Oncoplastic breast surgery: a guide to good practice

Key points

• Oncoplastic breast surgery (OPBS) should be considered in all patients who need surgery after a breast cancer diagnosis, and breast reconstruction in all suitable patients for whom mastectomy is recommended.
• Oncological principles always take precedence; immediate autologous reconstruction should still be offered to suitable patients expected to need post-mastectomy radiotherapy.
• Patients should be told that up to 1 in 10 lose their implant in the first 3 months and up to 1 in 4 may need revisional surgery within the first 10 years.
• The guideline sets out enhanced recovery after surgery (ERAS) measures and 19 audited quality criteria, including implant loss below 5% at 3 months.

Overview

These UK guidelines were written by an expert advisory group convened by the Association of Breast Surgery (ABS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) for the whole breast cancer multidisciplinary team (MDT). They are a consensus on the best oncoplastic and reconstructive practice at each stage of care, informed by peer-reviewed publications, and also apply to risk-reducing surgery.

Assessment and timing

Assessment should weigh disease burden, previous radiotherapy, genetic risk, comorbidities (including BMI and diabetes), smoking and lifestyle, together with breast morphology and medical photography. Neoadjuvant systemic therapy may reduce the need for mastectomy. There should be no time limit on delayed reconstruction, but at least 6 months should pass after adjuvant radiotherapy, and waiting more than 12 months may mean fewer complications. Tamoxifen carries a 2.3-fold increased risk of venous thromboembolism; for procedures over 90 minutes or higher-risk patients, stopping it for 3 weeks before surgery is suggested.

Surgical technique

The ABS advises a minimum clear radial margin of 1 mm after breast conservation surgery. Skin-sparing and nipple-sparing mastectomy are contraindicated in inflammatory breast cancer; nipple-sparing mastectomy should be used with caution in smokers and after previous breast or chest wall irradiation, and tissue from the nipple-areolar complex should be sent separately for histology. Volume displacement (therapeutic mammoplasty) and volume replacement with perforator flaps extend breast conservation. Many surgeons regard the deep inferior epigastric artery perforator (DIEP) flap as the gold standard for free autologous reconstruction, with reported failure rates of 2.2% total and 3.1% partial in unilateral flaps.

Implants and follow-up

National 3-month rates after implant-only mesh-assisted or dermal sling reconstruction are 18% readmission, 25% infection, 18% reoperation and 9% implant loss. Breast implant associated anaplastic large cell lymphoma (BIA-ALCL) has occurred 2 to 28 years after implant insertion (average 8 years), most likely presenting as a seroma and mostly with textured implants; breast implant illness is not a medical diagnosis. Bilateral annual mammography is recommended after OPBS, whereas after mastectomy with reconstruction only the contralateral breast is imaged annually.

ERAS and quality

Measures include stopping smoking for at least a month, low molecular weight heparin with intermittent pneumatic compression, opiate-sparing multimodal analgesia with paravertebral block as the first-choice regional technique, and aiming for day-case implant reconstruction and discharge on day 3 after DIEP flaps. Quality targets include breast reconstruction discussed with over 90% of suitable mastectomy patients, total free flap loss below 5% and pedicled flap loss below 1%.

Frequently asked questions

Can breast reconstruction be done years after mastectomy?

Yes; the guideline states there should be no time limit on delayed reconstruction, although at least 6 months should pass after adjuvant radiotherapy.

Do breast implants need routine replacement?

No; modern implants have no specific lifespan and need not be replaced in the absence of concerns, although revision may be needed for adverse symptoms or cosmetic deformity.

How is psychological support provided?

Psychological wellbeing should be assessed at key points, screening tools such as HADS or PHQ9/GAD7 considered, and complex difficulties referred to specialist psychology services.

Source

Gilmour A, Cutress R, Gandhi A, Harcourt D, Little K, Mansell J, et al. Oncoplastic breast surgery: A guide to good practice. Eur J Surg Oncol 2021;47(9):2272-2285. doi:10.1016/j.ejso.2021.05.006. Open access, CC BY-NC-ND 4.0. Guidelines of the Association of Breast Surgery and the British Association of Plastic, Reconstructive and Aesthetic Surgeons. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.