Comparing oncoplastic breast surgeries and mastectomies
When considering treatment options for breast cancer, there are many concerns and considerations that patients will face, including the type of procedure most suitable for them and the cosmetic outcome of this procedure.
Two procedures that are commonly used to treat breast cancer are mastectomies and oncoplastic breast-conserving surgery. Often a breast cancer patient will be offered a full mastectomy or a standard large lumpectomy when an oncoplastic approach could be more appropriate, so we’re going to take a look at these two types of procedures to help you understand how they differ.
In this guide, we will compare mastectomies and the oncoplastic technique across key areas such as patient suitability and recovery, to help you understand which procedure would be better for you.
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A standard, full mastectomy is a process of completely surgically removing the breast tissue and the skin covering it. It is a common breast cancer treatment when the cancer is inflammatory or is widespread throughout the breast. Other types of mastectomy include skin-sparing (where the breast tissue and nipple are removed but most of the skin on the breast is preserved) and nipple-sparing (a skin-sparing procedure in which the nipple isn’t removed). Sometimes breast reconstruction can occur within the same surgery using an implant to restore breast size and shape. When cancer is present in both breasts, a double mastectomy may be necessary.
In early breast cancer cases or when a tumour is not widespread, the cancer tumour can be removed along with a small margin of breast tissue surrounding it in a procedure known as a lumpectomy. A lumpectomy alone risks leaving the breast distorted, and reconstruction is therefore necessary to achieve a good aesthetic outcome.
Oncoplastic surgeries combine tumour removal and immediate breast reconstruction in one operation. The oncoplastic approach uses plastic surgery methods to reconstruct the affected breast, providing either a re-shaping of the affected breast with a lift or a reduction in breast volume, or the replacement of the lumpectomy defect with tissue from outside the breast. The goal of oncoplastic breast conserving surgery is to conserve as much of the natural breast as possible, while maintaining a good shape and symmetry, which many women prefer over a full mastectomy and reconstruction. Plus, it is possible to perform surgery on both breasts to achieve symmetry and a satisfactory appearance.
Many oncoplastic techniques use skin and tissue from the side of the torso beneath the armpit to fill in the gap left by removing the tumour and the surrounding breast tissue. In the LICAP flap, LTAP flap or TDAP flap procedure, for example, the natural tissue taken from the lateral chest wall and back remains connected to its blood flow. The tissue and the blood supply are tunnelled under the skin onto the chest to rebuild the breast.
Oncoplastic breast surgery should be recommended to a breast cancer patient where the tumour can still have a lumpectomy but a standard lumpectomy would cause the affected breast to appear deformed or misshapen. Because these procedures conserve as much natural breast tissue as possible, it is recommended that the patient follows oncoplastic surgery with radiation therapy to reduce the possibility of cancer returning.
Pedicled flap surgeries such as the LTAP flap and TDAP flap are more suited to patients with small to medium-sized breasts where re-shaping of the breast may not be possible. This would be an alternative to mastectomy in some patients. For patients with larger or ptotic (sagging) breasts, a therapeutic mammoplasty would be more appropriate. This procedure does not transplant tissue from elsewhere on the body to rebuild the breast, but rather preserves the breast by removing tissue and skin from the breast in addition to the tumour to provide a smaller, more uplifted shape.
When cancer takes up more than 25% of the breast or there are multiple lumps, oncoplastic surgery may not be possible. In these cases, it can be difficult to achieve a good aesthetic result and it may be more beneficial for the patient’s long-term quality of life to perform a full mastectomy and reconstruction. A mastectomy may be recommended if you if radiation therapy cannot be safely performed after breast surgery.
Oncoplastic breast surgeries tend to be a little easier to recover from than full mastectomies. This is because less tissue is removed and reconstruction is less involved than a total reconstruction using the latissimus dorsi muscle or DIEP flap from the abdomen, for example, so strength in the shoulder and arm will be unaffected.
However, any oncoplastic reconstructive surgery will still be intensive and will require you to rest for several weeks. You will need to avoid strenuous activity for at least six weeks after the procedure and should wear comfortable clothing such as a supportive sports bra throughout recovery. It’s normal to experience bruising, swelling and soreness after breast cancer treatment, and these will gradually ease over several weeks. It will be several months until you see the full results of your surgery as the tissues fully heal and settle down.
Patients can often be discharged from hospital after oncoplastic surgery the day of or one day after the procedure. With a mastectomy, on the other hand, a hospital stay can be up to three days or longer if an immediate reconstruction is performed with the mastectomy. This hospital stay may involve a drip in your arm, drainage tubes and painkillers.
Both procedures require several weeks for wounds to heal, in which patients can experience bruising and feel swollen. With mastectomies, there is a higher chance of arm and shoulder stiffness on the affected side requiring a gentle exercise routine to aid recovery.
Many patients prefer the long-term aesthetic results of oncoplastic breast conservation surgery over full mastectomy. They much prefer the appearance of natural breast tissue compared to implants or deformities following a lumpectomy. Plus, in cases where the surgery involves a breast reduction or lift, they enjoy the added benefit of new or more desirable breast size and shape.
With oncoplastic surgical techniques, the nipple is usually preserved and sometimes relocated. Many patients appreciate this and much prefer it over nipple removal which occurs with a standard or skin-sparing mastectomy.
The scar following a mastectomy and reconstruction are usually more extensive than an oncoplastic procedure. Additionally, breast sensation is retained with oncoplastic surgery whereas a mastectomy will rarely regain normal sensation.
Frequently asked questions
What factors can affect the choice of breast reconstruction method?
The size and location of a tumour, as well as breast size, are some of the most important factors that impact the suitability of reconstruction methods. Additionally, with oncoplastic procedures such as the LICAP flap, the surgeon can plan up to a certain point but cannot perform the surgery if they are unable to locate a suitable blood vessel from which to transplant the tissue for reconstruction.
What factors can affect the timing of breast reconstruction?
Sometimes breast reconstruction can happen at the same time as a mastectomy. However, if radiation therapy is required after a mastectomy, it may be better to opt for a delayed reconstruction so that the radiation therapy does not damage the reconstruction. Sometimes reconstruction will still go ahead even if radiotherapy planned. Radiation can cause shrinkage of breast tissue and affect chest symmetry. Your breast surgeon will be able to advise on when is the right time to have breast reconstruction.
In oncoplastic surgery the reconstruction of the lumpectomy nearly always happens immediately with the surgery. Occasionally it will be split into stages a few weeks apart but always before radiotherapy.
How do surgeons reconstruct the nipple and areola in oncoplastic breast surgery?
A plastic surgeon can usually retain the nipple and areola during oncoplastic surgery. In some cases, the position of the nipple will be adjusted and care is taken to maintain blood supply to minimise the risk of nipple loss.
If you’d like discuss the different reconstruction options available following breast cancer treatment, contact the Stephen McCulley team today.