Dr Johan van Heerden explains what oncoplastic surgery is and how it results in getting your tailor-made breast.
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Each woman sees her breasts in a unique way, and expectations may differ vastly among women being diagnosed with breast cancer. Not only is every woman’s journey unique, but also the options that are available; even if you choose not to have any form of reconstruction after breast cancer surgery.
Bernard Fisher is credited for pioneering the concept among surgeons that breast cancer isn’t only a surgical disease. Since the 80s, breast cancer surgery has become less and less radical, starting an era of breast conservation surgery and oncoplastic techniques.
Why breast reconstruction?
The breast is the most important external identification of femininity. Loss of a breast can have devastating psychological effects on a woman. If you have lost a breast through cancer, you may feel self-conscious, insecure, inferior to other women, or undesirable. Key benefits of breast reconstruction are improved body image, self-esteem, sexuality, and quality of life.
What is oncoplastic surgery?
The idea of combining cancer and reconstructive surgery slowly gained popularity over the past 40 years. Although not a new concept, it’s not applied yet in every surgical procedure. Teamwork and planning make it possible today to formulate a unique breast surgery plan for every patient. The emphasis is a tailor-made plan, according to the oncological requirements, your (patient) wishes, and the surgical team’s abilities.
Oncoplastic surgery not only includes reconstruction of partial or lumpectomy defects, but also volume replacement techniques, in the case of mastectomies.
Different oncoplastic surgical approaches
The essential role of multi-disciplinary team management of breast cancer patients can’t be emphasised enough. This is the starting point and whether upfront surgery or neo-adjuvant therapy is indicated. A detailed consultation with the surgical team is imperative to establish the plan for the future.
It’s important during consultation that the surgical team discuss the indications for lumpectomy or mastectomy with you and that you are well-informed of all the pros and cons of the planned surgical procedure.
Very few patients nowadays prefer delayed reconstruction, and quality of life studies have shown that immediate or immediate-delayed reconstructions perform the best.
From the reconstruction perspective, the planning starts with the oncological procedure, even if only an expander is inserted, or the incisions are planned for future second stage procedures.
Preservation: the modern approach
The modern approach to breast cancer surgery and reconstruction prioritises oncological management. Preservation of skin, the nipple-areola complex and breast volume are fundamental considerations in the initial planning of the surgical procedure.
Whether the volume loss is replaced with your own tissue or with an implant should form part of the initial informed consultation. Most patients qualify and benefit from single-stage procedures like nipple- sparing mastectomy and lumpectomy with immediate reconstruction.
Reconstructive options post-breast cancer surgery
1. Immediate
a. Direct to implant
b. Free DIEP or TRAM flap
c. Pedicled latissimus dorsi muscle with or without implant
d. Goldilocks procedure
e. Intercostal perforator flap
f. Thoracodorsal perforator flap
g. Immediate nipple-areola reconstruction
2. Immediate-Delayed
a. Expander immediately, implant delayed
b. Expander immediately, DIEP/TRAM flap delayed
c. Expander – implant-fat grafting
d. Fat-grafting only
e. Nipple-areola reconstruction in second stage
3. Delayed
a. Expander first stage, implant second stage
b. Free DIEP flap
c. Pedicled latissimus dorsi muscle with expander/implant
d. Thoracodorsal perforator flap
e. Free DIEP or TRAM flaps
f. Fat grafting
g. Nipple-areola reconstruction
Future articles will focus on the various oncoplastic surgery options for breast cancer.
MEET THE EXPERT – Dr Johan van Heerden
Dr Johan van Heerden is a plastic and reconstructive surgeon based at Cintocare Hospital, Pretoria and is part of the multi-disciplinary breast cancer team at Life Groenkloof Hospital. He recently passed the Certificate of Competence in Breast Cancer with The European School of Oncology.
Header image by Freepik
