The diagnosis and management of breast cancer has significantly changed over the last few decades and has moved towards a more conservative approach, especially in terms of the surgical treatment. For about 80 years, radical mastectomy introduced and described by Halstead was the gold standard for surgical treatment of breast cancer, irrespective of the size or type [1]. This was modified by David H Patey, to spare the pectoralis muscle and proceed with a modified radical mastectomy (MRM) [2]. MRM was being widely practiced through the 1960s and 1970s for all sizes of breast tumours until breast-conserving surgery (BCS) proved to be equally oncologically safe to MRM in relatively small breast tumours [3]. BCS was first described by Sir Geoffrey Keynes at St. Bartholomew Hospital in London in 1924 [4]. Following that, the National Surgical Adjuvant Breast and Bowel Project (NSABP) and Milan trials were instrumental in introducing the concept of BCS for early breast cancers (EBC) while looking at the safety and feasibility of BCS. The outcomes of these trials proved the equality in breast cancer-specific overall survival (OS) and disease-free survival (DFS) between mastectomy and BCS in EBC, advocating a less radical and less disfiguring surgical approach [5][6]. Furthermore, the inferior psycho-social outcome and body image concerns in those undergoing mastectomy, fuelled the argument to adopt and improve the conservative approach[7–9]. The trend of BCS varies between 20 and 60% depending on patient eligibility and preference [10–12].In 1980’s, Dr Audrestsch and Dr Krishna B. Clough started incorporating plastic surgery techniques to obviate the disfigurements occurring from wide local excisions (WLE) [13]. The main focus of OPBS is to achieve tumour resection with adequate margins, satisfactory cosmetic outcomes, and improve the quality of life by reducing the psychosocial burden associated with the physical deformation caused by simple BCS, particularly in younger patients [14–16]. OPBS was further described by Krishna Clough and his colleagues in the 2000’s based on the percentage of breast volume excised and type of oncoplastic reconstruction[13][17]. Level I OPBS includes minimal mobilization of breast tissue with or without minimal skin resection where no more than 20% of the breast tissue was resected and Level II OPBS was carried out when over 20% of the breast tissue was resected [18][19]. This was broadly divided into volume displacement and volume replacement techniques[18].
Volume displacement techniques are indicated in patients diagnosed with moderate to large cancers in relatively larger breasts. This involved reconstruction by redistribution of glandular breast tissue into the resection site [16]. A few of the volume displacement techniques described are round block mammaplasty, tennis racket, batwing mammaplasty, and vertical and wise pattern mammoplasty [19]. Most often, it is combined with a contralateral procedure to achieve symmetry. The contralateral procedure can be done simultaneously, avoiding asymmetry and a second procedure [17].
Volume replacement involves reconstruction with autologous tissue from more commonly a regional donor site or less frequent from a distant donor site into the resection area [16]. Volume replacement techniques are performed in women with relatively larger tumor-to breast ratio, keen on breast preservation, potentially avoiding and reducing the rates of mastectomy [16,20]. The pedicled latissimus dorsi myocutaneous flap (LDMF) is commonly done for immediate or delayed reconstruction following mastectomy, with or without an implant or expander [21]. The LDMF was the workhorse for whole breast reconstruction for decades [22]. Then came the mini latissimus dorsi (LD) flap, which is based on the descending branch and was being used to fill in lateral defects of the breast, following BCS [22,23]. In this technique, a part of the LD muscle is harvested, leaving behind the innervation and function of the LD muscle [23]. Considering it can be carried out through an axillary site incision, the back scar is avoided, and the rate of donor site seroma is also reduced [22]. However, the LD muscle cannot be used in further reconstructive or corrective procedures once a mini-LD has been done. The thoracodorsal artery perforator flap (TDAP) was then introduced and being used for reconstruction, particularly for lateral breast defects. This procedure involved harvesting the cutaneous island overlying the LD without raising the muscle. It did not gain popularity due to its anatomic inconsistencies and tedious and unreliable outcomes [24]. The mini LD was popular for years as a part of partial breast reconstruction until the advent of intercostal artery perforator-based flaps [22]. The TDAP is still done in a select group of patients.
A better understanding of the chest wall vascular supply and distribution led to the evolution of muscle sparing fasciocutaneous flaps based on the intercostal artery perforators (ICAP)[25]. The principle of the ICAPs was to raise skin and fat flaps without sacrificing muscle or nerve supply, reducing donor site morbidity [24]. They have become more popular over the years due to their robust vascularity, minimal donor site morbidity, good aesthetic outcomes, and reduced operating time compared to the traditional lattismus dorsi flap (LD)[26]. The lateral thoracic artery perforator (LTAP) flap is commonly used in conjunction with the LICAP or raised on its own pedicle with better mobilisation [27]. ICAP flaps have great potential in breast surgery as they replace the more morbid pedicled flaps for partial breast reconstruction. They also have a reasonably consistent vascular anatomy and provide large volume flaps, thereby assisting in wide oncological resections with satisfactory cosmetic outcomes, without negatively impacting patients [28].
The aesthetic outcomes of OPBS are best when immediate reconstruction is carried out [29]. With delayed corrections, complications are twice higher due to handling of irradiated and scarred tissues [30][31]. OPBS, however, is not suitable for all, particularly in women with fatty breasts, patients with high body mass index (BMI), smokers, women with collagen vascular diseases, and women with diabetes mellitus [32]. However, there is limited data on the use of perforator flaps in these groups. Therefore, the selection process for OPBS should be stringent.
The complication rates reported with OPBS are found to be comparable to BCS, additionally encouraging the use of these procedures[33]. Complications seen with BCS and OPBS such as hematomas, seroma, wound dehiscence, scarring, fat necrosis, and breast edema can be corrected without additional morbidity[34].
The ICAP flap for partial breast reconstruction following BCS permits wider resections and reduces the possibility of margin positivity. The generous flaps provide satisfactory aesthetic outcomes. This also provides room for decreasing mastectomy rates as we get more confident with raising large-volume flaps based on the ICAPs. There is also potential to combine LICAPs and AICAPs to provide more coverage of breast defects, further reducing mastectomy rates and better acceptance with the multicentric disease. A drawback is the time consumed compared to simple WLE. Further long-term studies will need to be performed to know long-term benefits and complications of these procedures.
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Dr. Kirti Katherine Kabeer Consultant Breast Specialist and Oncoplastic Surgery Kauvery Hospital
