Good surgical management is the cornerstone of breast cancer treatment and the restoration of self for patients. With surgical advancements in oncoplastic breast surgery, minimally invasive breast surgery and breast reconstruction, patients can now look forward to better cosmetic outcomes and quality of life.

INTRODUCTION

Breast cancer is the most common cancer affecting women in Singapore and the world. Much thanks to the international community’s efforts driving advancements in innovation and research, breast cancer therapy is one of the most rapidly evolving fields in medical and surgical practice, and personalised tailored treatment is the prioritised concept in the modern day.

THE FOCUS OF MODERN-DAY BREAST SURGERY

Oncological surgical resection, safety, function and aesthetics are now viewed as integral components of comprehensive breast surgical care. As the field of breast surgical oncology has evolved, surgeons have largely abandoned extensive disfiguring resections as standard therapy.

In its stead, modernised techniques now favour:

• Breast preservation
• De-escalation of axillary surgery
• Whole and partial breast reconstructions
• Mindful prophylactic measures to avoid long-term complications

This means respecting the value of scar minimisation, cosmetic optimisation and preservation of function in our surgical planning.

1. Oncoplastic breast surgery

Breast conservation concerns in the past

Oncoplastic breast surgery (oBCS) was revolutionary in the efforts towards breast conservation.

Before the evolution of oBCS, it was believed that the upper limit of reasonable resection was a mere 10% before a cosmetic deformity would result. That made for a very low threshold that pushed a good proportion of patients away from a breast conservation surgery (BCS) and towards mastectomy.

When BCS was introduced, the average five-year survival rate was about 65% (1940s to 1980s). Survival was the primary goal of treatment at the time, and it was commonly believed that cosmetic breast preservation was unachievable with what was considered an adequate cancer operation.

The emotional impact of losing a breast can be overwhelming. It induces trauma, disrupts the sense-of-self and sexual functioning (Figure 1).

Breast conservation today

The five-year age-standardised survival rate for breast cancer in Singapore is now 82.1%, and there is a definite expectation of long-term survival.

In addition, we are now certain that both aesthetic and functional outcomes contribute towards overall patient satisfaction, and are considered major determinants of quality of life.

oBCS increases the proportion of patients eligible for BCS, and considers cosmetic outcomes individualised to patient-tumour morphology, cancer biology and patient choice.

What is oBCS?

By definition, oBCS is a ‘tumour-specific, partial and immediate breast reconstruction method that applies aesthetically derived volume displacement, volume replacement or volume reduction techniques to the field of breast cancer surgery, to allow for higher volume excision with minimal aesthetic compromise’.¹

Types of oBCS

As an overview, the types of oncoplastic breast procedures can be thought of as:

1. Conventional BCS, but with thoughtful and favourable scar placement and orientation. Examples include incisions placed discretely at the edge of the areolar (periareolar), through the nipple base, in the bra line (inframammary fold) or underarm (axillary).

2. Volume displacement oBCS or reshaping procedures that transpose a dermoglandular flap of breast tissue into the defect site (e.g., mastopexy and mammoplasty) (Figure 2).

3. Volume reduction oBCS techniques when the removal of excessive parenchyma can result in an aesthetic or quality of life benefit (i.e., the reduction mammoplasty) (Figure 2).
    

4. Volume replacement oBCS which includes autologous tissue flaps or implants to correct the partial mastectomy defect (e.g., intercostal artery perforator flap, thoracodorsal artery perforator flap, latissimus dorsi flap or omental flap reconstruction) (Figure 3).
     

5. Complimentary contralateral breast symmetrisation, fat grafting (lipofilling), nipple-areolar tattoo or reconstruction and other cosmetic corrections are now regarded as vital components of our repertoire.

‘Levels’ have also been assigned to describe the spectrum of oncoplastic surgical techniques, according to the volume of tumour removed and to reflect the complexity of the reconstructive procedure required (i.e., level 1 comprises resection volumes less than 20% and level 2 around 20% to 50%).

Benefits of oBCS

1. Surgical safety:
   The oncological safety of oBCS has been widely established in terms of disease-free outcomes and overall survival. Complication rates were once thought to be higher, but with experience and time are now recognised to be comparable to BCS, and preferable to a mastectomy.

2. Good cosmetic outcomes:
   Good cosmetic outcomes, reported in more than 80% to 90% of patients, have contributed to quality survivorship. Complementing this is a strong collective of studies reinforcing the importance of quality of life in terms of vitality, self-esteem, social functioning and emotional and mental health.

The place of oBCS today

The lessons we have learnt as a community practicing oBCS have been invaluable. Ultimately, one can say that regardless of whether specialised techniques are indicated or otherwise, all breast surgeries ought to be oncoplastic in nature, permeating our practice right down to a cosmetically-optimised simple mastectomy.

2. Minimally invasive breast surgery

What it is

Minimally invasive breast surgery (MIBS) evolved in tandem with oBCS to push conventional boundaries of aesthetic outcomes. It utilises endoscopic-laparoscopic instruments or robotic surgical platforms.

On this journey towards the holy grail of discrete resection-restoration, the fundamentally unshakable tenets of practice are:

1. En-bloc resection (as opposed to fragmentation of the specimen which compromises oncological safety)

2. Surgical safety

Beyond this, there is no ceiling to creativity and artistry.

Initially utilised mainly for mastectomy (whole breast resection), more surgeons have been moving towards the application of MIBS in BCS (partial breast resection).

Benefits of MIBS

1. For the surgeon, the use of a camera and endorobotic instruments allows for improved visualisation, agility and precision in dissection and haemostasis.

2. But the most obvious advantage of the minimally invasive endoscopic or robotic techniques is that the surgeon is empowered to make smaller inconspicuous incisions that can even be sited off the main mound of the breast.

3. Planning an off-the-breast scar placement is not just purely aesthetic. Smaller inconspicuous incisions cause minimal scarring, less postoperative pain and greater patient satisfaction, and wound complications are said to be rare events.

Because the breast skin and nipple-areolar complex (NAC) remain surgically unaltered and a scar is potentially not found on the breast itself in a direct face-on manner, we have had patients who were very happy to report that the resultant natural effect could even allow them to forget that breast surgery, or even breast cancer, was once a part of their lives (Figures 4 and 5).²

BREAST RECONSTRUCTION

For any patient facing a mastectomy, skin and NAC preservation and consideration of breast reconstruction are requisite therapeutic components. The NAC represents a geometric and aesthetic focal point of the breast, and the breast itself retains significant psychoemotional importance to most women.

NAC preservation

Although we were once more conservative, there is increasing community consensus that the nipple-sparing mastectomy (NSM) can now be performed for any tumour of any size that does not involve the skin or NAC directly, independent of axillary status.

The main remaining contraindications to nipple and/or areola preservation are:

• Clinical signs of nipple involvement
• R1 resection at the nipple margin
• A positive retroareolar margin

Breast reconstruction

The community also recognises that autologous reconstruction establishes enduring natural aesthetics and tactile results.

The abdominal-based free perforator flap (e.g., deep inferior epigastric perforator [DIEP] flap), has edged itself as the preferred reconstruction method. It allows close to ideal breast defect restoration, while also minimising abdominal donor site morbidity since the ‘free’ DIEP flap spares the underlying rectus abdominis muscle (Figure 6).

Alternative flaps such as those listed below continue to provide the suitable individual niche benefits:

• Superficial inferior epigastric artery

• Profunda artery perforator

• Transverse rectus abdominis myocutaneous (TRAM)

• Latissimus dorsi (back)

• Gluteal artery (buttock)

• Upper gracilis (thigh)

• Omental (intra-abdominal adipose) flap

Prosthetics and other procedures

Prosthetics (breast implants) and adjunctive procedures continue to provide options for patients who present with challenging clinical scenarios or unavailable or inadequate abdominal donor sites, or as a component of patient choice.

CONCLUSION

Breast cancer is a complex disease that is multifactorial in aetiology and threatens life, function and identity. While therapy is ultimately multidisciplinary, good surgical management remains the cornerstone of locoregional management and restoration of self.

Multidisciplinary collaborative efforts and more effective treatments are continually evolving through research and clinical trials. As breast surgeons, we hold ourselves responsible for the guidance of decision making, coordination, communication, widening our collaborative efforts and seeking continual self-improvement in order to reach the ultimate goal of optimal recovery for every patient.

REFERENCES

1. Bertozzi N et al. Oncoplastic breast surgery: comprehensive review. Eur Rev Med Pharmacol Sci. 2017 Jun:21(11):2572-2585. PMID 28678328
2. Ngaserin S, Wong AW, Leong FQ, Feng JJ, Kok YO, Tan BK. A Preliminary Experience of Endoscopic Total Mastectomy With Immediate Free Abdominal-Based Perforator Flap Reconstruction Using Minimal Incisions, and Literature Review. J Breast Cancer. 2023 Apr;26(2):152-167. doi: 10.4048/jbc.2023.26.e10. Epub 2023 Mar 13. PMID: 37051645; PMCID: PMC10139846.

Assistant Professor Sabrina Ngaserin, a Consultant Breast Surgical Oncologist, is the Head of Breast Surgery at Sengkang General Hospital’s Breast Service. Her main interest lies in cutting-edge breast cancer surgical techniques that consider the patient’s disease alongside their need for aesthetic surgical solutions. She is particularly passionate about oncoplastic and minimally invasive breast surgery, tailoring ‘off-the-breast’ and ‘minimal-access’ incisions to provide the illusion of ‘nearly scarless’ breast resections. These practice principles prioritise not only disease eradication but also physical restoration, and optimise mental wellbeing and overall quality of life for cancer survivors.

GPs can call the SingHealth Duke-NUS Breast Centre for appointments at the following hotlines or click here to visit the website:

Singapore General Hospital: 6326 6060
Changi General Hospital: 6788 3003
Sengkang General Hospital: 6930 6000
KK Women’s and Children’s Hospital: 6692 2984
National Cancer Centre Singapore: 6436 8288