Introduction
Breast cancer is the most commonly diagnosed malignancy in women worldwide [1, 2]
and in the twentieth century, mastectomy was the primary surgical treatment for breast
cancer patients. Advances in breast-conserving surgery (BCS) propelled a change in
treatment rational from “maximum tolerable” to “minimum effective” therapy. Oncoplastic
breast surgery aims to restore the shape of the breast and has been widely adopted
since the past decade. Although the cosmetic outcome has been significantly improved,
the scar remaining on the surgeried breast skin is still a major pitfall that urges
urgent consideration. In this editorial, we review a series of techniques that can
be incorporated in oncoplastic breast surgery to minimize scarring, signifying the
beginning of an era for scarless oncoplastic surgery.
A brief history of breast surgical oncology
The Halstedian theory proposed that breast cancer developed in situ while its metastasis
developed in contiguous patterns via the lymphatic system. If the lymph nodes that
act as barriers were compromised, tumor cells were to then move into blood vessels,
causing distant metastasis [3]. Based on this theory, (modified) radical mastectomy
was proposed as the standard surgical treatment for breast cancer patients throughout
the first half of the twentieth century. The rationale behind this proposal was that
the eradication of tumor cells was more likely with more expansive resection of the
surgical region. In the 1960s, Bernard Fisher conducted a series of basic and translational
studies which suggested that tumor cells had no orderly pattern of metastasis. Breast
cancer cells might spread into the blood vessels at an early stage even in the absence
of lymph node metastasis [4, 5]. According to Fisher, the occurrence of distant metastasis
is determined by the complex host-tumor interactions (alternative hypothesis) [6].
Based on this theory, BCS was proposed and has been proven to be oncologically safe
in a series of multicenter randomized controlled trials [7–9]. BCS can significantly
improve the cosmetic outcome as well as the quality of life (QoL) of breast cancer
patients. However, due to the amount of tissues removed, the breast that received
traditional BCS might not be symmetric to the contralateral one, which compromises
the cosmetic outcomes in some patients. For example, Clough et al. [10] reported that
“bird’s beak” deformity is usually observed in breast cancer patients with tumors
located in the lower pole of the breast. Thus, oncoplastic breast surgery that integrates
techniques of breast surgical oncology with plastic surgery was proposed in order
to improve the cosmetic outcome of breast cancer treatment. Oncoplastic breast surgery
includes two different approaches: volume displacement and volume replacement [11].
The volume displacement approach utilizes glandular reshaping, tissue approximation
or reduction mammoplasty to make up for defects resulting from tumor extirpation.
Clough et al. [10] had proposed oncoplastic BCS techniques in a quadrant per quadrant
atlas, which were shown to be safe and had been widely used in clinical practices
[12, 13]. On the contrary, the volume replacement approach utilizes silicone implants
or autologous tissue flap to reconstruct a new breast.
Over the past century, the overall trends of breast cancer surgery were not only to
reduce the resection region (mastectomy to BCS) but also to focus more on its cosmetic
outcomes (BCS to oncoplastic surgery). Oncoplastic surgery is the current standard-of-care
for the surgical treatment for early-stage breast cancer patients worldwide. However,
oncoplastic surgery is sometimes associated with significant scarring, which may be
a painful and undesirable remembrance for breast cancer patients about their traumatic
experience. To conquer the final miles of this ongoing enhancing post-cosmetic-cancer
recovery marathon, we hereby propose a scarless oncoplastic breast surgery approach.
Definition
The scarless oncoplastic breast surgery is defined as an oncoplastic surgery that
uses modified techniques to minimize scarring on the breast. This scarless strategy
can be applied in both the volume displacement and volume replacement approach.
Scarless strategy in volume displacement approach
Clough et al. [10] reported an excellent summary of oncoplastic BCS in different quadrants.
However, most of the approaches might lead to significant scarring on the breast.
Scarless oncoplastic BCS can be used to minimize surgical scars for tumors located
in different quadrants of the breast. For tumors located in the upper inner quadrant
or upper pole of the breast, a rotation glandular flap can be used with a semi-nipple-areolar
incision to minimize the scarring (Fig. 1). Our approach is different from the one
reported by Massey et al. [14]. For tumors located at the upper outer quadrant, endoscopic-assisted
BCS can be applied, as Takahashi et al. [15] previously reported, describing that
this procedure would simply leave a semi-nipple-areolar incision scar on the breast.
Alternatively, the round-block technique [16] can be considered for upper quadrant
breast tumors (Fig. 2).
Fig. 1
Atlas of scarless oncoplastic breast-conserving surgery. a1, b1 The location of the
tumor, as well as the planned excision region, were marked on the skin of the breast,
and a semi-peri-nipple-areolar-complex incision was done to remove the tumor-containing
specimen. a2, b2 A lighted retractor is useful for the excision. The surgical margin
assessment was performed as a standard-of-care practice. a3, b3 The superficial layer
of the upper outer quadrant of the breast was undermined through a semi-peri-nipple-areolar-complex
incision and the axillary incision that was made for sentinel lymph node biopsy. The
corresponding retro-mammary space was not undermined completely. Usually, one-third
to half of the retro-mammary space is undermined. a4, b4 The upper outer quadrant
of the breast tissues were then rotated medially into the cavity. a5, b5 The scar
of this procedure can be minimized with satisfactory cosmetic outcome. The atlas (a1–a5)
was produced by Dr. Yinuo Huang; the surgery was performed by Dr. Erwei Song and Dr.
Kai Chen; the photographs were provided by Dr. Kai Chen, with consent obtained from
the patient
Fig. 2
Atlas of round-block technique for oncoplastic breast-conserving surgery a, b Pre-operation
marking of the incision, as well as the peri-NAC area for de-epithelialization. c
De-epithelialization of the planned area. d, e Removing the tumor-containing specimen,
and re-approximate the residue breast glands. f Post-operative photograph of the patient.
The surgery was performed by Dr. Fengxi Su and Dr. Jiannan Wu with consent obtained
from the patient
Scarless strategy in volume replacement approach
Immediate silicone implant-based breast reconstruction after nipple-sparing mastectomy
(NSM) is an important volume replacement strategy. We had previously reported the
oncological safety of NSM [17]. Several types of incisions can be used in NSM, including
periareolar incision with lateral extension, italic S incision on the upper outer
quadrant, and inframammary fold incision [18]. However, all of these incisions might
again leave significant scars on the breast. With the help of endoscopic technique,
NSM can be performed through a single axillary incision made for axillary surgery,
which is able to significantly minimize the scarring on the breast (endoscopic nipple
sparing mastectomy, ENSM technique). Lai et al. [19] reported their preliminary results
of ENSM, suggesting its oncological safety while Du et al. [20] reported in a prospective
non-randomized study that patients who underwent ENSM were more satisfied with their
cosmetic outcomes as compared to those who underwent the traditional BCS.
There are a variety of options available for immediate breast reconstruction after
ENSM besides silicone implant. Satake et al. [21] reported a novel technique that
uses multistage fat grafting after ENSM for breast reconstruction. We had also confirmed
the efficacy and feasibility of latissimus dorsi muscle (LDM) flaps after ENSM [22]
(Fig. 3). Deep inferior epigastric perforator (DIEP) flap is a free flap that has
much more advantages over pedicle flaps for breast reconstruction. To further improve
the cosmetic outcome, NSM that preserve the nipple-areola complex (NAC) can be used
for DIEP flap breast reconstruction. Fujimoto et al. [23] reported that NSM was oncologically
safe for DIEP flap breast reconstruction as long as their respective pathology examinations
confirmed the absence of tumor cells in the subareolar tissue. However, a skin paddle
that serves as a window for post-operative monitoring of arterial ischemia or venous
congestion of the flap, is often needed even if the NSM technique was used [24]. To
significantly reduce the scar on the surgeried breast, Frey et al. [25] placed an
implantable Doppler probe around the arterial and/or venous anastomoses, so as to
omit the need of a skin paddle. In a retrospective study, they reported that the flap
failure rates (2.0% vs. 2.3%) and re-operative rates (6.0% vs. 4.7%) were similar
between patients with and without a skin paddle after DIEP flap breast reconstruction
with NSM [25]. In fact, skin paddles and/or implantable Doppler devices are not necessary
for experienced surgeons. Levy et al. [26] “buried” the flap without any skin paddles
after DIEP flap breast reconstruction with NSM, and performed the surveillance by
transcutaneous Doppler and clinical observation, e.g. drainage, skin color and breast
volume. Their clinical outcomes were satisfactory. Similarly, we routinely performed
DIEP flap breast reconstruction with NSM without any skin paddles or implantable Doppler
surveillance, and the patients’ satisfaction is good (Fig. 4).
Fig.3
Endoscopy assisted nipple-sparing mastectomy to minimize the scar. ENSM with immediate
breast reconstruction using pedicled latissimus dorsi muscle flap (LDM flap). a1 Pre-operative
photograph of the patient. b1 200–250 cc of lipolysis fluid was injected subcutaneously,
and liposuction was performed 5 min after the injection. b2 After liposuction, single
port endoscopy was done and the subcutaneous space was established. Cooper’s ligament
and breast ducts under the NAC were identified. b3 The retro-mammary space was undermined.
c1 Lateral border of the LDM flap was elevated. c2 The subcutaneous layer was undermined,
and special attention was paid to preserve as much fatty tissues as possible. c3 The
LDM flap was elevated. c4 The thoracodorsal nerve was dissected after the LDM flap
was isolated. d1, d2 Post-operative photographs showing no scars on the breast and
the back. The surgery was performed by Dr. Erwei Song and Dr. Kai Chen. The photographs
were provided by Dr. Kai Chen, with consent obtained from the patient
Fig. 4
Nipple sparing mastectomy(NSM) with the burried DIEP flap breast reconstruction. DIEP
flap reconstruction after NSM with the peri-NAC incision. a1, a2 Pre-operation marking
of the incision, the contour of the breast, and the flap. b1 NSM was performed, and
the breast tissue was removed via the peri-NAC incision. b2 The second to third intercostal
space was exposed. c1, c2 The DIEP flap was harvested, and the anastomoses of the
right deep inferior epigastric vessels to the right internal mammary vessels were
performed. d1 Post-operative photograph of the patient. The surgery was performed
by Dr. Shunrong Li, Dr. Liling Zhu and Dr. Erwei Song. The photographs were provided
by Dr. Liling Zhu, with consent obtained from the patient
Unsolved riddles for the future
Although there have been advancements in improving the post-surgery cosmetic outcomes
of breast cancer patients, the scar left, no matter the age of the patient, still
have repercussions on the patient QoL [27, 28]. There are still several unanswered
issues that still need to be further examined before scarless oncoplastic breast surgery
can be widely incorporated into clinics or guidelines. First, the eligibility of patients
for each scarless oncoplastic surgery needs to be further addressed. For instance,
ENSM with liposuction might not be performed for large tumors, or tumors in close
proximity to the subcutaneous layer. But the detailed criteria needs further investigations.
Magnetic resonance imaging (MRI) examination might be needed to screen for eligibility
prior to ENSM. Second, the oncological safety and cosmetic outcomes should be fully
assessed in prospective, multicenter, randomized clinical trial. The underlying oncological
safety is considered as the most important prerequisite for scarless oncoplastic surgery.
Evaluation methods using standardized criteria such as relapse-free survival, disease-free
survival and overall survival can be used, however, the basis for evaluating its cosmetic
outcomes remained varied among different studies. A standardized method like Breast-Q
[29] is needed to ensure that the assessment of cosmetic outcomes is comparable between
institutions. Third, the development of novel biomedical techniques such as robotic
surgery may further facilitate scar less operative strategies. Post-operative treatments
such as taping, silicone gel and moisturizing have been demonstrated as optional prevention
methods for hypertrophied scar formation [30]. Other treatments such as oils, lotion,
laser therapy, massage therapy, radiotherapy, and more, are still being investigated
for their potential as post-operative treatments to minimize scar formation [30].
Over the past century, surgical treatment of breast cancer has evolved towards a better
cosmetic outcome, from mastectomy to BCS, and now to oncoplastic surgery. Improving
cosmetic outcomes have been found to be associated with improved QoL for breast cancer
survivors. Although oncoplastic surgery is successful in restoring the shape of the
original breast, the scars are the final mile of this marathon that remain to be solved
for optimizing the oncoplastic treatment of breast cancer.