Essentials for optimizing outcomes in oncoplastic breast reconstruction

Introduction

In the late 19^th century, the radical mastectomy became the gold standard for breast cancer surgery, involving extensive, disfiguring removal of the entire breast, nipple, areola, skin, lymph nodes, and pectoral muscles. This technique prioritized oncologic safety and remained dominant for nearly a century (1). This practice continued until the 1970s and 80s, when clinical trials revealed that lumpectomy (also known as segmental or partial mastectomy) with radiation therapy was equivalent in survival to mastectomy for select patients (2,3). Lumpectomy with radiation therapy became known as breast-conserving therapy (BCT) and marked a turning point in oncologic breast surgery. With the advent of BCT, breast surgeons and plastic surgeons began integrating previously taught techniques in parenchymal rearrangement and tissue redraping into breast reconstruction. This fusion of oncologic breast resection and cosmetic reconstruction was coined “oncoplastic surgery” (4,5).

Since then, oncoplastic breast-conserving surgery (OBCS) has become valued by surgeons and patients around the world due to improved cosmetic outcomes, patient-reported satisfaction, and ultimately fewer reoperations (6,7). Breast conservation has since continued to become more multidisciplinary, regularly involving the expertise of surgical oncologists, plastic surgeons, medical and radiation oncologists, and radiologists. Though OBCS has become more prevalent across the country, access has remained uneven, as it is highly dependent on surgeon comfort and training variability. The American Society of Breast Surgeons now offers an oncoplastic surgery certification, as well as numerous other international surgical organizations that offer oncoplastic breast surgery fellowships (8-10). Similarly, national and international societies have introduced guidelines and curricula to help standardize oncoplastic practices.

The purpose of this narrative review and expert commentary is to provide an overview of considerations for optimizing outcomes in oncoplastic surgery, starting with perioperative counseling and patient selection. Common secondary and revision procedures are reviewed. Furthermore, the authors highlight patient-reported outcomes (PROs) and satisfaction after OBCS.

Patient selection and oncologic safety

A multidisciplinary approach is key to determining which patients may be appropriate for an oncoplastic approach (11). Traditionally, oncoplastic reconstruction was best reserved for moderate to large breasts, given greater amounts of residual breast tissue after extirpation (6). However, the oncoplastic approach may also be suitable for a variety of patient and oncologic characteristics depending on several factors (Figure 1). The size and location of the tumor and size of the breast determine the available options in reconstructive technique and optimal blood supply to the nipple-areolar complex (NAC). Patients must be counseled in the preoperative setting regarding realistic postoperative size and lifted position from radiation, as well as the possible asymmetry once treatment is complete (12). Additionally, oncoplastic surgery is more straightforward for unifocal tumors, dependent on location within the breast and access required by the surgical oncologist (13,14). Other oncologic factors, such as neoadjuvant or adjuvant chemotherapy and neoadjuvant or adjuvant radiation, have impact and must be mapped out with the multidisciplinary team before starting down the OBCS path. For example, neoadjuvant chemotherapy regimens may yield a smaller tumor or complete pathologic response making for a smaller resection. Post-operative radiation nearly always accompanies partial mastectomy, but seeing a patient with prior mantle radiation may impact treatment options or outcomes. Multicentric cancer warrants additional planning but is not a direct contraindication to OBCS. Inflammatory cancers, on the other hand, are often considered contraindication to breast conservation and are better addressed with mastectomy.

Figure 1 Preoperative considerations in OBCS. BMI, body mass index; OBCS, oncoplastic breast-conserving surgery.

The oncologic safety of OBCS has been thoroughly examined. Perhaps most importantly, there is no significant difference in overall recurrence rate with oncoplastic surgery (15). When care is coordinated amongst the multidisciplinary team and coordinated properly, current literature supports that there may be no significant delay in adjuvant therapies (16). This is important to note during perioperative counseling. Furthermore, the effects of radiation must be discussed pre-operatively, namely the unpredictable effect on the breast and associated skin changes which can vary among whole breast irradiation, targeted boost, proton therapy or any number of the study protocols under investigation (17).

Oncoplastic techniques

The approach to oncoplastic breast reconstruction focuses on the following aspects: skin envelope (how the tumor is accessed for extirpation, how the skin will be redraped over the breast mound); parenchymal shaping (where is the defect located and what tissue can be used to close off the dead space); and perfusion (not only perfusion of the NAC but the remaining breast mound to avoid fat necrosis after radiation) (18). When approaching any partial mastectomy defect, no matter how big or small, the first priority is to close off the cavity; otherwise, the parenchyma and skin will collapse in toward the defect and yield a deformity of the breast, as seen in Figure 2. This is completed through rearrangement of residual breast tissue, utilizing foundational concepts in reconstructive surgery such as adjacent tissue transfer, rotation/advancement flaps, and elevation of local flaps, adapted for the vascular anatomy of the breast and chest wall. Oncoplastic reconstruction has been previously defined by level of volume displacement or replacement (18,19).

Figure 2 Clinical example of asymmetry and deformity after breast conservation and secondary procedures in oncoplastic breast reconstruction. This is a 42-year-old woman with right breast cancer in the upper outer quadrant who underwent partial mastectomy and radiation therapy elsewhere. There is resulting scar contracture and focal deformity of the lumpectomy defect as well as whole breast effect with a smaller, lifted position compared to the contralateral breast. Hyperpigmentation is minimal as seen in the preoperative photograph in the upper left panel. Autologous fat transfer with percutaneous scar release was performed for the focal defect as well as transfer to the remaining breast for volume and contralateral mastopexy for symmetry. The postoperative photographs on the right illustrate the improvement in size and contracture of the right breast with one round of grafting as well as the need for mastopexy to optimize symmetry. Placement of fat around the defect is illustrated in the bottom left panel. AFT, autologous fat transfer.

Level 1 volume displacement is considered for closure of parenchymal defects that result from removal of less than 20% of native breast tissue. Glandular reshaping must be adapted to the individual defect and generally consists of minimal undermining of the breast from the fascia and securing the parenchyma with absorbable suture to close the space. Care is taken to avoid tying fat up in the suture to mitigate fat necrosis. Often this requires mobilizing skin and subcutaneous tissue off the parenchyma or breast capsule and trimming the skin around the incision. We find that the ideal candidate is one with minimal ptosis, upper outer tumor location, and small resection, and this technique rarely requires a contralateral procedure upfront. However, asymmetry may result after irradiation lifts the breast position, also observed in Figure 2. Level 2 volume displacement is more common for larger resections, from 20% to 50%, and utilizes concepts from mastopexy and reduction mammoplasty to obliterate the residual dead space. This large volume displacement often involves repositioning of the NAC, as well as more significant skin excision and pedicle development. Tumor location, residual defect, and knowledge of vascular supply to the breast will aid in deciding the appropriate pedicle. Inferior and superomedial pedicles remain the most commonly used, provide reliable perfusion to the NAC and breast mound, and are appropriate for a variety of resections (Figure 3) (6,13,14). The authors routinely perform a symmetry mastopexy or reduction on the contralateral breast at the same time as the index oncoplastic surgery (Figure 4).

Figure 3 Illustration of breast mound pedicles. Tailoring the breast mound pedicle (pink) to the parenchymal resection (yellow) in oncoplastic breast reconstruction. Superomedial (left) and inferior (right) pedicles are the most reliable and can accommodate any resection location except central segmentectomy. Reproduced with permission (18).

Figure 4 Clinical example of primary procedures in oncoplastic breast reconstruction. This is a 44-year-old woman with an invasive ductal carcinoma of the lateral breast, requiring an 8 cm excision. The patient preferred a smaller but proportional breast. Preoperative circumvertical markings are shown in the upper left panel as well as needle-brackets for the lumpectomy. The initial lumpectomy specimen was 255 grams, resulting in a large lateral parenchymal defect that was reconstructed with the inferior extension of the superomedial pedicle (volume displacement). The inferior skin and tissue were wedged out for shaping and the total resection was 359 grams. A symmetrizing mastopexy was performed with resection of 421 grams of the left breast. Reproduced with permission (18).

For partial mastectomies that involve greater than 50% of the native breast tissue or in a less favorable location, volume replacement techniques are useful. As previously discussed in depth by Huang et al. (18), this technique typically involves local perforator flaps for tissue replacement, as shown in Figure 5, including lateral intercostal artery perforator flaps (LICAP), lateral thoracic artery perforator flaps, anterior intercostal artery perforator (AICAP), and thoracodorsal artery perforator (TDAP) or latissimus dorsi flaps. These local flaps, as well as dermal-adipose flaps, hybrid local flaps with fat grafting, and variations of the flaps described above have been previously described in-depth (20,21). As in any reconstruction, distant free flaps from a variety of donor sites remain an option for large defects; however, the authors will consider the value of a completion mastectomy in cases where a free flap is the “best” option for oncoplastic reconstruction. For surgeons typically operating independently, development of a multidisciplinary team with a plastic surgeon may demonstrate benefit by providing patients with the full spectrum of reconstructive options. While other authors have reported placement of breast implant at the time of OBCS (22), it is not routinely part of our practice given the proximity to whole breast irradiation before the implant capsule has fully matured. If that patient has previously placed cosmetic implants, consideration is given to replace or resize prior to radiation treatment if indicated. Breast implants carry a higher rate of complication in the setting of radiation, particularly capsular contracture (23); therefore, a thorough discussion of the expected outcomes and potential need for revision must be included with both the patient as well as the multidisciplinary oncology team.

Figure 5 Illustration of local tissue flaps. Common perforator flaps of the chest wall used in oncoplastic breast reconstruction. The authors’ preferred choice for volume replacement is the LICAP flap. The anterior intercostal or medial intercostal perforators can similarly be used for more medially located defects, though generally carry less volume. The TDAP or latissimus dorsi muscle/myocutaneous flap is an alternative for large defects but takes that option out later if mastectomy is warranted. Reproduced with permission (18). AICAP, anterior intercostal artery perforator; LICAP, lateral intercostal perforator; TDAP, thoracodorsal artery perforator.

Each of the volume displacement and replacement techniques above must consider incision location, parenchymal perfusion, and skin excision as the foundation of the reconstruction. Not only is this important for the aesthetic result and scar appearance postoperatively, but also in consideration of tension on the closure, reducing seroma, and mitigating wound complications or delay in adjuvant cancer treatment. Although some reviews have demonstrated increased rates of delayed incisional healing with oncoplastic surgery compared to lumpectomy alone, seroma rates are lower in OBCS, as are re-excision rates for positive margins (6). This is important to consider, as psychosocial outcomes have been shown to be negatively affected by the need for re-excision. Furthermore, studies have demonstrated that oncoplastic surgery is safe and feasible with proper marking during initial excision (24). Additional techniques to mitigate complications include adequate skin flap thickness, preservation of chest wall perforators, and optimizing modifiable risk factors such as body mass index (BMI), smoking cessation, and glycemic control as best as possible (25-27).

Patient-reported satisfaction and quality of life (QoL)

Overall, the goals of oncoplastic surgery are to minimize long-term deformity after BCT, achieve symmetry, and provide a good cosmetic outcome without impacting the oncologic needs. PROs remain a vital tool for analysis of symptoms, functional status, and expected outcomes around well-being and satisfaction. For example, the BREAST-Q™ is a validated survey tool that queries outcomes regarding psychosocial, sexual, and physical well-being. In addition, there are questions related to satisfaction with specific body parts, as well as the process of having surgery (satisfaction with surgeon, medical team, etc.). This module can elucidate key findings from the patient perspective (28,29). A systematic review and meta-analysis by Lisboa et al. in 2024 compared the degree of satisfaction of patients that underwent BCT with and without oncoplastic reconstruction. Their study demonstrated no significant difference in aesthetic outcomes between the two groups. Furthermore, the degree of satisfaction with oncoplastic reconstruction remained with larger tumor resections, indicating the utility of oncoplasty in both small and large resections (30). Losken et al. (6) completed a meta-analysis in 2014 comparing BCT patients to the oncoplastic technique. Though their review focused on specimen size, re-excision rates, and recurrence, they importantly demonstrated that the oncoplastic group had 89.5% satisfaction with aesthetic outcome compared to 82.9% in the BCT alone group.

Other studies have demonstrated that OBCS provides patients with improved aesthetic outcomes compared to mastectomy with reconstruction. Araújo Pereira Lisboa et al. [2023] compared aesthetic outcomes and QoL of 760 women who underwent “partial reconstruction”, i.e., oncoplastic reconstruction, and those who underwent mastectomy with “total reconstruction”. The oncoplastic group demonstrated significantly higher satisfaction with their breasts, surgical outcomes, psychosocial well-being, and sexual well-being (31). Additionally, these patients reported lower frequency of complications and required fewer surgeries overall to complete their reconstruction. A query of the Texas Cancer Registry comparing long-term outcomes in oncoplastic BCT with mastectomy and reconstruction in early-stage cancers reported statistically and clinically significantly higher psychosocial and sexual well-being scores after BCT (32). An evaluation of outcomes in OBCS conducted by Losken et al. showed significantly increased levels of self-confidence, feelings of attractiveness, emotional health, and satisfaction with sex life 1 year postoperatively (6). Rose et al. similarly found a significantly higher psychosocial well-being among patients who had undergone OBCS compared to lumpectomy alone (33). In a case-matched comparison between OBCS and mastectomy with immediate reconstruction, Kelsall et al. found significantly higher body-image scores and self-rated breast appearance, as well as faster return to work, among OBCS patients (34,35). In a systematic review and meta-analysis in 2024, Lisboa et al. (30) compared patients who underwent breast-conserving surgery with oncoplastic surgery to those without oncoplastic surgery, and found no differences in overall satisfaction with aesthetic result between the two groups. However, the study importantly noted that extreme oncoplasty also demonstrated satisfactory results. This upheld that satisfaction with larger resections is important when considering breast-conserving surgery versus traditional, more radical techniques.

Secondary procedures

Secondary or revision procedures after OBCS are approximately 20% with increased rates in younger patients (under 40 years) or with higher BMI (over 35 kg/m²) (36). Whether it be the result of poor scarring, residual asymmetry, or contour irregularities, additional procedures may be necessary to improve the aesthetic result. Fat grafting and symmetrizing procedures remain among the most common secondary procedures. Incisional scar revisions are relatively infrequent in this population, with reports ranging 1–13% (36). While non-surgical options (i.e., laser) may be utilized, scar excision or local tissue rearrangements are common to improve symmetry, shape, and overall scar appearance (37). Similarly, contralateral symmetry procedures are performed secondarily (38,39).

Autologous fat grafting, sometimes referred to as lipofilling or fat transfer, has become a cornerstone adjunct within cosmetic and reconstructive breast surgery. Adipose is harvested from a donor site such as the abdomen, flanks, or thighs, and is processed, then injected to the breast to enhance both volume and contour. In the context of OBCS, fat grafting may be considered to help restore volume loss, improve symmetry, smooth contour deformities, and potentially improve skin texture and tissue fibrosis after radiation therapy, though these last mechanisms have yet to be elucidated (40-43). Lipoaspirate is harvested via suction-assisted lipectomy followed by washing and filtration either manually or via a closed system (for example, REVOLVE™ Allergan Aesthetics. Puregraft^® Cytori Therapeutics, or Viality™ Tiger Aesthetics). Fat should be injected in small aliquots, avoiding large clumps or boluses of graft and spreading the fat evenly in multiple layers (44). This technique optimizes integration and revascularization of the harvested fat. Different injection planes may also be utilized for different indications in OBCS. The senior author (S.E.H.) uses smaller, subdermal injections for tissue fibrosis and remodeling, while contour from depressed scars requires rigotomies and fanning through multiple layers around the scar (Figure 2). Injection directly to the lumpectomy space or scar is less favorable or predictable and not routinely performed in our practice. Dermal scars and axillary incisions from sentinel node biopsy or axillary lymph node dissections may benefit from mechanically disrupting scar tissue, while encouraging remodeling of surrounding soft tissues better than breast parenchymal scar.

Timing of fat grafting in OBCS has been reported both immediately at the time of partial mastectomy or in a delayed fashion once treatment has been completed. While some authors have reported fat transfer at the same time as the index cancer operation (40), this is not a common practice, and we feel that further long-term outcomes studies are warranted. There has been no evidence to say that fat transfer increases the risk of recurrence or new cancer development in the setting of oncologic reconstruction (45,46); however, fat necrosis rates in BCT are significant with or without fat grafting (47). The success of fat transfer is dependent on neovascularization and radiation to the breast after BCT would generally occur within the engraftment process, thereby damaging the transferred adipocytes and progenitor cells and triggering fibrosis and inflammation in the surrounding macrophages (48-50). Instead, our practice is to use autologous fat transfer as an adjunct in OBCS once radiation is complete. We currently wait until 6 months from completion of radiation, after multidisciplinary review, and obtain new baseline mammogram (41); however, optimal timing after radiation is not well established in the literature. Fat grafting not only promotes neovascularization post-radiation, but has been shown to reduce overall fibrosis, improve skin elasticity, and reduce radiation-induced contracture (51-53). This can be expanded to staged procedures if large volume correction is required, typically with 3–6-month intervals between sessions.

Current literature supports the use of fat transfer in breast reconstruction, citing good patient satisfaction in terms of softness, natural feel, and overall aesthetic contour (54-57). However, surgeons must acknowledge possible complications when considering fat grafting, including unpredictable fat resorption, development of oil cysts, fat necrosis, and the possibility of palpable, visible, and even painful nodularity. Though these nodules are generally benign, patients may be concerned given their previous oncologic history, and further imaging, biopsy, and treatment are warranted (41,58). Furthermore, surgeons and radiologists ought to consider the radiologic findings after fat grafting. Mammography, ultrasound, and magnetic resonance imaging (MRI) are commonly used as diagnostic modalities, and may demonstrate radiologic differences such as fat necrosis, oil cysts, and distortion of the breast parenchyma. It is crucial that identification of these common benign changes is noted to avoid unnecessary biopsies or interventions (59-61).

Conclusions

While oncologic treatment must remain at the forefront of surgical decision making, it does not need to be at the expense of patient-reported satisfaction and well-being. Parenchymal tissue rearrangement, pedicle dissection, and skin excision are all aspects of oncoplastic surgical technique that should be taken into account to improve overall breast cosmesis, contour, and symmetry. Despite improvements in oncoplastic technique, secondary procedures may be required beyond oncoplastic reconstruction given the unpredictable fibrosis that may occur with whole breast irradiation. Oncoplastic surgery is an important set of techniques that optimize patient satisfaction, oncologic outcomes, and aesthetic results. These techniques ought to be strongly considered by all surgeons performing BCT.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Sarah N. Bishop) for the series “Aesthetic Breast Reconstruction” published in Gland Surgery. The article has undergone external peer review.

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-aw-506/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-aw-506/coif). The series “Aesthetic Breast Reconstruction” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this review are case examples for illustration; no clinical research is reported here. Written informed consent was obtained from the patient for use in the publication of this article and accompanying images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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