incorporate the new ideas and innovations into a compre-
hensive text that is state-of-the-art and up-to-date in every
respect.
The second edition has been organized into 3 sections
and 21chapters. The three sections are focused on get-
ting started, review of techniques, and outcomes. Most of
the authors are new and were chosen to prepare a chapter
based on their contributions to the field and track record
for success. As with the first edition, the second edition
includes new instructional videos that complement most of
the chapters and facilitates the readers’ ability to perform
these operations. There are several chapters that are com-
pletely new that will introduce readers to novel approaches
to oncoplastic breast surgery. I am excited about the Breast
vi
Augmentation Technique (Biplanar) for Oncoplasty pre-
pared by Dr. Barnea. This has been an effective approach in
my practice that can provide excellent cosmetic outcomes.
Dr. Sivalia, Dr. Khan, and Dr. Silverstein have prepared an
excellent chapter on Extreme Oncoplasty that expands the
indication for oncoplasty in properly selected patients. They
have contributed three wonderful videos that demonstrate
their techniques in a well-described and simplified manner.
Dr. Reiland will provide the breast surgeon’s perspective on
oncoplastic breast surgery in this ever-expanding field.
There are several individuals I would like to thank whose
efforts were instrumental in the preparation of this book.
First and foremost are the authors who prepared the chap-
ters. They are all very busy, exceptionally talented, and have
sacrificed a significant amount of their time for this project.
Second are the staff at Elsevier for their hard work and com-
mitment toward publishing this textbook that has exceeded
all of our expectations. Finally, I would like to again thank
my family, Anissa, Danielle, and Sophia, for their support,
patience, and understanding during the many hours spent
in the preparation of this book.
Maurice Y. Nahabedian, MD, FACS
List of Contributors

The editor(s) would like to acknowledge and offer grateful Kenneth L. Fan, MD
thanks for the input of all previous edition’s contributors, Resident Physician
without whom this new edition would not have been Department of Plastic and Reconstructive Surgery
possible. MedStar Georgetown University Hospital
Washington, DC, USA
Yoav Barnea, MD
Head, Plastic, and Reconstructive Breast Surgery Unit Jian Farhadi, MD, PD
Plastic Surgery Consultant
Tel Aviv Medical Center, affiliated with the Sackler Faculty Plastic and Reconstructive Surgery
of Medicine Guy’s and St. Thomas Hospital
Tel Aviv University London, UK;
Tel Aviv, Israel
Professor
University of Basel
Grant W. Carlson, MD
Basel, Switzerland
Wadley R. Glenn Professor of Surgery
Surgery Plastic Surgeon
Emory University Plastic Surgery Group
Atlanta, G, USA Zurich, Switzerland

Costanza Cocilovo, MD Allen Gabriel, MD, FACS

Medical Director Peacehealth Plastic Surgery
Breast Surgery Peacehealth
Inova Vancouver, WA, USA
Farifax, VA, USA
United States
Clinical Associate Professor
Randy De Baerdemaeker, MD, FCCP, FEBOPRAS
Plastic Surgery
Member of Staff
Loma Linda University Medical Center
Department of Plastic, Reconstructive, and Aesthetic
Loma Linda, CA, USA
Surgery
University Hospital Brussels
Moustapha Hamdi, MD, PhD
Brussels, Belgium
Professor
Plastic and Reconstructive Surgery
Kirsten Edmiston, MD
Brussels University Hospital
Medical Director
Brussels, Belgium
Inova Breast Care Center
Inova Fair Oaks Hospital
Tammy Ju, MD
Fairfax, VA, USA
Surgery Resident
Clinical Assistant Professor Surgery
Department of Surgery George Washington University Hospital
VCU/Inova Fairfax Medical Center Washington, DC, USA
Fairfax, VA, USA

vii
viii List of Contributors

Sadia Khan, DO, FACS Bridget A. Oppong, MD

Program Advisor - Breast Surgical Services Reston Breast Care Specialists
Breast Surgical Oncology Surgery
Hoag Memorial Hospital Presbyterian Reston Hospital Center
Newport Beach, CA, USA Reston, VA, USA
Assistant Clinical Professor Adjunct Faculty
Department of Surgery Lombardi Comprehensive Cancer Center
Keck School of Medicine USC Georgetown University
Los Angeles, CA, USA Washington, DC, USA

Steven J. Kronowitz, MD Gemma Pons, MD, PhD

Owner Head of the Microsurgery Unit
Kronowitz Plastic Surgery, PLLC Plastic Surgery
Houston, TX, USA Hospital de Sant Pau
Barcelona, Spain
Albert Losken, MD, FACS
Consultant
Emory University
Plastic Surgery
Division of Plastic and Reconstructive Surgery
Hospital de Sant Pau
Emory University Hospital
Barcelona, Spain
Atlanta, GA, USA
Juliann Marie Reiland, MD
Jaume Masia, MD, PhD
Program Director, Electron-based IORT Breast
Chief and Professor
Oncology
Plastic Surgery
Avera Cancer Institute
Sant Pau University Hospital (Universitat Autonoma de
Sioux Falls, SD, USA
Barcelona)
Barcelona, Spain Clinical Associate Professor
Surgery
Alex N. Mesbahi, MD Sanford School of Medicine
Assistant Clinical Professor Sioux Falls, SD, USA
Plastic Surgery
Chair: ASBrS Oncoplastic Surgery Committee
Georgetown University Hospital
American Society of Breast Surgeons
Washington, DC, USA
Partner Jordi Riba Vílchez, MD
National Center for Plastic Surgery Plastic Reconstructive and Aesthetic Surgery Department
McLean, VA, USA Hospital de Sant Pau
Barcelona, Spain
Alexandre Mendonça Munhoz, M, PhD
Plastic Surgery Rachel Rolph, MBBS MA(Oxon) MRCS
Hospital Sírio-Libanês, São Paulo Clinical Research Fellow
São Paulo, Brazil Department of Plastic and Reconstructive Surgery
Guys and St Thomas’ NHS Foundation Trust
Professor
London, UK
Plastic Surgery
Instituto do Câncer do Estado de São Paulo, São Paulo
Nirav B. Savalia, MD
Sao Paulo, Brazil
Clinical Assistant Professor of Surgery
Plastic Surgery
Maurice Y. Nahabedian, MD
USC/Keck School of Medicine
Professor
Los Angeles, CA, USA
Department of Plastic Surgery
Virginia Commonwealth University - Inova Branch Program Director for Oncoplastic and Aesthetic Breast
Falls Church, VA, USA Surgery
Hoag Hospital Memorial Presbyterian
Newport Beach, CA, USA
 List of Contributors ix

Hani Sbitany, MD, FACS Christine Teal, MD

Associate Professor of Surgery Director, Breast Care Center
Plastic and Reconstructive Surgery Surgery
University of California George Washington University
San Francisco, USA Washington, DC, USA

Melvin J. Silverstein Peter W. Thompson, MD

Hoag Hospital Memorial Presbyterian Assistant Professor of Plastic Surgery
Newport Beach, CA, USA Surgery
Department of Surgery, Keck School of Medicine, Emory University
University of Southern California Atlanta, GA, USA
Los Angeles, CA, USA
Mark Venturi, MD, FACS
Toni Storm-Dickerson, BS, MD Private Practice
Director Plastic Surgery
Surgical Services Compass Breast National Center for Plastic Surgery
Compass Oncology McLean, VA, USA
Vancouver, WA, USA
Louisa Yemc, PA-C
Medical Director Surgical Services
National Center for Plastic Surgery
Kearney Breast Center
McLean, VA, USA
PeaceHealth Vancouver
Vancouver, WA, USA
 I would like to dedicate this second edition of Oncoplastic Surgery of the Breast to my long-
time friend and associate, Scott Spear, MD. Scott was an inspiration to plastic and breast
surgeons around the world whose valuable insights and pearls of wisdom helped thousands
of surgeons who ultimately were able to help tens of thousands of patients. I was fortunate
to work with him at Georgetown University Hospital from 2005–2013, where he was the
founding Chairman of the Department of Plastic Surgery. Scott taught me to think critically,
analyze precisely, and to plan and execute accordingly. He raised the bar for all of us when it
came to surgical and aesthetic outcomes following reconstructive and aesthetic breast surgery.
I would also like to dedicate this book to the 69 plastic surgery chief residents that I have
had the privilege to work with and train while on the faculty at Johns Hopkins and George-
town Universities from 1996–2017. Their desire to learn was my inspiration to teach both in
the operating room and in the research arena. The friendships that have been established have
stood the test of time, and I am so proud of each and every one of them. Special thanks to
Mark Venturi, MD, and Alex Mesbahi, MD, who were two of my plastic surgery residents. It
has been a privilege to become a partner in their practice where we continue to provide state
of the art reconstructive and aesthetic breast surgery for our patients.
Finally I would like to thank my wife, Anissa, and my two daughters, Danielle and
Sophia. Their endless support and encouragement have made it possible to continue to educate
and teach surgeons around the world and to provide patients with the highest quality care
possible.

Maurice Y. Nahabedian, MD, FACS

1
Introduction to Oncoplastic
Breast Surgery
MAURICE Y. NAHABEDIAN
Oncoplastic breast surgery has become a common option
for women with breast cancer. Oncoplastic surgery is
defined as tumor excision with a wide margin of resection
followed by immediate or staged immediate reconstruction
of the partial mastectomy defect. It differs from traditional
breast conservation in that the margin of excision is signifi-
cantly wider ranging from 1–2 cm rather than 1–2 mm.
Oncoplastic breast surgery has been demonstrated to be
safe and effective and results in high patient satisfaction.
This introductory chapter will review the evolution and
many of the milestones associated with ablative breast can-
cer surgery and how oncoplastic breast surgery has evolved
as a primary option for women diagnosed with breast can-
cer.
History of Mastectomy
The management of breast cancer has been subject to
several paradigm shifts over the past century. Before the
era of William Stewart Halstead, the diagnosis of breast
cancer was often associated with few options for manage-
ment and poor patient survival. With the introduction of
the radical mastectomy, the morbidity and mortality of
breast cancer was markedly improved; however, the dis-
figurement following this operation was significant.1 The
modified radical mastectomy (MRM), in which the pec-
toral major muscle was preserved and the axillary lymph
node basin was dissected, maintained similar survival
statistics with slightly less physical disfigurement.2-4 The
simple mastectomy in conjunction with radiation therapy
was introduced at the same time and continued to provide
less aggressive surgical techniques.5 Further refinements in
mastectomy techniques allowed for skin-sparing patterns
that were demonstrated to equivalent local recurrence and
survival rates.6-8 With the introduction of sentinel lymph
node biopsy (SLNB) for breast cancer, the need to per-
form an axillary dissection was significantly reduced, and
the simple mastectomy with SLNB has become a common
mastectomy strategy.9,10 The most recent innovation has
2
been the widespread acceptance of nipple-sparing mastec-
tomy for malignant disease that has been applied to women
in select situations.11-15
The common feature of the early mastectomy tech-
niques was that the breast was removed, and the likeli-
hood of disfigurement was high. This ultimately led to the
need for reconstructive techniques that could minimize
this disfigurement. The advancements in breast recon-
struction paralleled the advancements in mastectomy so
these disfigurements could be eliminated. Reconstructive
options have included prosthetic devices, musculocutane-
ous flaps, and perforator flaps.16-23 The evolution of these
techniques has made a significant impact when it came
to mastectomy and outcome; however, the breast conser-
vation therapy (BCT) movement had been initiated and
represented a new frontier in the management of breast
cancer.
History of Breast Conservation
The breast conservation movement began to move forward
as our understanding of the pathophysiology of breast can-
cer improved and optimal utilization of radiation therapy
became standardized. The notion that total mastectomy
was not an absolute requirement and that lumpectomy
could be performed with equivalent safety and efficacy was
a significant breakthrough.24,25 Benefits included preserva-
tion of the nipple–areolar complex in many cases as well
as maintaining breast shape in the majority of women.26
Common to all patients having BCT is the need for postop-
erative radiation to eradicate microscopic disease that may
be present.
Outcomes following BCT have been generally favor-
able with survival statistics that have remained essentially
equal to that of MRM.27 However, local recurrence rates
are slightly increased. Although the aesthetic outcomes fol-
lowing BCT have been good to excellent in the majority
of women, some have required secondary procedures to
improve the appearance and achieve symmetry.28

History of Oncoplasty
In an effort to reduce the incidence of local recurrence and
maintain natural breast contour, the concept of oncoplastic
surgery was introduced.29,30 Oncoplastic surgery differs from
standard BCT in that the margin and volume of excision is
typically greater than that of lumpectomy or quadrantec-
tomy. With BCT, an excision margin of 1–2 mm is usu-
ally sufficient; whereas with oncoplastic surgery, excision
margins typically range from 1–2 cm and resection volumes
typically range from 100–200 cm3. The resultant deformity
is usually reconstructed immediately using volume replace-
ment or displacement techniques; however, a staged imme-
diate reconstruction can also be considered. Reconstructive
options include adjacent tissue rearrangement, reduction
mammaplasty, or distant flaps. When symmetry is desired,
contralateral procedures can be performed immediately at
the time of partial breast reconstruction or on a delayed
basis and include reduction mammaplasty, mastopexy, or
augmentation. Breast conservation using oncoplastic tech-
niques has resulted in survival and local recurrence rates that
are essentially equal to that of MRM.31,32
The purpose of this introductory chapter is to review
the history of these oncoplastic procedures and several of
the landmark studies as well as highlight some of the sur-
geons that have made significant contributions to onco-
plastic surgery. As oncoplastic surgery gains acceptance
and popularity, an optimal and systematic approach to
management is becoming increasingly necessary. This
introductory chapter will review many of the relevant
vignettes of oncoplastic surgery, and the subsequent chap-
ters will expand upon many of the principles, concepts,
and techniques.
Safety and Efficacy of Oncoplastic Surgery
The indications and patient selection criteria for oncoplastic
surgery is now well appreciated and accepted. Oncoplastic
surgeons should be aware of all aspects related to the indi-
cations, techniques, and recovery for women considering
partial mastectomy. Safety in oncoplastic surgery requires
an appreciation of tumor biology and an understanding
of what constitutes an appropriate margin. The process
begins by obtaining a diagnosis that can be accomplished
using various techniques that include fine-needle aspiration,
core needle biopsy, and excisional biopsy. The next step is
the excision. The importance of obtaining a clear margin
becomes evident when one considers that the relative risk
of developing a recurrence is 15-fold higher in patients in
whom the surgical margin was not clear of tumor.33,34 A
positive margin can be related to the size of the primary
tumor (T3 > T2 > T1) and to histological subtype (lobu-
lar > ductal).33 Preoperative identification of these women
with infiltrating lobular carcinoma who may be at higher
risk of a positive surgical margin can be sometimes made
via mammography based on the presence of architectural
distortion.35
CHAPTER 1 Introduction to Oncoplastic Breast Surgery 3
It is known that larger tumors have an increased likeli-
hood of a positive margin; therefore, obtaining wider mar-
gins may decrease the likelihood of a positive margin. Kaur
et al demonstrated that, as resection margins increase, the
incidence of a positive margin is reduced, especially when
comparing oncoplastic resection to standard quadrantec-
tomy.36 Mean resection volume in this study was 200 cm3
following oncoplastic resection and 117 cm3 following
quadrantectomy. Giacalone et al have demonstrated that,
following oncoplastic resection, glandular removal was
increased, histological margins were wider, and the need for
re-excision was decreased.37 In addition, there was a trend
toward fewer mastectomies following oncoplastic resection
(2/42, 4.8%) compared with standard lumpectomy (12/57,
21.1%). Additional studies and supportive data will be
reviewed in upcoming chapters.
Immediate Reconstruction of the Partial
Mastectomy Deformity
The techniques currently used for the reconstruction of
the partial mastectomy defect are based on two different
concepts: volume displacement and volume replacement.
Volume displacement procedures include local tissue rear-
rangement, reduction mammaplasty, and mastopexy. Vol-
ume replacement procedures include local and remote flaps
from various regions of the body. These techniques are usu-
ally applied independently; however, new strategies can uti-
lize them simultaneously.
The indications for volume displacement and replace-
ment are different and, various algorithms have been devised
to assist with the decision-making process.38-40 In general,
women with smaller breasts with minimal ptosis were found
to be better candidates for volume replacement procedures
(e.g., local flap, latissimus dorsi, and lateral thoracic flap),
whereas, in women with larger and more ptotic breasts,
volume displacement procedures (e.g., adjacent tissue rear-
rangement, reduction mammaplasty, and mastopexy) are
usually performed. The simultaneous use of replacement
and displacement has recently been described for women
with small to moderate breast volume in which parenchy-
mal rearrangement is combined with the use of a small
device.41-43 The history of these techniques as they relate to
oncoplastic surgery will be further reviewed.
Volume Displacement with Reduction
Mammaplasty
Reduction mammaplasty as an oncoplastic modality has
been performed since the early 1980s.44 Over the years,
this has become the principal method by which oncoplas-
tic reconstruction has been performed.45,46 Clough et al
reported on their 14-year experience in 101 women who
were selected for oncoplastic resection because a standard
lumpectomy would have resulted in a significant contour
4 S EC T I O N I Oncoplastic Breast Surgery – Getting Started

abnormality.45 The primary technique utilized was an

inverted “T” with nipple–areolar complex based on a supe-
rior pedicle. A contralateral reduction mammaplasty for
symmetry was performed immediately in 83% of women
and secondarily in 17% of women. Mean tumor excision
weight was 222 grams. The 5-year local recurrence rate was
9.4%, the overall survival rate was 95.7%, and the metas-
tasis-free survival rate was 82.8%. Cosmetic outcome was
satisfactory in 82% of women. It was demonstrated that
cosmetic outcome tended to deteriorate when radiotherapy
was delivered preoperatively compared with postoperatively.
Spear et al have reported on their 6-year multidisci-
plinary experience combining wide excision of tumor
with immediate bilateral reduction mammaplasty.47 All
women had mammary hypertrophy with a mean exci-
sion volume of 1085 grams per breast. Follow-up ranged
• Fig. 1.1Preoperative marking of a woman with mammary hypertro-
from 1–6 years with a mean of 24 months. Complications phy and left breast cancer in preparation for left oncoplasty and right
included fat necrosis (n = 3), nipple hypopigmentation reduction mammaplasty.
(n = 2), hematoma, and complex scar. Patient satisfaction
was scored on a visual analog scale that ranged from 1–4
with a mean score of 3.3. A panel of independent observ-
ers also graded the outcomes and scored the pre-radiation
outcome as a 2.9 and the post-radiation outcome as 3.03.
No woman developed a local recurrence, although one
woman died of metastatic disease. The principal con-
clusions from this study were that partial mastectomy
followed by oncoplastic and contralateral reduction mam-
maplasty was oncologically safe and avoided the asymme-
try that was typically observed following BCT alone or
following total mastectomy with immediate total breast
reconstruction.
Losken et al have reported on their 10-year experience
utilizing reduction mammaplasty in the setting of onco-
plastic surgery.39,48 A total of 20 women were included
in this review. Mean tumor size was 1.5 mm, and the
mean weight of the tumor specimen was 288 grams. The
excised surgical margins were negative in 80%. The most
common reduction technique was a superomedial or • Fig. 1.2
Postoperative image at 1 year following left breast radiation
therapy demonstrating good volume, contour, and symmetry.
inferior pedicle. Postoperative abnormal mammograms
were noted in eight women (40%), all of whom under-
went additional biopsy. No woman was noted to have a Volume Displacement with Adjacent Tissue
recurrence with a mean follow-up of 23 months. Breast Rearrangement
aesthetics and patient satisfaction were acceptable in all
women. Adjacent tissue rearrangement is the most common method
These studies and others have demonstrated the utility by which the partial mastectomy defect is reconstructed.
of reduction mammaplasty in the setting of oncoplastic sur- These techniques rarely require a two-team approach, as the
gery. It is important to note that no two oncoplastic reduc- ablative surgeon is usually able to use these techniques and
tion procedures are the same and that oncoplastic reductions close these defects. Adjacent tissue rearrangement is indi-
are different from standard breast reductions. Parenchymal cated when the partial deformity extends to the chest wall
displacement may take the form of a flap of vascularized and there is sufficient adjacent tissue to close the defect and
parenchyma or as parenchymal rotation advancement. If maintain a natural contour. Volume displacement is per-
there is doubt about obtaining a clear margin at the time of formed but without the need to create parenchymal flaps.
the primary excision, a staged immediate reconstruction can Volume replacement is usually not necessary because there
be performed following margin confirmation. Figs. 1.1–1.2 is sufficient local tissue. The primary goal of adjacent tis-
illustrate a patient before and after oncoplastic reduction sue rearrangement is to avoid the contour deformity that is
mammaplasty. sometimes seen with traditional breast conservation. With
this method of oncoplastic reconstruction, the excision is

usually extended to the chest wall, and the adjacent paren-
chyma is undermined and mobilized to permit the closure
of small or large deformities without creating a contour
abnormality.
Specific parenchymal rearrangement procedures include
batwing mastopexy, radial segment quadrantectomy, donut
mastopexy, and reduction mastopexy. Veronesi et al intro-
duced the concept of segmental parenchymal wide exci-
sion including the overlying skin.49 This allowed for the
quadrantectomy approach that was instrumental in estab-
lishing the feasibility of BCT. These operations were gener-
ally performed using a radial approach for tumors that were
laterally based. An alternative to the radial approach was the
periareolar approach initially described by Amanti et al.50
This permitted excisions that resulted in less conspicuous
scars. With the introduction of the periareolar subcutane-
ous quadrantectomy, also known as the periareolar donut
mastopexy, incisions could be created circumferentially
around the nipple–areolar complex and remain relatively
inconspicuous. Anderson et al. introduced various concepts
that include skin incisions using a parallelogram pattern and
batwing mastopexy.44 These parallelogram incisions allowed
for wider excision margins while maintaining the natural
contour of the breast. The batwing mastopexy is an exten-
sion of this concept and is used primarily for centrally situ-
ated tumors near the nipple–areolar complex. Clough et al
introduced the technique of reduction mastopexy lumpec-
tomy.45 This technique has been especially useful for tumors
situated near the lower pole of the breast. Standard lumpec-
tomy of these tumors would often result in an inferiorly
displaced nipple–areolar complex.
Volume Replacement with Local and
Remote Flaps
Local and remote flaps for volume replacement are most
useful for defects in which volume displacement procedures
would not be adequate due to small breast volume or due
to extensive resection. The selection of a local or remote flap
will depend upon the abilities of the reconstructive surgeon
and the location of the defect. Flaps can be musculocutane-
ous and perforator-based and can be transferred on a vas-
cularized pedicle or as a free tissue transfer. Many of these
options will be reviewed in the subsequent chapters. What is
provided in this chapter is a brief overview of the techniques
and their origins.
The most common flap for immediate reconstruction
following partial mastectomy has been the latissimus dorsi
musculocutaneous flap.51-56 This flap is indicated for
deformities of the superior, lateral, and inferior aspects
of the breasts. There are several methods by which the
latissimus dorsi flap can be harvested. The traditional
technique involves making a posterolateral thoracic inci-
sion, whereas more modern techniques utilize an endo-
scope.53,56 With the endoscopic technique, the muscle is
accessed through the breast and axillary incision without
CHAPTER 1 Introduction to Oncoplastic Breast Surgery 5
• Fig. 1.3 A lower pole defect is demonstrated following partial mas-
tectomy.
the need to incise or excise remote skin. Kat et al have
reviewed their 3-year experience in 30 women who had
oncoplastic surgery using the latissimus dorsi musculocu-
taneous flap.52 Flap survival was 100%, and all patients
were pleased with aesthetic outcomes. Losken et al have
reviewed their 5-year experience using the latissimus dorsi
muscle flap harvested endoscopically in 39 women.53
Donor site morbidities occurred in 12 women (31%) and
included a seroma in 7 women as well as skin necrosis,
lymphedema, dehiscence, hypertrophic scarring, and a
persistent sinus tract.
Harvesting the latissimus dorsi as a mini-flap is advan-
tageous because the size of the flap can be tailored to fit
the size of the defect.54,55 The LD mini-flap is generally
harvested through an extended anterolateral breast inci-
sion that is used for the resection as well. Rainsbury has
demonstrated that this flap extends the role of BCT and
oncoplastic surgery; enables reconstruction for a deformity
involving 20–30% of the breast; can be used for central,
upper inner, and upper outer quadrant tumors; and can
be performed immediately or on a delayed basis.55 Gendy
et al have used the latissimus dorsi mini-flap for oncoplasty
in 89 women and compared outcomes with immediate
breast reconstruction following total skin-sparing mastec-
tomy.54 Findings were favorable for the oncoplastic tech-
niques with regard to postoperative complications (8% vs
14%), further surgical interventions (12% vs 79%), nip-
ple sensory loss (2% vs 98%), restricted activities (54%
vs 73%), and cosmetic outcome (visual analog score: 83.5
vs 72). Figs. 1.3–1.6 illustrate a patient following partial
breast reconstruction with a latissimus dorsi musculocu-
taneous flap.
6 S EC T I O N I Oncoplastic Breast Surgery – Getting Started
• Fig. 1.4 A latissimus dorsi musculocutaneous flap is harvested in
preparation for delayed reconstruction.
• Fig. 1.5 The latissimus dorsi flap is inset into the defect.
•Fig. 1.6 Postoperative follow-up demonstrating restoration of vol-
ume, contour, and symmetry.
Perforator flaps for partial breast reconstruction include
the thoracodorsal artery perforator (TDAP) flap, the lateral
thoracic flap, and the intercostal perforator flap.57-60 The
TDAP is an adipocutaneous flap in which the latissimus
dorsi muscle is totally spared. The vascularity of the flap is
derived from the perforating branches of the thoracodorsal
artery and vein. The lateral thoracic flap is a fasciocutaneous
flap that is perfused via the lateral thoracic, axillary, or tho-
racodorsal artery and vein. The intercostal perforator flap is
perfused via a perforating intercostal artery and vein that is
based along the inferior aspect of the anterior axillary line.
These flaps are usually transferred on a vascularized pedicle
but may be transferred as a free tissue transfer as well.
Clinical experience with these flaps has been encourag-
ing. Levine et al have provided an algorithm for perfora-
tor flap utilization.57 The first choice is the TDAP flap,
followed by the lateral thoracic flap, and finally the inter-
costal perforator flap. The decision is based on the quality
of the vessels during the operative procedure. Munhoz et al
have used the lateral thoracic flap in 34 women for partial
breast reconstruction.59 Complications included partial flap
necrosis in three (8.8%), fat necrosis in two (5.8%), and
infection in one (2.9%). Donor-site complications included
a seroma in five women (14.7%) and wound dehiscence in
three (8.8%). Patient satisfaction was achieved in 88% of
women with a mean follow-up period of 23 months.
Combining Volume Displacement and
Replacement
A relatively recent innovation in the oncoplastic armamen-
tarium is to combine volume displacement and replacement
simultaneously.41-43 This technique is primarily indicated in
women with smaller breasts who desire oncoplasty but seek
an alternative to the classical volume replacement techniques
described. Alternatives to the use of mini-flaps or perforator
flaps can include the use of devices, namely implants, but also
resorbable materials that are available as three-dimensional
constructs that have been used for radiation imaging.
The biplanar oncoplasty was initially described by
Nahabedian et al. and Miraliakbari et al, and incorporates
the use of breast implants or tissue expanders placed under
the pectoralis major muscle as well as parenchymal rear-
rangement that occurs above the pectoralis major mus-
cle, hence, the name biplanar oncoplasty.41-42 The use of
prosthetic devices such as breast implants in the setting of
oncoplasty and radiation therapy has historically resulted in
higher complication rates such as capsular contracture, pre-
mature removal, and decreased patient satisfaction. How-
ever, the increased use of prosthetic devices coupled with
the use of acellular dermal matrices in the setting of radia-
tion therapy has reduced the incidence of capsular contrac-
ture and made the biplanar technique more feasible. Barnea
et al will discuss this operation in greater detail in one of the
later chapters. Figs. 1.7–1.10 illustrate a patient following
simultaneous volume displacement and replacement using
a prosthetic device.

• Fig. 1.7
Preoperative image of a patient with multifocal breast cancer
scheduled for partial mastectomy.
• Fig. 1.8 The 201-gram specimen is excised.
A second option that incorporates volume displacement
and replacement simultaneously utilizes an entirely different
prosthetic device called BioZorb®.61,62 This is an implant-
able, resorbable, three-dimensional coil that is used to mark
the site of tumor extirpation for radiation therapy localiza-
tion. Its other benefit is that it can behave like a filler mate-
rial to act as a volume replacement device. The difference
between this approach and the biplanar approach is that the
volume replacement and displacement occur above the pec-
toralis major muscle. Following insertion of the BioZorb®
device at the base of the partial mastectomy defect, paren-
chymal rearrangement occurs to cover the device followed
by skin closure. Contour and volume abnormalities can be
minimized. Nahabedian will review this technique in a sub-
sequent chapter.
Conclusion
This introductory chapter was prepared to review the his-
tory of oncoplastic surgery and to provide a framework for
CHAPTER 1 Introduction to Oncoplastic Breast Surgery 7
• Fig. 1.9
One-week follow-up in which the defect was reconstructed
with a biplanar technique consisting of tissue rearrangement and
placement of a 180mL subpectoral silicone gel implant.
• Fig. 1.10 One-year follow-up demonstrating good volume, contour,
and symmetry.
the remaining chapters. All of the principles, concepts, and
specific techniques will be discussed in greater detail in the
forthcoming chapters.
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CHAPTER 1 Introduction to Oncoplastic Breast Surgery 9
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Bostwick J. Immediate endoscopic latissimus dorsi flap. Ann Plast
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2
Safety of Oncoplastic Breast
Reconstruction
PETER W. THOMPSON AND GRANT W. CARLSON
Introduction
Historically, early stage breast cancer has been treated with
either mastectomy or breast conservation therapy (local
tumor excision with adjuvant radiation therapy). Clinico-
pathologic characteristics such as tumor size and extent of
breast involvement determine patient suitability for one
approach or the other. Landmark prospective studies have
shown that these two approaches have equivalent disease-
free and overall survival.1
Total mastectomy can be a cosmetically deforming and
psychologically taxing procedure. Breast reconstruction fol-
lowing mastectomy involves use of prosthetic techniques or
harvesting autologous tissue from distant sites to recreate a
breast mound. Breast conservation is therefore appealing in
its potential to preserve the native breast mound; however,
an acceptable cosmetic result is not guaranteed. Up to 40%
of patients who undergo breast conservation have had an
unacceptable cosmetic result.2
Oncoplastic techniques utilize plastic surgical methods
of volume displacement and replacement to achieve the pri-
mary goal of negative surgical margins as well as the sec-
ondary goal of optimal aesthetic result and breast symmetry.
Oncoplastic breast conservation has become an increasingly
common technique compared with traditional breast con-
servation over the last 10 years by facilitating reconstruc-
tion after larger volume resections.3 Oncoplastic surgery has
greatly expanded the group of patients who may be can-
didates for breast conservation, and studies using validated
questionnaires have demonstrated excellent levels of patient
satisfaction.4 Concerns regarding the oncologic safety
of these techniques have increased, mirroring their rising
popularity. Safety data pertaining to oncoplastic breast sur-
gery are limited by a lack of prospective data and long-term
follow-up.
When discussing reconstructive options with ­pati­ents,
oncologic risks and benefits should be reviewed. With
10
o­ ncoplastic procedures, appropriate patient ­counseling re-
quires attention to several important clinical questions:
• Do oncoplastic techniques affect the rate of positive
margins in breast conservation, and how should positive
margins be managed?
• Do oncoplastic techniques affect the rate of local recur-
rence, disease-free survival, and overall survival?
• Does oncoplastic surgery result in a higher incidence of
complications?
• Does oncoplastic surgery affect the delivery of radiation
or future surveillance of breast cancer?
In this chapter, the available data to answer these impor-
tant questions will be reviewed.
Margins in Oncoplastic Surgery
The three goals of breast conservation therapy (BCT) are
to remove the primary tumor, decrease breast tumor recur-
rence, and optimize cosmesis. Positive margins have been
clearly shown to be a risk factor for local recurrence, but
until recently there was no consensus as to what constitutes
a “negative” margin. Based on a meta-analysis of 33 stud-
ies reporting on more than 32,000 patients, the Society
for Surgical Oncology and American Society of Radiation
Oncology released a joint guideline defining a negative
margin as “no ink on tumor.”5 There was no evidence that
obtaining a wider margin, such as a threshold of >2 mm
or >5 mm, resulted in a lower rate of local recurrence. This
recommendation is important when considering an onco-
plastic breast conservation procedure, which is often offered
to patients with larger tumors who might not be good can-
didates for standard breast conservation. In a meta-analysis
of more than 8500 patients published in 2014, Losken et al
compared the outcomes of patients who had undergone
standard breast conservation with patients who had under-
gone immediate breast reconstruction using oncoplastic
techniques. They found that, despite overall significantly

larger tumor size and lumpectomy specimen weight in the
oncoplastic group, the overall positive margin rate was sig-
nificantly lower in the oncoplastic group compared with
the standard breast conservation group (12% vs 21%).6 An
acceptably low positive margin rate following oncoplastic
breast conservation has been confirmed in multiple stud-
ies, ranging from 0–21% according to a recent systematic
review published by Piper et al.7
One concern voiced by critics about oncoplastic breast
conservation techniques, which utilize volume displace-
ment and parenchymal rearrangement to fill the empty
space created by tumor excision, is that the architecture
and orientation of the lumpectomy cavity becomes dis-
torted. This has the potential to make identification and
re-excision of previous surgical margins more difficult, and
in these cases completion mastectomy may be necessary to
achieve negative surgical margins. Data from Piper et al
suggest that the overall rates of re-excision and comple-
tion mastectomy in patients undergoing oncoplastic breast
conservation are acceptably low (3.5% and 3.7%, respec-
tively).7 Despite larger tumor size in patients undergoing
oncoplastic breast conservation, available data comparing
re-excision and completion mastectomy rates between
patients undergoing oncoplastic and standard breast con-
servation suggest that re-excision of positive margins is
less frequently required in the oncoplastic group, whereas
completion mastectomy is required at similar rates between
the two groups.6,8,9
Piper et al suggest placement of clips in the cardinal
directions of the lumpectomy cavity to both facilitate re-
excision in the setting of positive margins and to assist
with targeting of the radiation boost. The authors make
the argument that, because local tumor recurrence usu-
ally occurs in the previous lumpectomy site, marking
with clips also allows a second re-excision of breast tissue
rather than completion mastectomy in the setting of local
recurrence.7
A good understanding of factors predictive of margin
positivity is necessary to properly counsel patients consider-
ing breast conservation versus total mastectomy, as a find-
ing of positive margins after breast conservation will often
necessitate additional surgery. In a retrospective review by
Clough et al of 272 patients undergoing oncoplastic BCT,
the only factor predictive of margin positivity after multi-
variate analysis was invasive lobular tumor histology.10 A
retrospective review by Amabile et al looking at 129 patients
undergoing oncoplastic breast surgery further identified
obesity, tumor multifocality, and the presence of microcal-
cifications on mammogram as predictive of the need for
re-excision.11
In summary, oncoplastic breast conservation techniques
can be offered to patients with acceptable rates of margin
positivity compared with standard breast conservation;
however, proper patient selection is essential, as margin
positivity is one of the primary factors predictive of local
recurrence.
CHAPTER 2 Safety of Oncoplastic Breast Reconstruction 11
Local Recurrence, Distant Recurrence,
Disease-Free Survival, and Overall Survival
Following Oncoplastic Breast Conservation
The primary determinant of the safety and applicability
of any oncologic procedure is its effect on recurrence and
survival. As mentioned previously, the efficacy of BCT as a
treatment for early stage breast cancer has been established
by landmark studies demonstrating equivalent disease-free
and overall survival compared with mastectomy.1 As onco-
plastic modifications of standard breast conservation tech-
niques have only become a mainstream treatment option in
the last 10–15 years, long-term follow-up data evaluating
safety and efficacy are less readily available. De La Cruz et al
performed a systematic review of 55 articles pertaining to
oncoplastic outcomes including 6011 patients with a mean
follow-up of 50.5 months. Most patients included in this
analysis had early-stage breast cancers with invasive ductal
histology. The authors analyzed recurrence and survival out-
comes for three different follow-up intervals. Among 871
patients with the longest follow-up (at least 5 years), the
rates of overall survival, disease-free survival, local recur-
rence, and distant recurrence were 93.4%, 85.4%, 6%, and
11.9%, respectively.12 The authors noted that these rates
compare favorably with rates of local recurrence and overall
survival after standard breast conservation, suggesting that
long-term outcome is more dependent on patient factors
and tumor biology than on surgical technique. Given the
equivalent recurrence and survival outcomes with onco-
plastic techniques, these procedures may be safely offered
to most women who might also be candidates for standard
breast conservation; the potential benefit of improved cos-
mesis with oncoplastic surgery does not appear to compro-
mise cancer recurrence and survival.
Complications Following Oncoplastic
Breast Reconstruction
Preoperative counseling of patients considering oncoplas-
tic breast reconstruction must also include a discussion of
complications. Overall safety of the oncoplastic approach
can be considered in comparison to standard breast con-
servation, in comparison to bilateral breast reduction, or in
comparison to total mastectomy with reconstruction. All of
these analyses have been performed with a finding of favor-
able complication profiles for oncoplastic reconstruction.
The overall complication rate of oncoplastic reconstruction
ranges from 14–16% in systematic review and meta-anal-
ysis of the literature.6,12 The most common complications
vary depending on publication but include delayed wound
healing, fat necrosis, infection, nipple necrosis, seroma,
and hematoma; these complications vary in incidence from
<1–4%.7,12 Complications requiring operative intervention
make up on average around 3% of all complications.6,13
12 S EC T I O N I Oncoplastic Breast Surgery – Getting Started
Compared with standard breast conservation with lum­p­­
ectomy, oncoplastic techniques may have a comparable or
slightly lower rate of complications. In a National Surgical
Quality Improvement Program (NSQIP) database analy-
sis of nearly 76,000 patients undergoing BCT, the overall
30-day rate of complications in patients undergoing onco-
plastic breast surgery was 1.7% compared with 1.9% in
patients undergoing standard breast conservation.14 In their
meta-analysis of oncoplastic breast reconstruction with an
average follow-up of 37 months, Losken et al found that the
overall rate of complications was 15.5% in the oncoplastic
group compared with 25.9% in the standard breast con-
servation group, albeit with a shorter follow-up period in
the oncoplastic group.6 Lower rates of seroma in oncoplas-
tic reconstructions compared with standard breast conserva-
tion may be attributable to filling of the lumpectomy cavity
by displacement and rearrangement of the remaining breast
parenchyma in a way that obliterates the dead space.3
Oncoplastic reconstruction also appears to have a lower
rate of complications compared with total mastectomy and
reconstruction. In their retrospective cohort study includ-
ing more than 9800 patients with breast cancer, Carter et al
found that patients undergoing oncoplastic reconstruction
had a lower rate of hematoma, infection, and wound heal-
ing complications compared with patients who underwent
total mastectomy and reconstruction.3 Losken et al demon-
strated that, in a population of breast cancer patients with
macromastia, patients who underwent total mastectomy
with reconstruction by either implant-based or autologous
methods had nearly twice the overall rate of complications
compared with patients who underwent oncoplastic recon-
struction (22% vs 43%).15 This difference is at least par-
tially attributable to risks associated with implants as well
as donor-site complications, although in women with very
large breasts, the potential for seroma, hematoma, infection,
and contour deformities are greater when a reconstruction
must fill a larger mastectomy cavity.
The oncoplastic reconstruction approach often involves
a contralateral mastopexy or reduction for symmetry on
the non-cancer breast. In this instance, the final result is
aesthetically similar to a bilateral reduction mammaplasty
performed for symptomatic macromastia. In a prospective
evaluation of patients undergoing bilateral breast reduction
either with or without breast cancer, the overall rate of com-
plications was similar (18.8% for oncoplastic group, 18.3%
for breast reduction group). Seroma was the most common
complication in both groups at around 5–6%. Interestingly,
approximately 50% of the complications in the oncoplastic
group occurred in the non-cancer breast.16 From this, the
authors conclude that oncoplastic reconstruction with con-
tralateral reduction has a safety profile similar to a standard
bilateral breast reduction.
Surgical complications immediately following oncoplastic
breast reconstruction can negatively affect oncologic outcome
by delaying the administration of adjuvant therapies. Data
directly analyzing timing of adjuvant therapies following
oncoplastic reconstruction are limited; most of the available
evidence, although lacking in detail, supports the claim that
complications following oncoplastic reconstruction have min-
imal effect on timing of delivery of adjuvant therapy.6,13,16 In
contrast, one retrospective institutional review published by
Hillberg et al examined outcomes of 150 patients undergoing
oncoplastic breast reconstruction performed by a single sur-
geon; the authors reported that 8.2% of patients experienced
a delay in receiving adjuvant radiation due to a complication.
These results may be affected by a higher than expected over-
all complication rate in this series (37.5%).17 Similarly, evi-
dence that oncoplastic reconstruction delays administration
of adjuvant chemotherapy is lacking. A retrospective review
of 169 breast cancer patients performed by Khan et al dem-
onstrated no difference in time to initiation of adjuvant che-
motherapy whether standard breast conservation, oncoplastic
breast conservation, mastectomy alone, or mastectomy with
immediate reconstruction was performed.18
Appropriate patient selection for oncoplastic reconstruc-
tion includes identification of patients at increased risk
for postoperative complications. In their NSQIP database
analysis, Cil et al identified several factors that were inde-
pendently associated with an increased risk of postopera-
tive complication in the 30-day period.14 These included
obesity, smoking, American Academy of Anesthesiologists
(ASA) category 3 or 4, diabetes, bleeding disorder, chronic
obstructive pulmonary disease (COPD), and a longer oper-
ative time. Of these, the presence of a bleeding disorder had
the highest association with postoperative complications
(odds ratio 1.8). Multiple other studies have identified ele-
vated body mass index (BMI) as a risk factor for postopera-
tive complications.16
In summary, patients who undergo oncoplastic recon-
struction have a favorable complication profile compared
with patients undergoing standard breast conservation or
other methods of reconstruction. Oncoplastic techniques
do not appear to negatively affect timing of radiation deliv-
ery. Appropriate technique and patient selection are crucial
to minimize postoperative morbidity.
Cancer Surveillance Following
Oncoplastic Reconstruction
Oncoplastic breast conservation techniques by definition
preserve the majority of the breast parenchyma; therefore,
ongoing mammographic surveillance of the remaining
breast tissue is crucially important to detect cancer recur-
rence. Critics of oncoplastic reconstruction have voiced
concerns that distortion of parenchymal architecture and
more extensive postsurgical changes compared with stan-
dard breast conservation may negatively affect the early
detection of local tumor recurrence. Oncoplastic breast
reconstruction combines time-tested techniques of stan-
dard breast conservation and breast reduction. The mam-
mographic changes following these procedures are well

documented and to a certain extent may be extrapolated
to predict changes following oncoplastic reconstruction.
In a small case-control study, Roberts et al compared the
mammographic findings of 87 patients who had undergone
breast reduction to those of 30 patients with macromastia
who did not undergo breast reduction. The authors found
that mammographic findings following breast reduction
did not increase the rate of obtaining additional imaging
studies or diagnostic interventions and suggested that this
finding was likely generalizable to oncoplastic breast recon-
struction.19 In contrast, two small series comparing post-
operative cancer surveillance between patients undergoing
oncoplastic reconstruction or standard breast conservation
suggested a higher rate of need for additional imaging and
tissue sampling in the oncoplastic group.20,21 Although the
expected mammographic changes following breast reduc-
tion (oil cysts, fat necrosis, calcifications) are distinct from
those found in patients with breast cancer, it is possible that
the increased pretest suspicion in a patient with a history
of breast cancer leads to an increased request for additional
imaging and biopsies.
Conclusions
Oncoplastic reconstruction techniques hold great appeal for
their ability to extend the indications for breast conserva-
tion to patients with larger tumors in whom standard breast
conservation would not provide acceptable cosmesis. The
widespread applicability of these techniques depends on an
oncologic safety profile comparable to standard BCT. Avail-
able data suggest that rates of positive margins, local recur-
rence, distant recurrence, disease-free survival, and overall
survival following oncoplastic breast reconstruction com-
pare favorably with outcomes following both breast conser-
vation and mastectomy. Oncoplastic breast reconstruction
can be accomplished with a reasonable complication rate,
and when complications do occur there is likely a minimal
impact on the timing of adjuvant therapy administration.
Appropriate patient selection and preoperative discussion
are essential to optimize patient decision making and sur-
gical outcomes following oncoplastic breast reconstruction.
References
1. Jacobson JA, Danforth DN, Cowan KH, et al. Ten-year results of
a comparison of conservation with mastectomy in the treatment of
stage I and II breast cancer. N Engl J Med. 1995;332(14):907–911.
2. Haloua MH, Krekel NM, Winters HA, et al. A systematic review
of oncoplastic breast-conserving surgery: current weaknesses and
future prospects. Ann Surg. 2013;257(4):609–620.
3. Carter SA, Lyons GR, Kuerer HM, et al. Operative and onco-
logic outcomes in 9861 patients with operable breast cancer:
single-institution analysis of breast conservation with oncoplastic
reconstruction. Ann Surg Oncol. 2016;23(10):3190–3198.
4. Losken A, Hart AM, Broecker JS, Styblo TM, Carlson GW.
Oncoplastic breast reduction technique and outcomes: an evolu-
tion over 20 years. Plast Reconstr Surg. 2017;139(4):824e–833e.
CHAPTER 2 Safety of Oncoplastic Breast Reconstruction 13
5. Moran MS, Schnitt SJ, Giuliano AE, et al. Society of Surgical
Oncology-American Society for Radiation Oncology consensus
guideline on margins for breast-conserving surgery with whole-
breast irradiation in stages I and II invasive breast cancer. Ann Surg
Oncol. 2014;21(3):704–716.
6. Losken A, Dugal CS, Styblo TM, Carlson GW. A meta-analysis
comparing breast conservation therapy alone to the oncoplastic
technique. Ann Plast Surg. 2014;72(2):145–149.
7. Piper ML, Esserman LJ, Sbitany H, Peled AW. Outcomes fol-
lowing oncoplastic reduction mammoplasty: a systematic review.
Ann Plast Surg. 2016;76(suppl 3):S222–S226.
8. Losken A, Pinell-White X, Hart AM, et al. The oncoplastic
reduction approach to breast conservation therapy: benefits for
margin control. Aesthet Surg J. 2014;34(8):1185–1191.
9. Wijgman DJ, Ten Wolde B, van Groesen NR, et al. Short term
safety of oncoplastic breast conserving surgery for larger tumors.
Eur J Surg Oncol. 2017;43(4):665–671.
10. Clough KB, Gouveia PF, Benyahi D, et al. Positive margins
after oncoplastic surgery for breast cancer. Ann Surg Oncol.
2015;22(13):4247–4253.
11. Amabile MI, Mazouni C, Guimond C, et al. Factors predictive of
re-excision after oncoplastic breast-conserving surgery. Anticancer
Res. 2015;35(7):4229–4234.
12. De La Cruz L, Blankenship SA, Chatterjee A, et al. Out-
comes after oncoplastic breast-conserving surgery in breast
cancer patients: a systematic literature review. Ann Surg Oncol.
2016;23(10):3247–3258.
13. Fitoussi AD, Berry MG, Fama F, et al. Oncoplastic breast surgery
for cancer: analysis of 540 consecutive cases [outcomes article].
Plast Reconstr Surg. 2010;125(2):454–462.
14. Cil TD, Cordeiro E. Complications of oncoplastic breast sur-
gery involving soft tissue transfer versus breast-conserving
surgery: an analysis of the NSQIP database. Ann Surg Oncol.
2016;23(10):3266–3271.
15. Losken A, Pinell XA, Eskenazi B. The benefits of partial versus
total breast reconstruction for women with macromastia. Plast
Reconstr Surg. 2010;125(4):1051–1056.
16. Gulcelik MA, Dogan L, Camlibel M, et al. Early complica-
tions of a reduction mammoplasty technique in the treatment of
macromastia with or without breast cancer. Clin Breast Cancer.
2011;11(6):395–399.
17. Hillberg NS, Meesters-Caberg MAJ, Beugels J, et al. Delay
of adjuvant radiotherapy due to postoperative complications
after oncoplastic breast conserving surgery. Breast. 2018;39:
110–116.
18. Khan J, Barrett S, Forte C, et al. Oncoplastic breast conserva-
tion does not lead to a delay in the commencement of adju-
vant chemotherapy in breast cancer patients. Eur J Surg Oncol.
2013;39(8):887–891.
19. Roberts JM, Clark CJ, Campbell MJ, Paige KT. Incidence
of abnormal mammograms after reduction mammoplasty:
implications for oncoplastic closure. Am J Surg. 2011;201(5):
611–614.
20. Dolan R, Patel M, Weiler-Mithoff E, et al. Imaging results fol-
lowing oncoplastic and standard breast conserving surgery. Breast
Care (Basel). 2015;10(5):325–329.
21. Losken A, Schaefer TG, Newell M, Styblo TM. The impact of
partial breast reconstruction using reduction techniques on post-
operative cancer surveillance. Plast Reconstr Surg. 2009;124(1):
9–17.
3
Indications and Patient Selection for
Oncoplastic Breast Surgery
KIRSTEN EDMISTON
Introduction
The newly diagnosed breast cancer patient and her interdis-
ciplinary treatment team must address both the local control
(breast) and systemic control (body) issues to minimize the risk
of recurrence. From a surgical perspective, the fundamental
goals are to remove the tumor with an adequate margin of nor-
mal tissue while optimizing the long-term aesthetic outcomes
for the patient. The technical decision then becomes whether
to proceed with breast conservation therapy (lumpectomy and
radiation) or a mastectomy with or without reconstruction.
With the pioneering work of the National Surgical Adjuvant
Breast and Bowel Project (NSABP), Umberto Veronesi, MD,
and others in the 1970s, breast conservation therapy (BCT) has
been well established as oncologically safe, offering similar local
control rates and equivalent long-term survival rates compared
with non-nipple-sparing mastectomy.1,2 More recently, nipple-
sparing mastectomy (NSM) has been demonstrated to be a
third alternative for patients requiring or requesting removal of
the breast parenchyma while preserving the skin envelope and
nipple–areolar complex (NAC). Breast-conserving lumpectomy
and radiation therapy must then be evaluated as an alternative
to both nipple-sparing and non-NSM with reconstruction.
The benefits of breast conservation over mastectomy
are well established. Clinical outcome studies with 20-year
follow-up have demonstrated that breast conservation is
equivalent to mastectomy in terms of overall survival.3 In
addition, preservation of the natural breast confers a signifi-
cant psychological advantage for many women diagnosed
with breast cancer. In most cases, preservation of the NAC
is possible; therefore, the natural breast elements remain,
and the majority of women are happy with the final breast
appearance. With the advent of oncoplastic techniques,
breast conservation can be expanded to include wider mar-
gins of resection and achieve local recurrence rates that are
similar to mastectomy.4 As the reconstructive options have
expanded, so has the prevalence of oncoplastic surgery.
There are several differences between traditional breast
conservation and oncoplastic surgery. With traditional
14
lumpectomy, the skin is opened directly over the localized
lesion. The tumor is then removed, oriented, and sent for
pathological evaluation. The skin is closed without attempts
to close the internal cavity. For small tumors (either duc-
tal carcinoma in situ [DCIS] or invasive breast cancer),
this approach is adequate. Unfortunately, up to 40–45% of
patients can be found to have positive margins requiring
re-operation to achieve negative margins.4-6 Historically,
30% of patients undergoing lumpectomy and subsequent
radiation therapy surveyed were found to be dissatisfied
with their cosmetic outcome.7 Cosmetic defects included
deformity of the overall shape of the breast, volume loss,
changes in the shape and location of the nipple, and Snoopy
deformities of the NAC after a transverse incision in the
lower central breast. The challenge thus becomes extending
the indications for lumpectomy while minimizing the risk
of positive margins to optimize the cosmetic results after not
only the surgical lumpectomy but also radiation therapy.
In the 1990s, Werner Audretsch, Christian Gabka, and
Heinz Bohmert applied reduction mammoplasty and mas-
topexy concepts to expand the number of patients who are
candidates for breast conservation as “oncoplastic surgery.”8
The term oncoplastic breast surgery is a Greek-derived word
that literally means “molding of tumor”; however, in its
present context it refers to excision of the tumor (onco)
and reconstruction and shaping of the breast (plastic). This
often requires a team approach between the oncologic and
reconstructive surgeon. Today, the spectrum of oncoplastic
surgery includes four basic techniques including:
1. Local tissue mobilization and rearrangement
2. Reduction pattern mammoplasty
3. Skin and nipple rearrangement
4. Volume replacement
This chapter will discuss the aspects of the tumor char-
acteristics, patient’s anatomy, medical comorbidities,
treatment-related issues, psychosexual concerns, and pos-
sible complications that affect the indications and patient
selection for oncoplastic breast surgery over NSM and
non-NSM.
 CHAPTER 3
Indications
Oncoplasty enables the breast surgery team to excise more
breast tissue, widening the margin of clearance between the
tumor and the normal parenchyma. In addition, natural
breast appearance is more likely to be achieved, although
the volume will be less. These benefits have expanded the
number of patients eligible for breast conservation. Many
women who are treated with oncoplastic breast conserva-
tion surgery would otherwise have needed a mastectomy
and/or have had a poor aesthetic result. Fundamentally,
the indications for oncoplastic breast surgery are the
same as those for breast conservation surgery. Patients
should be considered for BCT if they have an adequate
tumor-to-breast volume ratio to establish negative
margins and are candidates for radiation therapy. All
patients undergoing breast-conserving surgery (lumpec-
tomy, partial segmental mastectomy, quadrantectomy, and
tylectomy) should be assessed for their oncoplastic needs.
The most common indications for oncoplastic breast sur-
gery are tumor size (37%), poor tumor location (22%),
oncocosmetic (1%), multifocality (10%), skin retraction
(9%), positive margins after previous surgery (5%), and
other reasons (5%).9
It is also important to identify patients who are not
candidates for breast conservation. Historically, absolute
contraindications to BCT include (1) patients with a high
probability of recurrence due to multicentric disease or the
inability to obtain clear margins; (2) patients who are cur-
rently pregnant; (3) those with active collagen vascular dis-
ease, such as active lupus and scleroderma10; and (4) those
with a history of prior breast irradiation either related to
prior breast cancer or Hodgkin’s disease. Soft contrain-
dications include (1) patients with a high probability of
subsequent breast cancers including those with BRCA1/2
mutations, PTEN, etc.; (2) tumors that directly involve the
NAC; and (3) patients with high tumor-to-breast ratios.
The increasing use of neoadjuvant chemotherapy has in­c­
reased the number of patients eligible for breast-­conserving
surgery and oncoplastic tissue rearrangement. This is, in
part, predicated on the invasive tumor molecular subtype.
Neoadjuvant dual HER2 blockade with trastuzumab and
pertuzumab in combination with cytotoxic chemotherapy
for patients with HER2+ amplification results in a high
pathology complete response (pCR) (16.8–66.2%)11.
Patients with ER+/HER2- cancers have lower pCR rates
(7.0–16%), and those with triple negative tumors have
33–35% chances of achieving a pCR12; 40–70% overall will
achieve a partial response.
Patient Selection
Comprehensive preoperative evaluation is necessary to deter-
mine patients appropriate for oncoplasty and the necessary
type of reconstruction. The surgical team should obtain the
patient’s history of any prior breast surgery, chest radiation,
and infections. Risks factors for wound complications such
Indications and Patient Selection for Oncoplastic Breast Surgery 15
as diabetes mellitus, active smoking, cardiovascular condi-
tions, history of Ehlers-Danlos, coagulopathies, poor nutri-
tion, and obesity should be noted. Patients with a history of
chronic pain, fibromyalgia, and opioid dependence should
also be assessed to coordinate optimal care with their pri-
mary care provider.
It is also important to understand the patient’s psychosex-
ual concerns and feelings about her breast. Loss of nipple–
areolar and breast sensation may be important to patients
undergoing breast surgery in terms of quality of life and sat-
isfaction. Patients undergoing skin-sparing mastectomy and
NSM can have considerable loss in skin and nipple sensa-
tion. Many patients complain of loss of sexual arousal with
breast or nipple stimulation after mastectomy. As such, fear
of loss of nipple sensation may be an important consider-
ation for oncoplastic tissue rearrangement. Very little data
are currently available about the risks of nipple sensation
loss after oncoplastic breast surgery and radiation. Concerns
about nipple viability, postoperative nipple positioning,
fears about the risk of recurrence, and risks of needing addi-
tional surgery should be ascertained along with the patient’s
history of anxiety. Lastly, patients’ concerns about foreign
body implantation and complications, including the remote
risk of implant-associated anaplastic large-cell lymphoma,
should be addressed.
On physical exam, the surgeon should clinically evalu-
ate the patient’s breast and chest anatomy for breast sym-
metry, prior scars, bra size, and degrees of ptosis. Enlarged
lymph nodes should be assessed for possible regional dis-
ease. Patients who have had prior breast conservation and
radiation therapy are generally not good candidates for
oncoplastic surgery. Diagnostic mammogram, ultrasound,
and breast magnetic resonance imaging (MRI) should be
strongly considered to precisely identify the location and
extent of the breast tumor. Patients undergoing neoadju-
vant chemotherapy should undergo another preoperative
MRI to assess the extent of the residual tumor and rule out
the possibility of disease progression. This will confirm that
breast conservation and oncoplastic tissue rearrangement is
still possible.
Tumor Characteristics
Invasive Breast Carcinoma
Oncoplastic surgery has been shown to have no adverse
effects related to local recurrence, disease-free, or overall
survival for all stages of breast cancer.
For patients with invasive lobular carcinoma, extensive
microcalcifications, or multifocal breast cancer, the possibil-
ity or risk of positive margins is an important consideration
for oncoplastic planning.
Ductal Carcinoma In-Situ (DCIS)
The management of DCIS remains controversial to minimize
overtreatment and undertreatment. Despite this, margin
16 S EC T I O N I Oncoplastic Breast Surgery – Getting Started

status is one of the most important determinants in local recur-

rence and clinical outcomes. The Society of Surgical Oncol-
ogy (SSO)/ American Society Radiation Oncology (ASRO)/
American Society of Clinical Oncology (ASCO) Consensus
Guidelines on margins for DCIS, published in 2016, recom-
mend at least 2-mm margins to reduce the risk of in-breast
recurrence relative to narrower negative margins.13 Paren-
thetically, the multidisciplinary panel also noted that clinical
judgment was necessary to determine whether patients with
smaller negative margin widths (≥ 1 mm) require re-excision.
They identified additional factors important to consider
before additional surgery, including an assessment of residual
calcifications on postexcision mammogram, extent of DCIS
in proximity to margin, and which margin is close (anteriorly
just under the skin and posteriorly excised to the pectoral fas-
cia) versus margins associated with residual breast tissue. The • Fig. 3.1
Preoperative photograph of a patient with A cup breasts and
routine practice of obtaining negative margin widths wider not a candidate for oncoplasty.
than 2 mm is not supported by the evidence.
In a recent case-control study, De Lorenzi et al at the Euro-
pean Institute of Oncology (IEO) compared oncoplastic breast
surgery followed by radiation (44 patients) and conservative
breast surgery alone followed by radiation (375 patients).14
The primary endpoints were disease-free survival (DFS)
and ipsilateral breast tumor recurrence (IBTR). The tumor
size was larger in the oncoplastic group. This was expected
as oncoplasty can manage the resection of larger volumes of
breast tissue. The average annual rates of invasive IBTR were
1.6% and 1.0% for the oncoplastic and conservative patients,
respectively. The authors also found no difference in the rates
of contralateral breast cancer distant metastasis and contra-
lateral breast cancer. They observed similar rates of focally
involved margins (focally ink on DCIS) in 4.5% and 3.5%,
respectively, for the oncoplastic and conservative patients.
Close margins (<1 mm) were observed in 22.8% and 17.9%,
respectively. None of their patients underwent further surgery.
They conclude that oncoplastic breast surgery is a safe and • Fig. 3.2
Postoperative photograph following nipple-sparing mastec-
valid treatment component for patients with DCIS. tomy and two-stage reconstruction at 2-year follow-up.
In a recent review of DCIS, Song et al reviewed their
experience at Emory Healthcare System.15 Twenty-eight The Impact of the Tumor-to-Breast Size Ratio
patients were included in the study. Therapeutic mam-
on Oncoplastic Breast Surgery
moplasty was the definitive procedure in 64%. There were
10 patients (36%) who required re-operation: 9 for posi- In general, women with an A or B cup breast are poor can-
tive margins and 1 for residual microcalcifications. Positive didates for oncoplastic tissue rearrangement or reduction.
margin rates were independent of tumor location. All 10 They simply do not have enough breast tissue. In this popu-
patients requiring completion mastectomy or re-excision lation, small tumors can be excised with local tissue mobi-
had intermediate or high-grade disease. In addition, the lization for adequate closure. Alternatively, the patient may
women requiring re-operation were younger (mean 45.6; be a candidate for neoadjuvant chemotherapy to shrink the
median 43) compared with those who did not require re- tumor, allowing her to be converted from a mastectomy to
operation (mean 57; median 57). The authors concluded breast conservation. If not, the patient may be best suited
that oncoplastic reduction techniques are appropriate for for mastectomy and immediate implant reconstruction.
DCIS taking into account patient selection and improved Figs. 3.1 and 3.2 illustrate a patient with an A cup who
confirmation of negative margins. One strategy to minimize completed NSM and two-stage prosthetic reconstruction.
the incidence of positive margins is to obtain a preoperative Patients with a C cup breast may be candidates for an
breast MRI, which is useful in determining the extent of oncoplastic reduction. The decisions will be based on the
DCIS and establishing the boundaries for resection. Intra- tumor-to-breast ratio, degree of ptosis, and sufficient vol-
operative margin assessment can also reduce the risk of posi- ume to adequately rearrange the tissue. These are usually
tive margins. well suited for tissue rearrangement, particularly if they
 CHAPTER 3
• Fig. 3.3 Preoperative photograph of a woman with C cup breasts and
left breast cancer who is a good candidate for oncoplasty with tissue
rearrangement.
• Fig. 3.4Preoperative markings demonstrating wire localization in the
lower outer quadrant.
have significant ptosis and can tolerate a modification of
the NAC position. Lack of ptosis may be problematic due
to the fixed nipple–areolar position. Figs. 3.3–3.5 illustrate
a patient with a C cup breast following oncoplastic tissue
rearrangement.
Larger breasted women with a D or larger cup breast
often have some degree of ptosis. The additional breast tis-
sue and mobility of the NAC lend well to reconstruction
using reduction mammoplasty techniques. Figs. 3.6 and 3.7
illustrate a woman with DD breasts following oncoplastic
reduction mammaplasty.
Women who have had prior breast augmentation with
implants present a special challenge. Up front, it is impor-
tant to recognize that the presence of a breast implant does
not have an adverse effect on the efficacy of treatment to
Indications and Patient Selection for Oncoplastic Breast Surgery 17
• Fig. 3.5 Postoperative photograph following ipsilateral oncoplastic
tissue rearrangement and contralateral reduction mammaplasty for
symmetry at 2-year follow-up.
• Fig. 3.6 Preoperative photograph and markings of a patient with DD
breasts and a left breast cancer who is a good candidate for oncoplas-
tic reduction mammaplasty.
minimize the risk of recurrence. Although they often pres-
ent with D cup or larger, the pre-augmentation breast is
often an A or B cup with reduced breast tissue for recruit-
ment. This is complicated by the fact that women with
breast augmentation implants have an increased risk of
developing capsular contracture and fibrosis slowly over
time after breast radiation. This progressive contracture
may begin 6–9 months after radiation completion and
continue for 2–10 years. The patient may notice that the
implant becomes fixed, firm, and uncomfortable leading to
decreased patient satisfaction. Patients with breast implants
are also at increased risk for infection after radiation therapy.
Given these problems, the question remains how to
optimally treat these patients. One option for women
18 S EC T I O N I Oncoplastic Breast Surgery – Getting Started
• Fig. 3.7 Postoperative photograph following bilateral oncoplastic
reduction mammaplasty at 2-year follow-up.
• Fig. 3.8 Preoperative photograph of a woman status postbilateral
breast augmentation following a biopsy for left breast cancer.
with early stage disease would be a nipple-sparing or skin-
sparing mastectomy and replacement with a same size or
larger implant. This approach can achieve excellent cos-
metic results with the potential NAC preservation, albeit
often insensate. This can avoid the need for radiation. For
early stage patients who decline a mastectomy, the options
become either treat with the implant in place or remove
the implant and plan for a tissue flap reconstruction in the
future after radiation. The majority of women are reluc-
tant to have the implants removed, which results in a much
smaller breast volume. For these reasons, oncoplastic sur-
gery is not usually recommended for women with breast
implants to avoid the long-term aesthetic issues related to
capsular contracture and infection. Figs. 3.8 and 3.9 illus-
trate a patient with breast cancer in the setting of breast
• Fig. 3.9 Postoperative photograph following breast conservation
demonstrating severe capsular contracture and distortion of the left
breast.
augmentation following biopsy (see Fig. 3.8) and onco-
plasty with radiation (see Fig. 3.9).
It is important to recognize that it is not just the tumor
size that defines the type of oncoplastic tissue reconstruction
procedure but rather the interplay between the tumor size,
breast size (volume and bra size), and estimated percentage
of breast volume that would be removed (see Fig. 3.10).
Extent and Location of the Anticipated
Breast/Skin Excision
Tumor location is a critical factor in determining the type of
reconstruction and pedicle design. In a recent study of 980
patients, Rummel et al identified approximately 51% of tumors
were located in the upper outer quadrant (UOQ) compared
with 15.6% in the upper inner quadrant (UIQ), 14.2% in
the lower outer quadrant (LOQ), 10.6% in the central breast,
and 8.1% in the lower inner quadrant (LIQ).16 A thorough
preoperative discussion and review of the mammogram and
MRI images by both the breast surgeon and the reconstructive
surgeon is essential to understand the extent and location of
the planned resection and reconstructive needs. Both need to
have a shared mental model. The presence of tumor within or
extremely close to the skin is an indication to consider neoad-
juvant chemotherapy for tumor shrinkage except for patients
with ER/PR+/HER2 neu(-) tumors or DCIS. As such, the
need to remove breast skin as part of a partial segmental mas-
tectomy is now rare. Skin involvement of the LIQ and LOQ
quadrant can frequently be excised within the boundaries of
the inverted T pattern. For skin involvement of the UOQ and
UIQ outside the boundaries of a traditional inverted T pat-
tern, consideration can be given to rotate, split, or otherwise
modify the inverted T skin pattern.
For central/NAC skin involvement, a vertically oriented
elliptical incision can be made for a central resection with pres-
ervation of the anterior projection and native shape. Tumors
close to but not directly involving the NAC may be managed
 CHAPTER 3 Indications and Patient Selection for Oncoplastic Breast Surgery 19

38F 40F
36E 38E 40E
Bra size 34DD 36DD 38DD 40DD
32D 34D 36D 38D 40D
32C 34C 36C 38C 40C
32B 34B 36B 38B 40B
32A 34A 36A
25
5

4
20

3
Replacement

Therapeutic
Mastopexy
% Breast excised

Volume

2
15

1
Therapeutic
Reduction Tumour
10
Mammaplasty diameter
(cm)

5
Simple
Wide Local Excision

0
00

00

00

00

00

00
0

0
20

30

40

50

60

70

80

90

10

11

12

13

14

15
Volume of breast (cm3)
• Fig. 3.10
An algorithmic chart listing oncoplastic treatment options. (From Macmillan RD, McCulley SJ.
Oncoplastic breast surgery: what, when and for whom? Curr Breast Cancer Rep 2016; 8:112–117.)

with a batwing resection or a central resection to assure negative
margins. Radiation therapy will still be needed in this situation.
Alternatively, the patient may be considered for a skin-sparing
mastectomy with immediate volume reconstruction using
either a tissue expander/implant or tissue transfer. This would
potentially eliminate the need for radiation therapy and the
potential complications of capsular contracture and fibrosis.
The challenge occurs when a large amount of skin needs to
be resected, particularly in the UOQ or UIQ. The team will
need to consider the overall breast volume and the patient’s
aesthetic goals. The patient may be best served with a mas-
tectomy and immediate reconstruction. A latissimus flap can
be considered for a large UOQ skin defect. The potential
problems with a latissimus flap in this context include skin
color and texture mismatches. In addition, the latissimus flap
is then no longer available for future reconstructive needs if
the patient develops a recurrence after radiation therapy or
needs a flap reconstruction and is not a candidate for a deep
inferior epigastric perforator (DIEP) flap, transversus rectus
abdominus myocutaneous (TRAM) flap, or other flap.
Immediate versus Delayed Reconstruction
Kronowitz et al reviewed their experience with 69 patients
at The University of Texas MD Anderson Cancer Center.17
Fifty patients underwent immediate repair of partial mastec-
tomy defects before external beam radiation therapy, which
included local tissue rearrangement in 28%, breast reduc-
tion in 66%, and flaps in 6%. Nineteen patients underwent
delayed reconstruction after external beam radiation therapy
of which 32% had local tissue rearrangements, 42% had
breast reductions, and 26% had flaps. Results included a
complication rate of 26% for immediate reconstruction and
42% for delayed reconstruction. Autologous flaps were asso-
ciated with increased complications when performed imme-
diately compared with local tissue rearrangement; however,
flaps were associated with a lower complication rate when
performed on a delayed basis. The authors concluded that the
immediate repair of partial mastectomy defects with volume
displacement techniques (reduction mammaplasty, tissue
rearrangement) resulted in fewer complications and better
aesthetic outcomes. Spear et al demonstrated that reduction
mammaplasty or mastopexy performed following radiation
therapy resulted in a complication rate of 28%.18 Figs. 3.11
and 3.12 illustrate a patient following breast conservation
without oncoplasty followed several years later with ipsi-
lateral autologous fat grafting and contralateral reduction
mammaplasty for symmetry. Figs. 3.13–3.15 illustrate a
patient following breast conservation followed several years
later by performing a bilateral reduction mammaplasty.
20 S EC T I O N I Oncoplastic Breast Surgery – Getting Started

• Fig. 3.11
Preoperative photograph following right breast conservation
demonstrating a mild contour abnormality.

• Fig. 3.13
Preoperative photograph of a woman with severe mammary
hypertrophy following left breast conservation therapy.

• Fig. 3.12Postoperative photograph following autologous fat grafting • Fig. 3.14

Postoperative anterior view following bilateral reduction mam-
of the lumpectomy defect as well as a contralateral reduction mam- maplasty demonstrating mild asymmetry and distortion of the left breast.
maplasty for symmetry.

Impact of Intraoperative Radiation Therapy

Intraoperative radiation therapy (IORT) has become an
alternative to whole breast radiation therapy. IORT delivers
a single intraoperative dose of radiation to the tumor bed
at the time of surgical excision. The Targeted Intraoperative
Radiotherapy Versus Whole Breast Radiotherapy for Breast
Cancer (TARGIT-A) demonstrated similar breast cancer
mortality in patient undergoing IORT and whole breast
radiation after lumpectomy (WBRT) (2.6% [1.5–4.3%] for
TARGIT vs 1.9% [1.1.–3.2] for WBRT; p = 0.56). Wound-
related complications were similar for both groups, but
grade 3 or 4 skin complications were significantly reduced
with TARGIT (4 of 1720 vs 13 of 1731, p = 0.029).19 The
main advantage of IORT is that a single dose of 20 Gy can
safely be delivered directly to the tumor bed while sparing • Fig. 3.15 Postoperative oblique view demonstrating distortion along
the healthy surrounding tissue. the inframammary region due to delayed healing at the trifurcation point.
 CHAPTER 3
IORT in patients undergoing oncoplastic tissue rear-
rangement raises the possibility of wound-healing compli-
cations. Cracco et al studied the surgical outcomes, early
complication rates, and esthetic results after oncoplastic
breast surgery of 83 patients undergoing IORT and 109
patients treated with WBRT with a mean follow-up time of
17 months.20 The early postoperative complication rate after
IORT was 26.6%. The majority were liponecrosis (12%),
seroma formation (7.4%), and infection/dehiscence (2.4%).
In contrast, the early postoperative complication rate after
WBRT was 14.7%. The most common complications were
hematomas (7.6%), liponecrosis (1.9%), and seroma for-
mation (1.9%). The complication rates after IORT were
statistically higher (p < 0.0001). Despite this increase in
early complications, the late cosmetic results were good in
both IORT and WBRT groups (84.3% and 88%, respec-
tively). They concluded that IORT did not appear to nega-
tively influence the cosmetic outcomes after conservative
breast surgery and oncoplastic reconstruction.20 Crown and
Grumley analyzed their experience with oncoplasty patients
undergoing either IORT or WBRT at Virginia Mason Med-
ical Center.21 Minor surgical site complications occurred in
29 patients (17.9%) in the IORT group, compared with 20
patients (6.9%) in the WBRT group (p = 0.001). Obesity,
smoking, diabetes, chemotherapy, advanced age, tumor size,
and need for re-excision were not associated with increased
rates of complications.8 Overall, oncoplastic breast surgery
is a safe reasonable reconstructive option for patients under-
going IORT.
Indications for Nipple-Sparing Mastectomy
An increasing proportion of women with newly diagnosed
unilateral breast cancer are choosing mastectomy (either
unilateral or bilateral) for treatment with immediate breast
reconstruction. Expanded genetic testing has also identified
women at high risk for developing breast cancer for whom
bilateral prophylactic mastectomy is recommended. NSM is
generally indicated in women with small to moderate breast
volume (A, B, and C cup) based on vascular perfusions fac-
tors following mastectomy. Traditional indications included
tumors that were less than 3 cm in diameter, greater than
2 cm from the NAC, and with clinically negative axillary
lymph nodes.22 Current guidelines however suggest that
NSM can be safely performed so long as margin status is
appropriate.23 The topic of mastectomy versus oncoplasty
will be further discussed in a separate chapter.
Conclusion
Collaboration between the breast surgeon and plastic sur-
geon is recommended to develop a shared mental model of
the patient’s tumor and anatomy, treatment plan (includ-
ing the need for radiation therapy), and the patient’s aes-
thetic goals both in the short term as well as in the long
term. Together the team must answer the questions: Is the
patient a candidate for breast conservative surgery and
Indications and Patient Selection for Oncoplastic Breast Surgery 21
oncoplasty? If so, what type of oncoplastic surgery would
best suit the patient’s needs and its timing? Alternatively,
would the patient be best served with an NSM or non-
NSM with reconstruction? As oncoplastic techniques con-
tinue to evolve and expand and the evidence mounts that
this technique is safe and effective with excellent surgical
and aesthetic outcomes, the indications and prevalence of
this technique will certainly increase.
References
1. Veronesi U, Bonadonna G, Zurrida S, et al. Conservation surgery
after primary chemotherapy in large carcinomas of the breast.
Ann Surg. 1995;222(5):612–618.
2. Veronesi U, Salvadori B, Luini A, et al. Breast conservation is a
safe method in patients with small cancer of the breast. Long-
term results of three randomised trials on 1,973 patients. Eur J
Cancer. 1995;31A(10):1574–1579.
3. Fisher B, Anderson S, Bryant J, et al. Twenty year follow up of a
randomized trial comparing total mastectomy, lumpectomy, and
lumpectomy plus irradiation for the treatment of invasive breast
cancer. N Engl J Med. 2002;347(16):1233–1241.
4. Kaur N, Petit JY, Rietjens M, et al. Comparative study of surgi-
cal margins in oncoplastic surgery and quadrantectomy in breast
cancer. Ann. Surg. Oncol. 2005;12(7).
5. Losken A, Pinell-White X, Hart AM, Freitas AM, Carlson GW,
Styblo TM. The oncoplastic reduction approach to breast con-
servation therapy: benefits for margin control. Aesthet Surg J.
2014;34(8):1185–1191.
6. Macmillan R, McCulley S. Oncoplastic breast surgery: what, when
and for whom. Curr Breast Cancer Rep. 2016;8:112–117.
7. Clough K, Cuminet J, Fitoussi A. Cosmetic sequelae after con-
servative treatment for breast cancer: classification and results of
surgical correction. Ann Plast Surg. 1998;41(5):471.
8. Gabka C, Bohmert H. Future prospects for reconstructive sur-
gery in breast cancer. Int J Surg Oncol. 1996;1996(12):67–75.
9. Clough K, van la Parra R, Thygese H, et al. Long-term results
after oncoplastic surgery for breast cancer: a 10 year follow-up.
Ann Surg. 2018;268:165–171.
10. Zaremba N, Tamkus D, Dicarlo L, Herman J, Martin M, Bum-
pers H. The dilemma of breast cancer treatment and existing col-
lagen vascular disease: a case of scleroderma and review of the
literature. Breast J. 2016;22(4):451–455.
11. Zardavas D, Piccart M. Neoadjuvant therapy for breast cancer.
Annu Rev Med. 2015;66:31–48.
12. Zhu Q, Tannenbaum S, Kurtzman S, DeFusco P, Ricci A, Vavadi
H, et al. Identifying an early treatment window for predicting
breast cancer response to neoadjuvant chemotherapy using
immunohistopathology and hemoglobin parameters. Breast Can-
cer Res. 2018 14;20(1):56.
13. Morrow M, Van Zee K, Solin L, et al. Society of Surgical
Oncology-American Society for Radiation Oncology-American
Society of Clinical Oncology consensus guideline on margins
for breast conserving surgery with whole-breast irradiation in
ductal carcinoma in situ. Ann Surgical Oncol. 2016;23(12):
3801–3810.
14. De Lorenzi F, Di Bella J, Mainsonneuve P, Rotmensz N, Corso
G, Orecchia R, et al. Oncoplastic breast surgery for the manage-
ment of ductal carcinoma in situ (DCIS): Is it oncologically safe?
a retrospective cohort analysis. Eur J Surg Oncol. 2018;44(7):
957–962.
22 S EC T I O N I Oncoplastic Breast Surgery – Getting Started
15. Song H, Styblo T, Carlson G, Losken A. The use of oncoplastic
reduction techniques to reconstruct partial mastectomy defects in
women with ductal carcinoma in situ. Breast J. 2010;16(2):141–146.
16. Rummel S, Hueman M, Costantino N, Shriver C, Ellsworth R.
Tumor location within the breast: does tumour site have prognos-
tic ability? eCancer. 2015;9:552.
17. Kronowitz SJ, Feledy JA, Hunt KK, et al. Determining the opti-
mal approach to breast reconstruction after partial mastectomy.
Plast Reconstr Surg. 2006;117(1):1–11.
18. Spear SL, Rao SS, Patel KM, Nahabedian MY. Reduction mam-
maplasty and mastopexy in previously irradiated breasts. Aesth
Surg J. 2014;34(1):74–78.
19. Vaidya J, Wenz F, Bulsara M, Tobias J, Joseph D, Keshtgar M,
et al. Risk-adapted targeted intraoperative radiotherapy ver-
sus whole-breast radiotherapy for breast cancer: 5-year results
for local control and overall survival from the TARGIT-A ran-
domised trial. Lancet. 2014;383(9917):603–613.
20. Cracco S, Semprini G, Cattin F, Gregoraci G, Zeppieri M, Isola
M, et al. Impact of intraoperative radiotherapy on cosmetic out-
come and complications after oncoplastic breast surgery. Breast J.
2015;21(3):285–290.
21. Crown A, Grumley J. Association of intraoperative radiotherapy
in the treatment of early-stage breast cancer with minor surgi-
cal site complications in oncoplastic breast conserving surgery.
JAMA Surgery. 2017;152(12):1180–1182.
22. Spear SL, Willey SC, Feldman ED, et al. Nipple-sparing mastec-
tomy for prophylactic and therapeutic indications. Plast Reconstr
Surg. 2011;128:1005–1014.
23. Endara M, Chen D, Verma K, Nahabedian MY, Spear SL. Breast
reconstruction following nipple-sparing mastectomy: a system-
atic review of the literature with pooled analysis. Plast Reconstr
Surg. 2013;132:1043.
4
Oncoplasty versus Mastectomy:
Decisions and Outcomes
MAURICE Y. NAHABEDIAN AND COSTANZA COCILOVO
Introduction
As reconstructive techniques have improved, patient expec-
tations have evolved. From the simplest to the most com-
plex resection, patients expect to be satisfied with their final
esthetic result. Trying to decide on the operation that is best
for patients now involves not only understanding the tumor
biology but also patient preference and how to achieve the
best esthetic results. Patients can choose breast conservation
with or without oncoplastic reconstruction, and mastec-
tomy with nipple sparing or without and with or without
reconstruction. The challenge is helping the patient choose
the optimal oncologic and cosmetic solution for them.
Understanding expectation is critical before operative inter-
vention. For some women, it is important to preserve as much
of their natural breast as possible; whereas for others, achiev-
ing the lowest local recurrence risk is the driving force even
when the statistical benefit is minimal. Some women hope to
end up with a smaller or larger breast. In all cases, the role of
the breast surgeon is to help patients understand their choices.
Safety of Oncoplastic Breast Surgery
Oncoplastic surgery is considered oncologically safe. A review
of outcomes demonstrated high rates of overall survival (95%)
and disease-free survival (90%) as well as low rates of local
recurrence (3.2%), positive margins (10.8%), and re-excisions
(6%).1 Equivalent survival rates are an accepted norm. A pop-
ulation study of early breast cancer in the Netherlands suggests
an improvement in overall survival in early stage breast cancer
compared with mastectomy, likely due to the added benefit of
radiation.2 For years, we have recognized that shrinking the
tumor with neoadjuvant chemotherapy can allow a better cos-
metic outcome and increase the chance of breast conservation.
Benefits of Oncoplastic Surgery
The benefits of oncoplastic surgery have been demonstrated
throughout the literature. In a review from the MD Anderson
Cancer Center of 9861 patients with breast conservation
and oncoplastic reconstruction, it was demonstrated that
there was a lower rate of seroma formation (13.4 vs 18%,
p = 0.002) and a lower rate of positive margins (5.8 vs 8.3%,
p = 0.04).3 Although mastectomy rates have increased across
the country, the MD Anderson review demonstrated that
rates of breast conservation with oncoplastic reconstruction
have also increased. Patients choosing oncoplasty tend to be
older than patients choosing mastectomy; however, obesity
rates were similar. The majority of patients (75%) in the
study had a T1 or T2 tumor; however, patients who chose
oncoplastic reconstruction tended to have larger tumors,
and the majority of patients who had lymph node-positive
breast cancer and T4 tumors chose mastectomy.
The location and characteristics of the tumor are other
factors that can influence choice. The quadrant the tumor
was located in did not influence the choice of oncoplastic
reconstruction except when located in the lower outer quad-
rant, in which case slightly more women had breast conser-
vation alone. Tumor characteristics were generally similar,
with a slight increase in HER-2 neu positive tumors choos-
ing oncoplastic reconstruction, as did patients who under-
went neoadjuvant chemotherapy. This may have to do with
the fact that their tumors were larger at diagnosis and so, in
the initial discussion on surgical options, the suggestion for
oncoplastic reconstruction was made.
Wound-related complications and surgical site infections
were lower in patients who underwent breast conservation
and oncoplastic reconstruction compared with mastectomy
and reconstruction. The seroma rate was lower with onco-
plastic reconstruction compared with breast-conserving sur-
gery alone. The hematoma rate was lower compared with
mastectomy, as was wound-related complications.3
The goal of oncoplastic surgery is to improve the esthetic
outcome while performing an oncologically safe opera-
tion. A Brazilian study compared esthetic results using a
semiautomatic software device demonstrating improved
outcomes with oncoplastic surgery.4 In general, when sur-
geons evaluate esthetic outcomes, they are more favorable
23
24 S EC T I O N I Oncoplastic Breast Surgery – Getting Started

to oncoplastic resection than patients are. In a recent review

of observational studies that included 8659 patients, it was
demonstrated that patient satisfaction was increased after
oncoplastic surgery compared with breast-conserving sur-
gery; however, the difference was slight (89.5% vs 82.9%).5
As the field of oncoplastic surgery has evolved over the
past decade, many breast and plastic surgeons remember the
significant contour deformities that occurred with breast
conservation alone. Managing patient expectations is an
important aspect for all surgical procedures of the breast
because patients will often compare their outcomes to their
original breasts or to ideal versions that they have seen in
images. We have found in our institution that, although
patients are initially surprised by the change, as time goes
on they are generally pleased. The patients who express the
greatest satisfaction are those with larger more ptotic breasts
who in essence have a lift and reduction with increased pro-
jection. Patients with smaller breasts who chose breast con- • Fig. 4.1
Preoperative image of a woman with right breast cancer and
mammary hypertrophy scheduled for oncoplastic reduction mamma-
servation because it is a simpler and less invasive operation plasty.
are often disappointed because of the flattening and loss of
projection that can occur.
A Spanish review of 801 patients comparing oncoplas-
tic reduction mammaplasty to tumorectomy alone dem-
onstrated similar overall survival at 10 years.6 Patients
undergoing oncoplastic reconstruction were younger, had
larger tumors, and the tumor was most likely located in the
lower pole. Although the oncoplastic reduction mamma-
plasty cohort had a higher rate of tissue necrosis (2.5% vs
0.1%), both were low. In their experience, reduction mam-
maplasty using an inverted T pattern made up 17% of the
group. Adverse events related to this approach included an
increased risk of having a lower pole deformity as well as
delayed healing or tissue necrosis. Similar to other studies,
they demonstrated that ductal carcinoma in situ (DCIS),
invasive lobular cancer, and larger tumors were the most
likely causes of positive margins. The BreastQ questionnaire
was used and demonstrated that patient satisfaction ranged
from 70–83 out of 100 at the 1-year mark with regard to
psychosocial status as well as satisfaction of the breast in the
sexual sphere.
• Fig. 4.2 Preoperative marking using an inverted T pattern.

Radiation and Oncoplastic Surgery

The question often arises, does radiation therapy harm onco-
plastic reconstruction? The majority of patients having breast
conservation will receive radiation unless they are elderly or
have a favorable in situ cancer. The indications for radia-
tion have broadened over the years such that many patients
after mastectomy with one or two positive lymph nodes
will have radiation therapy in lieu of an axillary dissection.
Other indications for radiation therapy include having three
or more positive lymph nodes. In a recent systematic review
of oncoplastic surgery in the setting of breast conservation,
Yoon et al did not find any increased local recurrence fol-
lowing whole breast radiation and boost given to patients
who had an oncoplastic reconstruction.7 In this review, the
benefits of whole breast irradiation (WBI) and accelerated
partial breast irradiation (APBI) were reviewed. The general
consensus was that the data on APBI with breast conserva-
tion therapy (BCT) and oncoplastic surgery with WBI is still
early to make any meaningful comparisons. The study found
that 70–100% of patients reported good to excellent satis-
faction. One of the limitations of APBI becomes evident in
the patient who has had oncoplastic tissue rearrangement;
the location of the actual tumor bed may be obscured, and
there may not be space to place and expand the catheter.
New emerging techniques that can accurately deliver APBI
externally may overcome the challenge of placing catheters in
this space. Given the safety and positive cosmetic results with
radiation and oncoplastic surgery, there may be an esthetic
advantage to oncoplasty over mastectomy. Figs. 4.1–4.3 illus-
trate a patient following oncoplastic reconstruction.
 CHAPTER 4
• Fig. 4.3 Postoperative result following the oncoplastic reduction and
radiation therapy on the right as well as a reduction mammaplasty
demonstrating excellent volume and contour symmetry.
Further support of oncologic safety has been demon-
strated in several studies. Piper et al in a systematic review
demonstrated that, even in patients who had a positive mar-
gin after the initial surgery and underwent a re-excision,
higher recurrence rates were not observed compared with
patients undergoing completion mastectomy.8 In another
review of 980 patients from the United Kingdom, Mansell
et al compared three cohorts of patients that included those
having oncoplastic breast-conserving surgery (OBCS), wide
local excision (WLE), or mastectomy with or without imme-
diate reconstruction.9 It was demonstrated that 5-year local
recurrence rates were similar in all three groups (WLE 3.4%,
OBCS 2%, and mastectomy 2.6%). Distant recurrence rates
were higher after mastectomy (13.1%) and OBCS (7.5%)
compared with WLE (3.3%, p < 0.001). The potential ben-
efits of oncoplastic surgery include improved patient satis-
faction and quality of life as well as decreased health care
costs compared with mastectomy with full reconstruction.9
This then begs the question as to why women choose
mastectomy or bilateral mastectomy instead of OBCS?
Younger women in urban settings with private insurance
and planned reconstruction were more likely to choose
mastectomy and reconstruction.10 Interestingly there seems
to be no link to tumor grade or stage. In other countries,
however, the choices are different. In Western Australia, for
example, tumor size was the greatest determinant of mastec-
tomy versus breast conservation.11 Women with T1 tumors
were most likely to choose breast conservation; however,
as tumor size increased beyond 2 cm, mastectomy became
the more preferred option. Women who chose mastectomy
tended to be older and live in a rural area and have positive
nodes. In another analysis of 11,654 patients maintained in a
National Surgical Quality Improvement Program (NSQIP)
database, 9571 underwent breast conservation surgery and
2074 underwent simple mastectomy with implant recon-
struction.12 The study demonstrated that the simple mas-
tectomy with implant group had significantly higher total
complication (5.5% vs 2.1%), wound complications (2.8%
Oncoplasty versus Mastectomy: Decisions and Outcomes 25
• Fig. 4.4 Preoperative image of a woman with right breast cancer
scheduled to have bilateral skin sparing mastectomy and two-stage
prosthetic reconstruction.
vs 1.4%), surgical site infection (1.9% vs 0.4%), and bleed-
ing (0.2% vs 0.05%) rates compared with the breast conser-
vation group.
So then how do we decide who should get breast con-
servation with oncoplastic surgery and who is a better can-
didate for mastectomy? Clough et al have defined this as a
level 1 resection in which <20% of the breast is removed.13
This is typically corrected with local tissue rearrangement.
A level 2 resection is defined as removal of 20–50% of
the breast volume that typically correlates with a resection
weight that exceeds 200 grams resulting in a significant
deformity. These are often corrected with volume displace-
ment techniques such as reduction mammaplasty. They
reported on 101 patients managed with oncoplastic tech-
niques because standard breast conservation would have
resulted in poor esthetic outcomes. Mean weight of excised
breast on the tumor side was 222 grams. The actuarial 5-year
local recurrence rate was 9.4%, the overall survival rate was
95.7%, and the metastasis-free survival rate was 82.8%.
Cosmesis was favorable in 82% of cases. Preoperative radio-
therapy resulted in worse cosmesis than when given post-
operatively, which is not surprising.13 Performing a partial
mastectomy without reconstruction but with the intent of
delayed reconstruction rarely resulted in a good cosmetic
outcome. Achieving symmetry for optimal cosmesis usually
requires a contralateral symmetry technique. They can result
in longer operating time and require specialized training in
oncoplastic technique. Figs. 4.4–4.8 illustrate a patient fol-
lowing mastectomy, prosthetic reconstruction, and radia-
tion therapy.
The benefit of oncoplastic WLE compared with standard
excision associated with breast conservation has been dem-
onstrated by studies from the United Kingdom. Down et al
retrospectively reviewed tumor clearance and the need for
further margin excision following standard WLE (group A,
n = 121) and OBCS (group B, n = 37).14 They found that,
compared with standard surgery, oncoplastic techniques can
26 S EC T I O N I Oncoplastic Breast Surgery – Getting Started
• Fig. 4.5 Intraoperative image demonstrating placement of a dual
plane tissue expander and acellular dermal matrix.
• Fig. 4.6Postoperative image following right breast radiation therapy.
The skin on the right is more fibrotic than the skin on the left.
• Fig. 4.7 Intraoperative image at the time of exchange of the tissue
expanders for permanent implants as well as autologous fat grafting to
improve the contour and quality of the mastectomy skin flaps.
• Fig. 4.8 Postoperative image at 2-year follow-up with nipple–areolar
tattooing demonstrating good volume and contour symmetry.
be employed for significantly larger tumors (17.6 mm vs
23.9 mm, p = 0.002), higher mean specimen weights (58.1
grams vs 231.1 grams, p < 0.0001), higher specimen vol-
umes (112.3 cm3 vs 484.5 cm3, p < 0.0001), wider clear
margins (6.1 mm vs 14.3 mm, p < 0.0001), and lower rates
of further surgery (28.9% vs 5.4%, p = 0.002) (down).
There was no statistical increase in complication rates fol-
lowing oncoplastic surgery. Radiation is more easily given to
women with smaller breasts, so the reduction mammaplasty
adds that benefit as well.14
The group at MD Anderson published their recommen-
dations for choosing mastectomy versus breast conservation
with oncoplastic repair.15 For women with an A or B cup
breast, mastectomy is usually the better choice because the
remaining breast tissue is usually inadequate for perform-
ing an oncoplastic repair using tissue rearrangement tech-
niques. However, the use of a vascularized tissue flap such
as a latissimus dorsi can be considered to correct the defor-
mity. For women with larger breasts with a C or D cup,
oncoplasty using a breast reduction technique is considered.
The inverted T pattern skin incision allows access to most
areas of the breast for resection while allowing the nipple–
areolar to maintain a blood supply via a dermoparenchymal
pedicle. They also describe a modification that retains the
medial wedge of breast tissue that is usually discarded with
a standard inferior pedicle design. When a standard inferior
pedicle is impinged on by the tumor resection, the inferior
pedicle is extended medially (the least frequent location for
breast cancer) to increase the blood supply (intercostals and
internal mammary perforating blood vessels) and the vol-
ume of breast tissue available for repair. This medial wedge
can be used to repair the upper inner quadrant, which is
often challenging. Similarly for defects in the inferior medial
quadrant, a more lateral pedicle can be used. They recom-
mend reducing the contralateral breast after radiation for a
more precise match.
 CHAPTER 4
Conclusions
Women diagnosed with breast cancer can choose partial or
total mastectomy and achieve esthetic outcomes. Despite no
survival advantage, some women will prefer mastectomy to
breast conservation with oncoplasty. At many institutions
throughout the United States, women with A and B cup
breasts often choose to have nipple-sparing mastectomy
and prosthetic reconstruction that generally confers excel-
lent cosmetic results. As breast size increases, particularly
in relation to tumor size, these patients are excellent can-
didates for breast conservation with immediate oncoplastic
surgery. Aside from the cosmetic advantage, adding onco-
plastic surgery decreases the risk of positive margins and
thus a second surgery compared with breast conservation
alone because a larger volume of breast parenchyma can be
resected. Skilled plastic surgeons are able to correct ever-
larger defects expanding the number of patients who are
able to have breast conservation. In patients with mammary
hypertrophy who desire nipple-sparing mastectomy rather
than breast conservation and oncoplasty, plastic surgeons
have a variety of mammaplasty techniques to reduce the
breast in a staged procedure so that the patient can have a
nipple-sparing mastectomy several months later. The ulti-
mate goal for any patient with breast cancer is to deliver an
oncologically safe operation that is esthetically pleasing.
References
1. De La Cruz L, Blankenship SA, Chatterjee A, et al. Outcomes after
oncoplastic breast-conserving surgery in breast cancer patients:
a systematic literature review. Ann Surg Oncol. 2016;23(10):
3247–3258.
2. Van Maaren MC, de Munck ML, de Bock GH, et al. 10 year
survival after breast conserving surgery plus radiotherapy com-
pared with mastectomy in early breast cancer in the Netherlands:
a population based study. Lancet Oncol. 2016;17(8):1158–
1170.
3. Carter SA, Lyons GR, Kuerer HM, et al. Operative and onco-
logic outcomes in 9861 patients with operable breast cancer:
single institution analysis of breast conservation with oncoplastic
reconstruction. Ann Surg Oncol. 2016;23(10):3190–3198.
Oncoplasty versus Mastectomy: Decisions and Outcomes 27
4. Santos G, Urban C, Edelweiss MI, et al. Long-term comparison
aesthetical outcomes after oncoplastic surgery and lumpectomy
in breast cancer patients. Ann Surg Oncol. 2015;22(8):2500–
2509.
5. Losken A, Dugal CS, Styblo TM, Carlson GW. A metaanalysis
comparing breast conserving therapy alone to oncoplastic tech-
nique. Ann Plast Surg. 2014;72(2):145–149.
6. Acea-Nebril B, Garcia-Novoa A, Builes-Ramirez S, et al. The role
of oncoplastic breast reduction in the conservative management
of breast cancer: complications, survival and quality of life. J Surg
Oncol. 2017;115(6):679–686.
7. Yoon JJ, Green WR, Kim S, et al. Oncoplastic breast surgery in
the setting of breast conserving therapy: a systemic review. Adv
Radiat Oncol. 2016;1:201–215.
8. Piper ML, Esserman LJ, Sbitany H, Peled AW. Outcomes fol-
lowing oncoplastic reduction mammoplasty: a systemic review.
Ann Plast Surg. 2016;76(3):222–226.
9. Mansell J, Weiler-Mithoff E, Stallard S, Doughty JC, Mallon E,
Romics L. Oncoplastic breast conservation surgery is oncologi-
cally safe when compared to wide local excision and mastectomy.
Breast. 2017;32:179–185.
10. Bhat S, Orucevic A, Woody C, Heidel R, Bell J. Evolving trends
and influencing factors in mastectomy decisions. Am Surg.
2017;83(3):233–238.
11. Martin M, Meyricke R, O’Neill T, Roberts S. Mastectomy or
breast conserving surgery? Factors affecting type of surgical
treatment for breast cancer- a classification tree approach. BMC
Cancer. 2006;6:98. https://doi.org/10.1186/1471-2407-6-98.
http://www.biomedcentral.com/1471-2407/6/98.
12. Pyfer B, Chatterjee A, Chen L, et al. Early outcomes in breast
conservation surgery versus mastectomy with implant recon-
struction: a NSQIP analysis of 11,645 patients. Ann Surg Oncol.
2016;23:92–98.
13. Clough K, Lewis J, Couturaud B, Fitoussi A, Nos C, Falcou MC.
Oncoplastic techniques allow extensive resections for breast con-
serving therapy of breast carcinomas. Ann Surg. 2003;237(1):
26–34.
14. Down S, Jha PK, Burger A, Hussien M. Oncological advantages
of oncoplastic breast conserving surgery in treatment of early
breast cancer. Breast J. 2013;19(1):56–63.
15. Kronowitz SJ, Kuerer HM, Buchholz TA, Valero V, Hunt K.
A management algorithm and practical oncoplastic surgical tech-
niques for repairing partial mastectomy defect. Plast. Reconstr.
Surg. 2008;122:1631–1647.
5
Breast Surgeons and Oncoplastic
Surgery
JULIANN MARIE REILAND
Breast surgeons utilizing oncoplastic techniques is common-
place in the United Kingdom, Europe, and parts of South
America. In Canada and the United States, the adoption
of oncoplastic surgery by breast surgeons has been slow to
advance. Many factors play a role in the slow adoption, but
education and training are most likely the greatest obstacles
breast surgeons face. Breast surgery has evolved into its own
specialty, and breast surgeons have widened their scope of
practice to embrace and integrate aspects of other specialties
to better care for the cancer patient. Oncoplastic techniques
should be an essential addition to that scope of practice.
The treatment of breast cancer is a rapidly changing and
dynamic field. The breast surgeon is the “first responder” to
the crisis of a woman with a new breast cancer diagnosis.
The breast surgeon explains the disease to the patient and
partners with her to develop the best treatment plan based
on multiple variables. Each woman has unique physical, bio-
logical, and emotional variables that must be factored into
that plan. The patient with breast cancer has the best results
when her care involves a multidisciplinary approach with
all specialties involved in her treatment.1 As first responder,
the breast surgeon has knowledge of the basic aspects of the
specialties involved and navigates the patient to the other
specialists when their expertise is required. In an effort to
expedite the patient’s care, the breast surgeon has adopted
aspects of radiology, genetics, and integrative medicine into
their practice.
A newly diagnosed breast cancer patient will likely
undergo multiple tests both before and after her diagnosis.
Breast surgeons read mammograms daily and perform ultra-
sounds both in the clinic and in the operating room to bet-
ter facilitate the treatment of their patient. Advanced breast
imaging such as 3D mammography, magnetic resonance
imaging, and ultrasound have improved the evaluation
and diagnosis of breast cancer. Innovations such as contrast
enhanced digital mammography2 and automated breast
ultrasound3 are being recognized as new tools in advanced
imaging. It is the breast surgeon who determines which
tests are needed to obtain the best information regarding
28
treatments. Many breast surgeons are certified to perform
ultrasound and stereotactic core biopsies in the diagnosis
of breast disease. Breast surgeons and radiologists work
together to bridge specialties to facilitate the evaluation and
surveillance of the woman with breast cancer.
With the new diagnosis comes the question of “why me?”
Understanding and identifying risk factors for the occur-
rence of an initial or second breast cancer have also advanced
significantly. There has been an explosion of information
regarding genetic defects that increase a woman’s lifetime
risk from 25–80%.4 The understanding of genetics is cru-
cial in the ability to counsel the patient as to her options
for treatment. Breast surgeons have adopted this knowledge
into their practice and have been recognized as appropriate
providers to counsel patients in genetics and genetic testing5
and share these responsibilities with geneticists when they
are available.
When a woman is diagnosed, one of her first reactions
is to have surgery yesterday. However, tumor biology of a
woman’s breast cancer is often the driver of the order in
which she will be treated. Biologically aggressive tumors
such as estrogen and progesterone negative, HER-2 neu
positive (Luminal B), and triple negative tumors are now
recommended for treatment with neoadjuvant chemo-
therapy. With genomic sequencing, determining the precise
treatment for each individual cancer is evolving. The abil-
ity to effectively downstage tumors gives women with later
stage breast cancers more options in their surgical treatment.
Now, more than ever, the breast surgeon must be aware of
the nuances of tumor biology and identify the patient who
needs referral to medical oncology. The breast surgeon must
also impress upon the patient who is so anxious to have
surgery first, the importance of neoadjuvant chemotherapy,
when appropriate, to her total care.
Radiation therapy after partial mastectomy is an impor-
tant component of breast conservation therapy. With the
acceptance of varying modalities and time courses of radia-
tion therapy, a 6-week course of daily whole breast radia-
tion is being replaced by shortened whole breast radiation

courses or better partial breast radiation options. Today a
woman can potentially have her breast cancer surgery and
her entire radiation therapy dose performed together in
1 day, with many other options offering shortened courses
of radiation from 2–21 days.6 The breast surgeon evaluates
the patient for the possible options of partial breast or whole
breast radiation and works closely with the radiation oncol-
ogist to determine patient selection and the intraoperative
placement of the radiation delivery system, as appropriate.
After the acute crisis of a breast cancer diagnosis and
treatment, the patient begins the process of putting her life
back together and understanding her “new normal.” The
breast surgeon again is a part of this process. Many breast
surgeons participate in monitoring the patient between 2–5
years after her cancer diagnosis.7,8 In the United States,
most women are diagnosed with early stage disease. These
women will have 98% survival.9 Survivorship becomes an
important part of the treatment plan for every woman with
breast cancer. Breast surgeons determine appropriate imag-
ing needed for each patient in surveillance. They counsel
women on lifestyle changes such as diet and exercise that are
known to affect recurrence rates. They are knowledgeable in
survivorship options from integrative medicine to psycho-
logical counseling, and refer the patient to these services to
help the survivor thrive in her posttreatment life.10-12
As a vital participant of so many advances in the mul-
tidisciplinary aspects of breast cancer, one would expect
the breast surgeon to also be adept in the use of the mul-
tiple surgical options available today when a woman desires
breast conservation. Sadly, this does not appear to be the
case. If oncoplastic surgery has gained wide acceptance in
Europe, the United Kingdom, and parts of South America,
why are breast surgeons in the United States and Canada
significantly behind in adopting these techniques?
A common model for oncoplastic repair in the United
States and Canada is the two-surgeon approach. The breast
surgeon removes the breast cancer and the plastic surgeon
reconstructs the breast defect. One survey investigated cur-
rent practices and polled members of both the American
Society of Plastic Surgeons (ASPS) and the American Soci-
ety of Breast Surgeons (ASBrS). This survey reported 50%
of plastic surgeons believed they were not involved in recon-
struction after partial mastectomy because breast surgeons
did not refer patients to the plastic surgeon.13 Another
survey polling ASBrS members showed 63% of breast sur-
geons refer patients to a plastic surgeon for a breast reduc-
tion with their cancer surgery when a reduction would
be indicated.14 Only half of the breast surgeons surveyed
routinely discuss oncoplastic procedures during the initial
breast cancer surgical consultation, whereas 29% some-
times do and 20% never discuss such procedures.14 From
the patient perspective, a recent Canadian report surveying
women with breast conservation regarding their options for
reconstruction indicated only 1.6% were referred to plas-
tic surgery before surgery, but a full 30% would have seen
a plastic surgeon if it were offered.15 It is apparent from
these surveys that a disconnect is occurring between plastic
CHAPTER 5 Breast Surgeons and Oncoplastic Surgery 29
and breast surgeons. Failure to adopt oncoplastic surgical
techniques in the United States and Canada could in part
be due to the breast surgeons’ lack of knowledge of these
techniques. When surveyed regarding the desire to learn
oncoplastic techniques, 99% of breast surgeons indicated
an interest in learning the techniques with 77% being
extremely interested.14 Seventy percent of polled breast sur-
geons believed adoption of oncoplastic techniques would
be dependent upon training breast surgeons in those tech-
niques, and 52% thought increasing awareness for breast
surgeons using oncoplastic techniques as they work with
plastic surgeons would improve adoption of oncoplastic
surgery techniques.13
The simplistic definition of oncoplastic surgery is the best
oncologic surgery with the best cosmetic result. Another
clarifying definition: “oncoplastic surgery is surgery that is
considerate to what we leave women to live with for the rest
of their lives and should be an integral part of treatment for
all women with breast cancer.”16 Why would any surgeon
not consider this for every patient? Which patient deserves
less than the best aesthetic result?
To suggest oncoplastic techniques are merely specific
procedures would do the field of oncoplastic surgery a
great injustice. Instead, oncoplastic surgery begins as an
embraced philosophy as the surgeon collaborates with
other surgeons in the care of the patient. The ability to
evaluate a woman’s breast and consider all the possible sur-
gical approaches for the removal of cancer and restoring
the appearance of both breasts is mentored and developed
through sharing these techniques. The spectrum of options
from basic to advanced will require skill sets of both breast
and plastic surgeons. As the breast surgeon discovers the
benefits of the basic oncoplastic techniques, the surgeon
will also understand the importance of partnering with
plastic surgeons to rely on their expertise for appropriate
patient treatment.
Training breast surgeons to perform basic principles
in oncoplastic surgery will be the start to ensure the best
aesthetic result for every woman undergoing breast cancer
surgery.
Hidden Incisions
Unfortunately, with wired-, wireless-, and ultrasound-
guided localization of tumors, breast surgeons have become
accustomed to placing incisions over the cancer or wire and
dissecting directly down to the lesion. However, any breast
surgeon could easily make an incision at the nipple–areolar
complex (NAC), the inframammary fold (IMF), or axilla
and develop a plane of dissection in the superficial breast to
either reach the lesion found on ultrasound or wireless local-
ization or intercept the guidewire as it traverses the skin and
breast tissue to reach the lesion. This approach uses the same
techniques of dissection in the anterior mammary fascia for
a skin-sparing or nipple-sparing mastectomy. Although this
may take more time initially, the benefits to the patient in
these hidden incision techniques will be invaluable.
30 S EC T I O N I Oncoplastic Breast Surgery – Getting Started
Volume Displacement Techniques
Involving Local Tissue Rearrangement
Closure of the defect produced by the lumpectomy cavity
is a skill only 60% of breast surgeons reported performing
routinely.14 For decades, surgeons have been taught to leave
the lumpectomy cavity intact and allow it to fill in with
seroma. This caused a normal-appearing breast for the first
few weeks as the cavity remained full of fluid. Long-term
aesthetic sequela of leaving a large fluid-filled space in the
breast cancer patient cannot be understated. The seroma that
fills the space generally absorbs before whole breast radia-
tion, and the skin begins to sink into the defect. Radiation
will only cement this process and cause disfiguring results,
requiring time and extensive surgery to correct. Oncoplastic
surgery fills in the lumpectomy defect with local tissue and,
in the process, restores the full breast mound, which results
in better cosmesis.17 In certain volume displacement opera-
tions (level 1 volume displacement oncoplastic surgery),18
the breast surgeon has the technical ability to repair this
lumpectomy defect. The development of glandular flaps,
and dissection of the breast from the skin fold in the ante-
rior mammary fascia and off the pectoralis muscle in the
posterior are techniques used daily in the performance of
any mastectomy. For a basic partial mastectomy using onco-
plastic techniques, this dissection can be done for at least the
quadrant of the breast with the lesion. The dissection in this
plane is best when it extends beyond the lesion to the edge
of the glandular tissue. The defect is closed by either advanc-
ing or rotating the glandular flaps into the empty space to
close the defect.17-19 If the skin is tethered to the breast and
creates a dimple or pulls at the NAC, extending the dissec-
tion of the superficial breast from the skin envelope easily
corrects dimple or pucker in the skin.
These two steps can dramatically improve the cosmetic
result for any woman who requires breast surgery for benign
or malignant disease. They are well within the skill set of the
breast surgeon.
Volume Displacement Techniques
Involving a Reduction in the Skin Envelope
In the patient with a larger breast lesion, consideration
must first be given to tumor biology and determining if the
patient would be better suited for neoadjuvant chemother-
apy.20 Today all surgeons need to understand any woman
with triple negative or HER-2 neu positive breast cancer
needs a medical oncology evaluation before any surgery.
Neoadjuvant chemotherapy has been used to downstage
breast cancers, enabling a woman to pursue breast conserva-
tion safely without decreased survival.21
In early stage breast cancer and due to downstaging of
later stage breast cancer with neoadjuvant chemotherapy,
the use of volume displacement techniques becomes more
straightforward. In addition to approaching the tumor
from the hidden incisions and developing advancement
or rotational flaps, decreasing the breast skin envelope to
accommodate larger resections of breast is needed. Fitoussi’s
graph of oncoplastic surgical approaches to breast cancer was
developed when removal of skin was required in the patient
with a lesion greater than 20% breast volume.22 With neo-
adjuvant chemotherapy, the skin above the lesion is safely
preserved, and either the donut, the vertical mammaplasty,
or wise pattern skin incisions can be easily utilized for the
majority of cases while still maintaining the best oncologic
surgical principles. The term therapeutic mammaplasty23 has
also been used to describe the technique of removing the
breast lesion with adequate margins, reshaping the breast
mound, and reducing the breast skin envelope using the
wise pattern skin reduction. In most circumstances, an
inferior, superomedial, or superior pedicle can be used and
modified for autoaugmentation techniques.24-27 Surgeons
performing these operations need training in plastic surgery
techniques to ensure safety and optimal outcomes.
Contralateral Equalization for Symmetry
For the woman whose bra size is B–DD and does not desire
breast reduction, careful consideration must be given to the
contralateral breast to maintain symmetry. When an onco-
plastic repair of the affected breast changes the position of
the NAC, failure to perform a symmetry procedure will sig-
nificantly affect the aesthetic result. Today when queried,
only 50% of breast surgeons referred patients to plastic
surgeons for evaluation for symmetrization.14 A surgeon
trained in plastic surgery techniques will be able to safely
provide the simple skin reduction or minor mammaplasty
for equalization. The patient may consider this an improve-
ment from the appearance of her breasts preoperatively and
add to factors that improve her quality of life.
Moving Forward: Training Breast Surgeons
Breast surgeons and plastic surgeons have differing opinions
on how to increase the adoption of oncoplastic surgery in
the United States. Both surgeon groups agreed that increas-
ing awareness of the oncoplastic team approach would be
helpful. However, 67% of breast surgeons believed train-
ing breast surgeons in oncoplastic techniques would facili-
tate the adoption of those techniques, whereas only 28%
of plastic surgeons believed this to be true.13 When revisit-
ing the practice patterns of breast and plastic surgeons dis-
cussed earlier, perhaps the breast surgeons do not refer their
patients to plastic surgeons for reconstruction because they
are not aware of the options available.
Oncoplastic breast surgery needs to be a concept that is
ingrained in the surgeon during general surgery residency
training. Teaching basic surgical planning and the impor-
tance of hidden incisions for long-term cosmesis in general
surgery residency will be an important step in ensuring all
women with either benign or malignant breast disease have
a surgeon who has been taught to integrate aesthetic results
in their surgical planning.

Basic oncoplastic surgery training is not standardized in
breast fellowships. There are currently no requirements for a
set of oncoplastic surgical techniques performed by the fellow
while in training. Depending upon the experience in onco-
plastic techniques by the breast surgery faculty and the plas-
tic surgery faculty’s attitude toward training breast surgeons’
oncoplastic techniques, the training provided by fellowships
can be either sparse or robust. Although there are no surveys
asking graduating fellows about their comfort with performing
basic oncoplastic techniques independently, 28% of practicing
breast surgeons reported learning oncoplastic techniques in fel-
lowship training.14 Coordination with the American Society
of Breast Surgeons and the Surgical Society of Oncology to
develop a minimum set of basic oncoplastic techniques mas-
tered by a graduating fellow could be one step to increasing
adoption of oncoplastic techniques. Plastic surgery depart-
ments that embrace the breast fellow and train them in basic
oncoplastic techniques rather than relegate them to holding
retractors will help develop a better collegiality among the two
specialties and foster the team approach that is vital in our sys-
tem. The culture of the two specialties working together in fel-
lowship training will encourage coordination in practice of the
breast/plastic surgeon team for the patient requiring advanced
oncoplastic (level 2 volume displacement procedures).17
Today the practicing breast surgeon has an increasing
number of options for oncoplastic training in the United
States. There are both industry-sponsored and academic
courses that provide multiple learning opportunities. The
obstacles in obtaining the training include the cost of train-
ing in both the course and time away from practice. The
surgeon capable of integrating oncoplastic techniques into
the practice philosophically and technically will self-select
by taking courses to expand their knowledge and skills.
Basic oncoplastic surgical techniques as the new standard
of care for all women undergoing breast surgery will improve
the quality of breast surgery across the board. Breast surgeons
will be expected to provide the best aesthetic results possible
by both their patients and referring colleagues. If the breast
surgeon is unable to master the basic skills, they will need
to partner with plastic surgery on a regular basis to pro-
vide optimum results. Failure to do so may result in loss of
referrals and losing that patient population in their practice.
The breast surgeon who does have the skills to safely mas-
ter basic oncoplastic techniques with good aesthetic results
will develop stronger referrals and build their practice. That
surgeon will also be aware of the importance in partnering
with plastic surgeons to ensure that more patients requir-
ing breast reduction techniques and volume replacement
techniques (intercostal perforator flaps, thoracodorsal artery
perforator flaps, implants, etc.) are appropriately managed
by the team approach. Finally, as a long-term future pos-
sibility, for those breast and plastic surgeons who wish to
concentrate their entire practice on the treatment of breast
cancer and reconstructive efforts, the United States may join
Europe and the United Kingdom in efforts to develop onco-
plastic fellowship programs that train surgeons in all aspects
of oncologic and reconstructive efforts.
CHAPTER 5 Breast Surgeons and Oncoplastic Surgery 31
In the end, it must always be about the patient. If
every woman with breast cancer deserves the best onco-
logic and cosmetic result, then every surgeon operating
on a breast cancer patient needs to have the knowledge
and understanding to offer the best results whether it is
delivered by one surgeon or a team of surgeons. Lead-
ership from plastic, breast, and general surgery societies
need to come together to develop a plan to safely train
breast and general surgeons in basic oncoplastic surgery
and establish a standard for implementing the breast/
plastic surgery team.
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6
Plastic Surgeon’s Approach to
Oncoplastic Breast Surgery
MAURICE Y. NAHABEDIAN
Introduction
Oncoplastic breast surgery has become a common option for
women with breast cancer and is currently being performed
throughout the world on a regular basis. This operation has
provided women with the best of oncologic and reconstruc-
tive options in that they can achieve oncologic safety and
efficacy, retain the majority of their breast, and retain a nat-
ural breast appearance. In many parts of the world, breast
surgeons and plastic surgeons perform oncoplastic breast
surgery as a team and work together to optimize surgical
outcomes. Breast and plastic surgeons each have a unique
perspective on oncoplastic surgery and how to perform it.
Many breast surgeons have expanded their scope of practice
and now perform simple reconstructive procedures in addi-
tion to ablative procedures.1 Plastic surgeons continue to
be an integral component of the oncoplastic team in that
they can provide expertise in both simple and complex situ-
ations. This chapter will provide a plastic surgeon’s perspec-
tive on oncoplastic breast surgery.
Role of Plastic Surgery
Plastic surgeons have a long-standing interest in reconstruc-
tive breast surgery and have been at the forefront of recon-
structive innovation. The role of the plastic surgeon is to
provide expertise in the management of complex defects of
the breast following partial mastectomy and not just to close
a defect. Plastic surgeons are able to incorporate principles
and concepts to reshape and contour the breast in a predict-
able and reproducible manner. Oftentimes, this is relatively
straightforward and may not require complex maneuvers;
however, there are times when a defect may be larger than
usual relative to the volume of the breast or it may be in a
location that will be difficult to reconstruct.
There are many surgeons who feel that plastic surgery
comprises a collection of techniques that can be performed
by anyone.2 Being able to perform a particular procedure can
be learned, but understanding the principles and concepts
that dictate the optimal operation requires training and spe-
cialization. Fellowship programs now exist that combine
the oncologic and plastic surgical principles to optimally
care for these patients.3 Plastic surgeons have an intricate
understanding of blood supply and tissue perfusion and are
able to use local parenchymal flaps and, in more complex
cases, remote adipocutaneous flaps. Inherent to this is an
understanding of tissue tension, perfusion analysis, appro-
priate suturing techniques, the use of drains, and a working
knowledge of breast aesthetics and how to achieve them.
It is clearly appreciated that not every partial mastectomy
defect will require the assistance of a trained plastic surgeon.
Defects that are relatively small may be easy to close with-
out the assistance of a trained plastic surgeon and result in
minimal to no breast distortion. There are a number of tech-
niques and approaches that have been described to facili-
tate these reconstructive maneuvers, and if breast surgeons
can perform them safely and effectively, then they should
do so.4 One of the principles that plastic surgeons adhere
to is that the performance of a particular operation should
be based on the ability to take care of any complications
that may arise following that operation. In the case of onco-
plastic surgery, this includes, but is not limited to, delayed
healing, fat necrosis, skin necrosis, nipple–areolar necrosis,
infection, bleeding, seroma, asymmetry, and complex scar-
ring. The role of the plastic surgeon should not solely be to
manage complications but rather to perform operations that
will minimize the risk of complications.
In the specialized field of oncoplastic breast surgery, there
are currently three pathways for plastic and breast surgeons
to collaborate.5 The first and traditional pathway is for plas-
tic and breast surgeons to work together on all cases. It can
be argued that this option will provide patients with opti-
mal outcomes based on the combined expertise with the
oncologic and reconstructive management of the patient.
The second pathway also involves both the breast and plas-
tic surgeons with specific involvement based on the com-
plexity of the reconstruction. This is the model that exists
throughout much of Europe in which the breast surgeon
33
34 S EC T I O N I Oncoplastic Breast Surgery – Getting Started
will perform certain reconstructive procedures such as an
implant, latissimus dorsi flaps, and reduction mammaplasty,
and the plastic surgeon will perform the more complex pro-
cedures such as pedicled abdominal flaps or free tissue trans-
fers. The third pathway is the least common in which a sole
surgeon provides the oncologic and reconstructive options
in all cases. The specialist may be a breast surgeon trained
in reconstructive techniques or a plastic surgeon trained in
oncologic management.
Breast reconstruction and oncoplastic surgery have
evolved over the years to the point that they are regarded as
oncologically safe and aesthetically advantageous.6 Surgeons
now practice in an era of high patient expectations where
many patients will desire to have their appearance enhanced
following surgery. This is why the role of trained plastic sur-
geons is so important when it comes to oncoplastic pro-
cedures of the breast. Studies have confirmed the ability
of plastic surgeons to create ideal breast proportions based
on case complexity and the optimization of operative tech-
niques. In a recent survey of membership from the Ameri-
can Society of Plastic Surgeons and the American Society
of Breast Surgeons, 70% of breast surgeons felt that partial
breast reconstruction following lumpectomy compromised
a good portion of their practice, whereas 50% of plastic sur-
geons felt that their ability to perform oncoplastic surgery
was limited due to a lack of referrals.7 Interestingly, both
societies opined that complex partial breast reconstruction
was best performed using the team approach. Benefits of the
team approach included being able to take wider margins
and enhanced aesthetics.
Based on this survey, it is important for plastic surgeons
who have an interest in oncoplastic breast surgery to make
their referring breast surgeons aware of their interest and
desire to collaborate. Many breast surgeons become frus-
trated with their plastic surgery colleagues because they are
often not available or are busy doing other operations. Coor-
dinating the two schedules can sometimes be a challenge,
but plastic surgeons should make every effort to facilitate a
good relationship with breast surgeons and have designated
blocks for these operations. Failure to do so will result in a
reduction in referrals and the gradual erosion of our ability
to stay active in breast reconstruction. Plastic surgeons have
advanced the field of breast reconstruction and have been
performing high-level aesthetic and reconstructive breast
surgery for decades. It would be a shame for the specialty of
plastic surgery to become obsolete in the oncoplastic care of
breast cancer patients.
Vascular Anatomy
When considering oncoplastic surgery, a thorough under-
standing of the vascular anatomy of the breast is critical.8
The primary blood supply to the breast is derived from
the perforating branches of the internal mammary and
lateral thoracic vascular systems. These perforators will
traverse through the breast to form an anastomotic clus-
ter around the periareolar region and provide vascularity
to the nipple–areolar complex (NAC). It is important to
realize that the vascularity to the parenchyma and the skin
are distinct and can be compartmentalized. Another domi-
nant source of blood supply is via the intercostal perfora-
tors. Studies have demonstrated that the second, third, and
fourth perforating branches of the intercostal system course
within the horizontal ligament of the breast toward the
nipple.9 The remainder of the vascular supply to the breast
is derived from the thoracoacromial and superficial tho-
racic arteries. This knowledge is important when designing
parenchymal flaps and in maintaining the perfusion to the
skin and NAC.
Patient Selection
When a patient with breast cancer is referred for reconstruc-
tive options, more often than not, the breast surgeon has
reviewed the oncologic options with the patient and men-
tioned some of the reconstructive options. During the initial
consultation, a thorough history and physical examination
is performed. An assessment of comorbidities is completed
with an emphasis on cardiac disease, pulmonary disease,
tobacco use, and diabetes mellitus. Poorly controlled dia-
betes and active tobacco use are indicative of poor wound
healing following oncoplastic surgery. Cardiac and pulmo-
nary disease are also important given that these procedures
are usually performed under general anesthesia, and good
health will promote safe surgery.
Understanding patient expectations is a critical compo-
nent of all breast surgery and especially oncoplastic breast
surgery. It is important to appreciate how a patient feels about
her breasts before the diagnosis of breast cancer and what
she would like modified. This may pertain to breast volume,
shape, symmetry, contour, nipple position, or diameter of
the NAC. It is important to explain that oncoplastic breast
surgery is performed more often on women with mammary
hypertrophy; however, women with normal or small vol-
ume breasts can also have oncoplastic procedures. Studies
evaluating complications, recurrence, and patient satisfac-
tion following breast conservation, oncoplastic reduction
mammaplasty, and oncoplastic flap reconstruction have
demonstrated increased satisfaction and fewer recurrences
and complications with oncoplastic procedures compared
with breast conservation alone.10
Technique Consideration
When considering the options for oncoplastic surgery, it is
important to recognize that there are two fundamental strat-
egies that include volume displacement and volume replace-
ment.11,12 These are typically performed independently but
can be performed together. Volume displacement techniques
include reduction mammaplasty, mastopexy, and adjacent
tissue rearrangement. Volume replacement includes the use
of remote flaps such as a thoracodorsal artery perforator
or a latissimus dorsi flap as well as the use of implants in
select cases. Volume replacement techniques are the most
 CHAPTER 6
common form of oncoplastic reconstruction with reduction
mammaplasty being the workhorse. These operations can be
performed immediately following the partial mastectomy or
on a staged bases following confirmation of clear pathologi-
cal margins.
The classic candidate for oncoplastic breast surgery is
the patient with mammary hypertrophy because the breast
cancer and adjacent parenchyma can be removed and eas-
ily reconstructed without resulting in a complex deformity.
These patients are usually reconstructed using techniques
of adjacent tissue rearrangement that includes reduction
mammaplasty, mastopexy, or parenchymal undermining
and advancement. Performance of these operations requires
a thorough understanding of the vascular anatomy of the
breast.
Reduction Mammaplasty with Parenchymal
Flaps
In women with mammary hypertrophy, reduction mam-
maplasty coupled with parenchymal flaps to fill the
partial mastectomy defect is the most common variant
of oncoplastic reconstruction.13 It is important to rec-
ognize that an oncoplastic reduction mammaplasty is
very different from a standard reduction mammaplasty.
With a standard reduction mammaplasty, the skin and
parenchyma are usually excised in a symmetric and bal-
anced method, and the NAC is transposed on a vascu-
larized pedicle. With an oncoplastic reduction, a partial
mastectomy defect is created that will need to be filled
with a parenchymal flap that is sometimes different from
the parenchymal flap used to transpose the NAC. Many
patients will choose to have the oncoplastic procedure
coupled with a contralateral reduction mammaplasty. In
these situations, it is common to perform a completely
different operation on the cancerous and noncancerous
breast; however, the goal is to achieve final volume and
contour symmetry.
Creation of parenchymal flaps can be challenging and
requires an understanding of the anatomy and tissue perfu-
sion. It is especially important to recognize that the vascular-
ity to the parenchyma and skin are distinctly different and
that multiple variations are possible. The location and size of
the defect will dictate the location and size of the parenchy-
mal flap. The orientation of the parenchymal flap typically
depends upon the location of the defect. In general, paren-
chymal flaps are oriented opposite to the defect such that a
superior breast defect would be typically reconstructed with
an inferiorly based flap. Detaching the distal segment of the
parenchymal flap from the chest wall to adequately rotate
it and fill the defect without tension facilitates mobiliza-
tion. It is important to constantly assess the perfusion to
the parenchymal flap to maintain its vascularity; thus, it is
critical to minimize the extent of detachment. Perfusion can
be assessed clinically by noting arterial and venous bleeding
from the distal edges and, if questionable, by using fluores-
cent angiography.
Plastic Surgeon’s Approach to Oncoplastic Breast Surgery 35
• Fig. 6.1 Preoperative markings of a woman with right breast can-
cer scheduled for right oncoplasty and left reduction mammaplasty
for symmetry.
Once the flap has been adequately mobilized, it is inset
into the breast defect and sutured in place. The perimeter of
the chest wall defect is tagged with surgical clips or staples
to facilitate identification of the tumor bed for the radia-
tion oncologist. Once complete, the next step is to decide
how much additional breast skin and parenchyma needs
to be excised to create a natural breast contour. This will
depend upon the skin pattern utilized. It is advised to keep
the cancer side approximately 10% larger than the contra-
lateral because of radiation-related shrinkage of the breast
over time. Closed suction drains are routinely placed in
these cases because of the flap mobilization and to maintain
negative pressure in the space to promote flap adherence.
Figs. 6.1–6.5 illustrate a patient having a right oncoplas-
tic reduction mammaplasty and an immediate contralateral
reduction mammaplasty for symmetry.
Oncoplasty in Patients with Small Breast
Volume
In patients with small volume breasts, proper assessment
and counseling is necessary. These patients are informed
about the risks and benefits of total and partial mastectomy.
With total mastectomy, standard reconstructive techniques
are employed and include prosthetic devices or autologous
flaps. However, in patients who desire lumpectomy or par-
tial mastectomy, contour abnormalities without reconstruc-
tion are likely and breast asymmetry may be problematic.
Because these patients are not candidates for reduction
mammaplasty variations, alternative strategies must be con-
sidered to ensure that the likelihood of acceptable contour
and breast symmetry is achieved. For the ipsilateral breast,
these include mastopexy, parenchymal rearrangement, and
placement of a small implant or a remote flap. Contralateral
procedures can also be considered and include mastopexy,
minimal reduction, or augmentation in some cases.
36 S EC T I O N I Oncoplastic Breast Surgery – Getting Started
•Fig. 6.2 Intraoperative image demonstrating a full thickness upper
pole parenchymal defect extending to the pectoralis major muscle.
Note the surgical clips placed along the periphery of the defect.
• Fig. 6.3 A medial-based pedicle with a lateral extension is created.
Autologous Flaps
In women with smaller breast volume who desire breast con-
servation that are not candidates for reduction techniques,
the use of regional flaps such as the latissimus dorsi mus-
culocutaneous flap, latissimus dorsi fasciocutaneous flap, or
the thoracodorsal artery perforator flap are considered.14-16
Consideration for these operations is based on the desire to
avoid mastectomy and reconstruct the partial mastectomy
defect with similar tissue resulting in breast contour that is
nearly identical to the preablative appearance. The preferred
donor site for reconstruction is the posterolateral chest
• Fig. 6.4 The pedicle is rotated into the upper pole defect and sutured.
• Fig. 6.5 An early postoperative image demonstrating nice volume
and contour symmetry.
because the amount of harvested tissue will approximate the
defect and is ideally suited for partial mastectomy recon-
struction. Although the abdominal donor can be used, this
usually is reserved for total breast reconstruction because
there is a greater quantity of tissue available.
When considering the design or template of the flap, it
is important to know exactly where the partial mastectomy
defect will be. These posterolateral-based flaps are ideally
suited for lateral, inferior, and central breast defects, and
are less suitable for medial breast defects due to limitations
in the arc of rotation. These flaps can all be transferred on a
pedicle and do not usually require free tissue transfer utiliz-
ing an operative microscope. Because these defects require
replacement of skin and parenchyma, it is important to
design the cutaneous territory of the flap so that the arc of
 CHAPTER 6
• Fig. 6.6 A preoperative image of a right breast defect involving the
inferolateral quadrant following breast conservation.
• Fig. 6.7 A latissimus dorsi flap is elevated for reconstruction.
rotation will easily reach and the flap skin matches the speci-
men skin. The technical details of these operations will be
described in subsequent chapters. Figs. 6.6–6.10 illustrate
a patient with a partial breast deformity following partial
mastectomy who was reconstructed with a latissimus dorsi
musculocutaneous flap.
Biplanar Oncoplasty
An alternative approach for women with localized breast
cancer who have smaller breasts that preclude them from
oncoplastic reduction mammaplasty and who desire breast
conservation is the biplanar technique.17-19 Simply stated,
this technique involves volume displacement and replace-
ment simultaneously and includes prepectoral parenchy-
mal rearrangement to reestablish adequate breast contour
and subpectoral placement of a small breast implant to
reestablish breast volume. With these cases, it is highly
Plastic Surgeon’s Approach to Oncoplastic Breast Surgery 37
• Fig. 6.8 The latissimus dorsi flap is tunneled and inset. The skin terri-
tory of the flap is de-epithelized to fit the skin defect.
recommended that the breast and plastic surgeon operate
together because the technical aspects are more complex and
require a thorough understanding of breast vascularity and
the principles and concepts related to parenchymal advance-
ment flaps. The performance of this technique requires a
moderate degree of detachment between the breast paren-
chyma and the skin envelope, and a mild to moderate degree
of detachment between the parenchyma and the pectoralis
major muscle. Assessment of tissue perfusion is critical in
these cases as it can be compromised if the operation is not
performed correctly. In some patients, a small implant can
be placed under the pectoral major muscle to restore the
volume.
Preoperative assessment includes determining the degree
of ptosis and if volume replacement will be necessary. If there
is no ptosis, the nipple position does not need to change;
however, if present, the NAC may be elevated as needed,
and a small amount of infraareolar skin can be excised. If
the tumor is small and the expected volume of resection
is less than 25% of the breast perimeter, this procedure is
considered. If, however, the volume of excision exceeds this
or a multifocal tumor is present, this technique may not be
ideal or indicated due to vascular considerations. A thor-
ough discussion about radiation therapy will be necessary as
this can result in breast distortion and capsular contracture
over time.
The salient aspects of the operation will be reviewed. A
circumvertical incisional pattern is always utilized because
this will facilitate exposure of the breast parenchyma, the
ablative portion, the parenchymal rearrangement, and the
placement of a small implant. The typical weight of the
excised specimen in these patients is small and typically
ranges from 40–100 grams. The parenchymal rearrange-
ment typically involves advancement of the medial and lat-
eral aspects of the parenchymal defect followed by suture
closure. If an implant is used, it is usually a low profile
Another random document with
no related content on Scribd:
3,338,016.49
From dividend received for account of
Kansas Pacific Railway.
821,891.70
From Postal Service.
102,354,579.29

Total receipts
669,595,431.18

The expenditures for the same period were:

For the civil establishment, including foreign

intercourse, public buildings, collecting
the revenues, District of Columbia,
and other miscellaneous expenses
$98,542,411.37

For the military establishment, including

rivers and harbors, forts, arsenals, sea
coast defenses, and expenses of the war
with Spain and in the Philippines
134,174,761.18

For the naval establishment, including

construction of new vessels, machinery,
armament, equipment, improvement at
navy-yards, and expenses of the war
with Spain and in the Philippines
55,953,077.72

For Indian Service.

10,175,100.76
For pensions.
140,877,316.02
For interest on the public debt.
40,160,333.27
For deficiency in postal revenues.
7,230,778.79
For Postal Service.
102,354,579.29

Total expenditures.
590,068,371.00

Showing a surplus of
79,527,060.18

"As compared with the fiscal year 1899, the receipts for 1900
increased $58,613,426.83. … There was a decrease of
$117,358,388.14 in expenditures."

United States Secretary of the Treasury,

Annual Report on the State of the Finances,
1900, pages 7-9.

UNITED STATES OF AMERICA: A. D. 1900 (June).

Return of losses from all causes in the armies of the
United States since May 1, 1898.

In response to a resolution of the Senate, the following

return (56th Congress, 1st Session, Senate Document 426) was
made by the Secretary of War, June 1, 1900, showing the losses
from all causes in the armies of the United States between May
1, 1898, and June 30, 1899; casualties in the Philippines
during the war with Spain, and after the close of the war with
 Spain down to May 20, 1900; and other interesting details:

Statement showing losses, from all causes, in the armies of

the United States between May 1, 1898, and June 30, 1899.

Average strength.

1898:
Regular Army, 55,853:
Volunteers, 163,103.

1899:
Regular Army, 63,370;
Volunteers, 45,457.

REGULAR ARMY.
CAUSES. Officers. Enlisted
Men. Total.

Deaths:
Killed in action. 24 270
294
By Wounds. 7 114
121
Disease. 51 1,524
1,575
Accident. 1 72
73
Drowning. 2 48
50
Suicide. 1 32
33
 Murder or homicide. 26
26
Total 86 2,086
2,172

Wounded. 109 1,586

1,695

{667}

VOLUNTEERS.
CAUSES.
Officers. Enlisted
Men Total.

Deaths:
Killed in action. 17 188
205
By wounds. 3 78
81
Disease. 114 3,820
3,934
Accident. 5 137
142
Drowning. 1 40
41
Suicide. 1 20
21
Murder or homicide. 26
26

Total. 141 4,309

4,450
 Wounded. 88 1,178
1,266

GRAND TOTAL.
CAUSES.
Officers. Enlisted
Men

Deaths:
Killed In action 38 458
By wounds 10 192
Disease 165 5,344
Accident 6 209
Drowning 3 88
Suicide. 2 52
Murder or homicide. 52

Total 224 6,395

Wounded 197 2,764

Casualties in the Philippines during the war

with Spain, June 30, 1898, to August 13, 1898.

Average strength, 10,900.

Officers.
Enlisted Men. Total.

Killed
 (no deaths from wounds)
18 18

Wounded 10
99 109

Total 10
117 127

In the Philippines, from February 4, 1899, to

May 20, 1900,

Average strength, 43,232.

Officers.
Enlisted Men. Total.

Killed or died of wounds. 43 579

622

Deaths:
By disease 19 1,054
1,073
Accident 1 43
44
Drowning 2 94
96
Suicide 6 23
29
Murder or homicide 11
11
 Total 71 1,804
1,875
Wounded. 132 1,897
2,029

Grand total 203 3,701

3,904

Casualties in the Fifth Corps in the

operations against
Santiago, June 22 to July 17, 1898:

KILLED.
WOUNDED.
ACTIONS.
Officers. Men.
Officers. Men.

Las Guasimas, June 24 1 15

6 43
El Caney, July 1 4 77
25 335
San Juan, July 1-3 15 127
69 945
Aguadores, July l-2 2
10
Around Santiago,
July 10-12 1 1
1 11

Total. 21 222
101 1,344
 Died of wounds received in the five battles
named:
Officers, 5; men, 70.
Total killed and died of wounds:
Officers, 26; men, 292.

Statement of the number of insane soldiers

admitted to the
Government Hospital for the Insane,
Washington, D. C., from
the Philippine Islands, May 24, 1900, and the
disposition made
of them:

Regulars.
Volunteers.
Admitted 47
15
Discharged recovered 16
3
Discharged unimproved 1
On visit from hospital 1
Remaining in hospital 29
12

UNITED STATES OF AMERICA: A. D. 1900 (June).

Immigration for the year ended June 30.

"The Commissioner-General of Immigration, in the annual report

of the operations of his Bureau for the fiscal year ended June
30, 1900, submits tabulated statements showing the arrival in
this country during that period of 448,572 alien immigrants,
 425,372 through ports of the United States and 23,200 through
Canada. Of these, 304,148 were males and 144,424 females;
54,624 were under 14 years of age, 370,382 were from 14 to 45
years old, and 23,566 were 45 and over. As to the literacy of
persons 14 years of age and over, there were 93,576 who could
neither read nor write, and 2,097 who could read but were
unable to write; 54,288 brought each $30 or over, and 271,821
showed sums less than $30, the total amounts displayed to
inspectors aggregating $6,657,530. There were returned to
their own countries within one year after landing 356, and
hospital relief was rendered during the year to 2,417. The
total debarred, or refused a landing at the ports, were 4,246,
as compared with 3,798 last year. Of these, 1 was excluded for
idiocy, 32 for insanity, 2,974 as paupers or persons likely to
become public charges, 393 on account of disease, 4 as
convicts, 2 as assisted immigrants, 833 as contract laborers,
and 7 women upon the ground that they had been imported for
immoral purposes. In addition to the foregoing, there were
excluded at the Mexican and Canadian borders a total of 1,616
aliens.

"It appears that the Croatian and Slovenian races sent an

increase of 99 per cent over those of the same races who came
last year; the Hebrew, an increase of 62 per cent; the South
Italian (including Sicilian), 28 per cent; the Japanese, 271
per cent; the Finnish, 106 per cent; the Magyar, 181 per cent;
the Polish, 64 per cent; the Scandinavian, 41 per cent.; the
Slovak, 84 per cent. These nine races, of the total of
forty-one races represented by immigration, furnished nearly
as many immigrants as the total arrivals for the last year, or
310,444, and their aggregate increase represented 85 per cent of
the total increase shown for the year.
{668}
The total immigration reported, 448,572, is in excess of that
for the preceding year, 311,715, by 136,857, or 43.9 per cent.
As to countries of origin, 424,700 came from European, 17,946
from Asiatic, 30 from African, and 5,896 from all other
 sources. The Commissioner-General points out that in addition
to the 448,572 immigrants there arrived 65,635 other alien
passengers, who, he contends, should be included in conformity
to law with those classified as immigrants."

United States, Secretary of the Treasury,

Annual Report, 1900, page 37.

UNITED STATES OF AMERICA: A. D. 1900 (June).

Shipping, compared with that of other countries.

See (in this volume)

SHIPPING OF THE WORLD.

UNITED STATES OF AMERICA: A. D. 1900 (June).

Alaska Act.

See (in this volume)

ALASKA: A. D. 1900.

UNITED STATES OF AMERICA: A. D. 1900 (June).

Returns of Filipinos killed, wounded and captured from the
beginning of hostilities with them.

See (in this volume)

PHILIPPINE ISLANDS: A. D. 1900 (MAY).

UNITED STATES OF AMERICA: A. D. 1900 (June-December).

Co-operation with the Powers in China.

See (in this volume)

CHINA.

UNITED STATES OF AMERICA: A. D. 1900 (July).

Appeal of citizens of Manila to the
Congress of the United States.
 See (in this volume)
PHILIPPINE ISLANDS: A. D. 1900 (JULY).

UNITED STATES OF AMERICA: A. D. 1900 (July).

Forces sent to China under General Chaffee.

See (in this volume)

CHINA: A. D. 1900 (JULY).

UNITED STATES OF AMERICA: A. D. 1900 (August).

Agreement with Russian proposal to withdraw troops
from Peking.

See (in this volume)

CHINA: A. D. 1900 (AUGUST-DECEMBER).

UNITED STATES OF AMERICA: A. D. 1900 (September).

Opposition to German proposal for dealing with China.

See (in this volume)

CHINA: A. D. 1900 (AUGUST-DECEMBER).

UNITED STATES OF AMERICA: A. D. 1900 (September-November).

Legislative measures of the Philippine Commission.

See (in this volume)

PHILIPPINE ISLANDS: A. D. 1900 (SEPTEMBER-NOVEMBER).

UNITED STATES OF AMERICA: A. D. 1900 (October).

Military forces in the Philippine Islands.

See (in this volume)

PHILIPPINE ISLANDS: A. D. 1900 (OCTOBER).

UNITED STATES OF AMERICA: A. D. 1900 (December).

Amendment and ratification of the Hay-Pauncefote Convention.
 See (in this volume)
CANAL, INTEROCEANIC: A. D. 1900 (DECEMBER).

UNITED STATES OF AMERICA: A. D. 1900 (December).

Celebration of the 100th anniversary of the removal of
the capital to Washington.

See (in this volume)

WASHINGTON.

UNITED STATES OF AMERICA: A. D. 1900 (December).

Exports for the calendar year exceeding those
of any other nation.

A Press despatch from Washington, dated February 21, 1901,

announced the fact that the "complete figures for the calendar
year 1900, when compared with those of other nations, show
that American exports of domestic products are greater than
those of any other country. The total exports of domestic
merchandise from the United States in the calendar year 1900
were $1,453,013,659; those from the United Kingdom, which has
heretofore led in the race for this distinction were
$1,418,348,000, and those from Germany $1,050,611,000.
Additional interest is given to the first rank which the
United States now holds as an exporting nation by the fact
that a quarter of a century ago she stood fourth in that list.
In 1875 the domestic exports of the United States were
$497,263,737; those of Germany, $607,096,000; those of France,
$747,489,000, and those of the United Kingdom, $1,087,497,000.
To-day the United States stands at the head of the list, the
United Kingdom second, Germany third and France fourth, with
the figures as follows: United States, $1,453,013,659; United
Kingdom, $1,418,348,000; Germany, $1,050,611,000; France,
$787,060,000. All of these figures, it should be remembered,
relate to the exports of domestic products. Thus in the
quarter century the United States has increased her exports
from $497,263,737 to $1,453,013,659, or 192 per cent; Germany,
 from $607,096,000 to $1,050,611,000, or 73 per cent; the
United Kingdom, from $1,087,497,000 to $1,418,348,000, or 34
per cent, and France, from $747,489,000 to $787,060,000, or 5
per cent.

"The following table, compiled from official reports, shows

the exports of domestic merchandise from the United States,
the United Kingdom and Germany in each calendar year from 1875
to 1900:

Year United States United Kingdom

Germany

1875 $497,263,737 $1,087,497,000

$607,096,000
1876 575,735,804 976,410,000
619,919,000
1877 607,666,495 967,913,000
672,151,000
1878 723,286,821 938,500,000
702,513,000
1879 754,656,755 932,090,000
675,397,000
1880 875,564,075 1,085,521,000
741,202,000
1881 814,162,951 1,138,873,000
724,379,000
1882 749,911,309 1,175,099,000
776,228,000
18&1 777,523,718 1,166,982,000
796,208,000
1884 733,768,764 1,134,016,000
779,832,000
 1885 673,593,506 1,037,124,000
695,892,000
1886 699,519,430 1,035,226,000
726,471,000
1887 703,319,692 1,079,944,000
762,897,000
1888 679,597,477 1,141,365,000
780,076,000
1889 814,154,864 1,211,442,000
770,537,000
1890 845,999,603 1,282,474,000
809,810,000
1891 907,333,551 1,203,169,000
772,679,000
1892 923,237,315 1,105,747,000
718,806,000
1893 854,729,454 1,062,162,000
753,301,000
1894 807,312,116 1,051,193,000
720,607,000
1895 807,742,415 1,100,452,000
807,328,000
1896 986,830,080 1,168,671,000
857,745,000
1897 1,079,834,296 1,139,882,000
884,486,000
1898 1,233,564,828 1,135,642,000
894,063,000
1899 1,203,460,000 1,287,971,039
1,001,278,000
1900 1,453,013,659 1,418,348,000
1,050,611,000
UNITED STATES OF AMERICA: A. D. 1900-1901.
Questions relating to the political status of the new
possessions of the nation submitted to the Supreme Court.

Questions of surpassing importance, touching the political

status of the new possessions which the nation had acquired
from Spain, the relations of their inhabitants to the
government and laws of the United States, the source and
nature of the authority to be exercised over them by the
Congress of the United States, whether exercised under the
constitution of the United States or independently of it, were
taken, in December and January (1900-1901), into the Supreme
Court for authoritative decision, by appeals to that tribunal
made in several suits which had arisen from disputed exactions
of duty on importations from Porto Rico and the Philippine
Islands. The questions had been burning ones in American
politics, from the moment that the treaty of peace with Spain
was signed, and the whole cast, character and consequence of
the new policy of over-sea expansion on which the American
Republic was then launched depended on the decision of the
Court.
{669}
Soon after the January argument and submission of these cases
to the Supreme Court, their extraordinary importance was
touched upon with impressive eloquence by the Honorable W.
Bourke Cockran, in an address upon "John Marshall," in which
he said:

"At this moment the [Supreme Court] is considering the gravest

question ever submitted to a judicial tribunal in the history
of mankind. Within a few days it must decide whether the
government of the United States, or rather whether two of its
departments can govern territory anywhere by the sword, or
whether authority exercised by officers of the United States
must be controlled and limited everywhere by the Constitution
of the United States.
"I do not mention this momentous question to express the
slightest opinion upon its merits, but merely that this
assemblage of judges and of lawyers may realize the part which
the judiciary is now required to play in determining the
influence which this country must exercise forevermore in the
family of nations. The power of Congress to acquire territory
is of course unquestioned, but the disposition to exercise
that power will always be controlled by the conditions under
which newly acquired territory must be held, and these
conditions the court must now prescribe. On the one hand it
may hold that wherever power is exercised under the
constitution there the limitations of the constitution must be
obeyed—that wherever the executive undertakes to administer, or
Congress to legislate, there the judiciary must enforce upon
both respect for the organic law to which they owe their
existence. If this doctrine be established it is clear that no
scheme of forcible conquest will ever be undertaken by this
government, for the simple reason that there can be no profit
in such an enterprise. On the other hand the Court may decide
that Congress can hold newly annexed territories on any terms
that it chooses—that it may govern them according to the
constitution or independently of it—that they may be
administered to establish justice among the governed or for
the glory and profit of the governors. If it be held that
government for profit can be maintained under the authority of
the United States, conceive the extent to which it may be
carried and the consequences which it may portend. If it be
possible to maintain two forms of government under our
constitution, it is possible to establish twenty in as many
different places. Territory may be annexed to the North, to
the South, to the East and to the West. The President of the
United States may be vested with imperial powers in one place,
with royal prerogatives in another and perhaps remain a
constitutional magistrate at home. He may be made a military
autocrat in some South American State, an anointed emperor in
some Northern clime, a turbaned sultan in some Eastern island.
Nay, more, Congress can move itself and the seat of government
from Washington to some newly annexed territory governed by
officers of its own creation, subject to its own unlimited
power, and thus take both outside the jurisdiction of the
Supreme Court.

"Has the world ever before seen—could the framers of this

constitution have conceived—a bench of judges exercising such
a power amid the universal submission and approval of the
whole people. And more extraordinary than all, this submission
remains unanimous though the decision of the court may
seriously affect its own position in the structure of our
government. For if it be held that the constitution does not
extend of itself over newly annexed territory, then clearly
the authority of the court cannot extend to it except by the
action of Congress and the executive. If the authority, that
is to say, the existence of the court in any part of the
territory of the United States, depends upon the other
departments, then it is idle to contend that it is an
independent and coordinate branch of the government. To decide
that the executive and legislative departments have the right
to govern territory outside the constitution the court must
deliberately renounce the importance which it has heretofore
enjoyed and accept for itself an inferior place in our
political system.

"To me this is the most sublime spectacle ever presented in

the history of the world. Think of it! A war has been waged
with signal success, vast territory has been exacted from a
conquered foe; a great political campaign has been fought and
won upon the policy of taking this territory and governing it
at the pleasure of Congress and the executive, yet if the
court should hold that what the executive has attempted, what
Congress has sanctioned, and what the people appear to have
approved at the polls is in contravention of the constitution,
not one voice would be raised to question the judgment or to
resist its enforcement. I have said the spectacle is sublime;
 my friends, even a few weeks ago it was inconceivable. Before
the late election I confess I believed and said that the
success of the present administration would be interpreted as
a popular endorsement of its foreign policy and that the
popular verdict would very probably be made to exercise a
strong if not decisive influence on the court. I admit now
that I was mistaken. It is evident that this question will be
decided on its merits without the slightest attempt to coerce,
intimidate or influence the judges, and I say now with all
frankness that whatever may be the judgment it will be the
very best outcome for the people of this country, for the
peace of the world, for the welfare of the human race. I
cannot tell what this outcome may be, but I know that whenever
a crisis has arisen in the pathway of the republic, the
statesmanship of the common people has always met it with
justice and solved it with wisdom."

W. Bourke Cockran,
John Marshall: an address before the Erie County Bar
Association, February 4, 1901, at Buffalo.

Argument before the Supreme Court was begun on the 17th of

December, 1900, on two cases thus stated in the brief
submitted for the government: "On June 6, 1899, Goetze
imported from Porto Rico into the port of New York a quantity
of leaf or filler tobacco, upon which duty was assessed at 35
cents per pound as filler tobacco not specially provided for,
in accordance with the provisions of paragraph 213 of the
tariff act of 1897, commonly known as the 'Dingley Act.' The
importer protested, claiming that the merchandise was not
subject to duty, because Porto Rico at the time of the
importation was not a foreign country and because, therefore,
the imposition of duties on goods brought from a place within
the territory of the United States into a port of the United
States is not lawful and valid under the Constitution.
{670}
The Board of General Appraisers sustained the assessment of
duty imposed by the collector upon the merchandise in
question, and thereupon the importer appealed to the United
States circuit court for the southern district of New York, by
which court the decision of the Board of General Appraisers
was affirmed in an opinion rendered by District Judge
Townsend. From the judgment of the circuit court this appeal
was taken.

"Porto Rico was partially occupied by the war forces of the

United States during the months of July and August, 1898. By
the protocol of August 12, 1898, between the United States and
Spain, Spain agreed to cede Porto Rico to the United States
and immediately evacuate. The evacuation was effected and full
possession of the island assumed by the United States prior to
January 1, 1899. From that date until the 1st of May, 1900,
Porto Rico was occupied and governed by the military forces of
the United States, under the command of the President, as
conquered territory, under the law of belligerent right. The
treaty of Paris, made in pursuance of the protocol, was signed
December 10, 1898, ratified by the Senate February 6, 1899,
and ratifications exchanged April 11, 1899. So that the
importation in this case was subsequent to the ratification of
the treaty, but prior to the establishment of a civil
government in the island under act of Congress. It does not
appear that the importers are citizens of the United States or
of Porto Rico, nor whether or not the imported tobacco was the
product of Porto Rico.

"In the case of Fourteen Diamond Rings, it appears that the

claimant, Pepke, is a citizen of the United States and served
as a United States soldier in the Island of Luzon; that while
there he purchased or acquired the rings in question and
brought them into the United States without paying duty
thereon some time in the year 1899, between July 31 and
September 25. The rings were seized, on May 18, 1900, at
Chicago, by a United States customs officer as merchandise
liable to duty which should have been invoiced, and was
fraudulently imported and brought into the United States
contrary to law. An information for the forfeiture of the
rings was filed on behalf of the Government, June 1, 1900, to
which the claimant pleaded. Setting up that at the time he
acquired said property Luzon was a part of the territory of
the United States and that the seizure of said goods was
contrary to the claimant's right as a citizen of the United
States under the Constitution, and particularly under section
2, Article IV, thereof, and he insisted that under Article I,
section 8, Congress is required in laying and collecting taxes
to see to it that all taxes and duties shall be uniform
throughout the United States. To this plea the United States
demurred, and upon hearing of the demurrer, the district court
gave judgment of forfeiture for the Government. This judgment
the claimant has removed into this court by a writ of error."

The contention of the government as set forth in the same

brief, and the main contention of the appellants in the case,
against which the argument for the government was directed,
were partly as follows:

"The Tariff Act of 1897 declares that 'there shall be levied,

collected and paid upon all articles imported from foreign
countries and mentioned in the schedules herein contained, the
rates of duty which are by the schedules and paragraphs
respectively prescribed.' (30 Stat., 151.)

"The Government contends, and the circuit court so held, that

this act applied to merchandise imported from Porto Rico and
the Philippine Islands after their cession to the United
States exactly as it did before; that within the meaning of
the act these countries are to be regarded as foreign,
belonging to but not forming in a domestic sense a part of the
United States.

"That it is within the constitutional province of the

treaty-making power to accept the cession of foreign territory