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BACKGROUND

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The progressive evolution of conservative approaches to breast cancer has been influenced over the years by the development of advanced screening programs that have allowed for early diagnosis of the tumors and increasing use of preoperative chemotherapy in patients with locally advanced breast cancer. Mainly, four steps characterize the conservative approach: breast conservation, axillary lymph node conservative dissection (e.g., sentinel node biopsy), minimal breast irradiation, and breast reconstruction. This great revolution began in the early 1970s with the advent of quadrantectomy procedure which has led to the actual multidisciplinary approach with which breast lesions are managed in breast nits by dedicated teams composed of breast surgeon, plastic surgeon, radiologist, pathologist, clinical oncologist, physiotherapist, psychooncologist, and clinical geneticist who synergically discuss and choose the appropriate treatment to individual patients.1-3

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Oncoplastic surgery represents the combined approach of plastic surgery procedures with breast-conservation therapy to achieve better cosmetic results without compromising complete tumor extirpation.4-6 The purpose of this chapter is to expose many of the principles, concepts, and techniques of oncoplastic breast surgery.

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TYPES OF DEFECTS (CLASSIFICATION)

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The approach to repair immediate defects following breast conservative surgery varies by the volume of resection and tumor location. Different authors, to facilitate management and predict postoperative outcomes, have defined a classification of post–breast conservation surgery (BCS) defects. Clough et al7 proposed a bilevel classification system based on volume of breast tissue excised to practical guide of oncoplastic surgery techniques: type 1 defects less than 20% of breast volume excision, possibly managed by breast surgeons without specific training in plastic surgery; type 2 defects of 20% to 50% of breast volume excision, requiring a two-team approach with both breast and plastic surgeons, or breast surgeons with specific training in oncoplastic surgery. The location of tumor is a second most common way to classify post-BCS defects. Even if some authors have assigned numbers to specific areas of the mammary gland,8 traditionally the breast is divided into four quadrants: superolateral, superomedial, inferolateral, and inferomedial. Among these areas, specific quadrants are more favorable locations for good aesthetic results, while other quadrants are at the higher risk of deformity following BCS. Excisions of superolateral quadrant of the breast are less likely affected by poor aesthetic outcomes, while resections of tissue from superomedial quadrant often expose to major risk of breast deformity. However, in relative terms, location and size of tumor excision must always be compared to the size of the breast in order to correctly evaluate the final cosmetic impact of BCS. Appropriately, the larger the breast, the more easily it tolerates larger resections; small to medium breasts show lower compliance to accommodate increasing resection volumes than larger breasts. If immediate reconstruction is not performed in cases with unfavorable locations, different breast deformities will finally impair the aesthetic outcome. Berrino et al9 classified post-BCS deformities into four types: type 1, displacement of the nipple-areola complex; type 2, localized deficiency of ...

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