Making Oncoplastic Surgery Available to More Patients

Removing malignancy while maintaining breast appearance

Following a new breast cancer diagnosis, all Cleveland Clinic breast cancer patients meet with a treatment team that includes not only a medical oncologist, radiation oncologist and breast surgeon, but also a plastic surgeon experienced in breast reconstructive surgery. “The best time to get a plastic surgeon involved is before the initial surgery. We work together to design a surgery that completely removes the cancer and also leaves the patient with a cosmetically pleasing breast,” says Stephanie Valente, DO, a surgeon in the Department of Breast Services at Cleveland Clinic Cancer Center.

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Offered at Cleveland Clinic for about two decades, oncoplastic surgery, which combines lumpectomy with reconstructive surgery, is an option for an increasing number of breast cancer patients. “It’s like artistic lumpectomy,” says Steven Bernard, MD, a plastic surgeon at Cleveland Clinic. “We started by offering oncoplastic surgery to patients with smaller breasts and large tumors and have made oncoplastic surgery a standard treatment approach over the past five years.”

Same-day surgery

The two procedures are performed on the same day which reduces recovery time, minimizes surgical risk and avoids surgery following radiation therapy which can interfere with wound healing. For women who choose breast reduction, radiation is easier on smaller breasts which can reduce the radiation side effects.

About half of Cleveland Clinic breast cancer patients choose some sort of reconstructive procedure, which can include redistributing breast tissue to fill in the area of tissue that was removed, adding implants, making surgical scars less noticeable and reducing the size of the contralateral breast for symmetry. “Our patients are absolutely thrilled with their results. Some have said that they have always wanted a breast reduction and this is a win-win for them.  At the end of their surgery, their cancer is out, and they look as good if not better than they did when they started,” says Dr. Valente.

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Recently, the oncoplastic surgery program has offered “extreme oncoplasty” — removing larger cancers in difficult positions within the breast by lumpectomy — as an alternative to mastectomy. “If a patient has large breasts, we push the boundary beyond the usual 20 percent of breast volume limit. We can remove some portion of the breast and maintain the good form and aesthetic,” says Risal Djohan, MD, Vice Chairman of the Department of Plastic Surgery at Cleveland Clinic.

Surgeons can use 3D technology to plan surgery for extreme oncoplasty procedures and other cases. It helps ensure that all areas of concern are targeted for removal and allows the reconstructive surgeon to determine the best design to rearrange remaining tissue and where to make incisions to reduce scarring.

Close collaboration between breast and plastic surgeons critical

At Cleveland Clinic, breast and plastic surgeons have clinic together in a multidisciplinary space where they can discuss patients and design a plan. “Major medical centers are an ideal place to do oncoplastic surgery,” says Dr. Djohan.

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First, the breast surgeon “learns the unique way to approach cancers in a three-dimensional space, anticipating the amount of breast tissue needing to be removed, and trying to figure out how the breast tissue will come together. I think about things like the size of the cancer compared with the breast size, the breast shape, the position of the nipple and importantly, what does the patient want? Any surgeon can remove cancer; it takes finesse and training to make the breast look good,” says Dr. Valente. Cleveland Clinic offers a variety of training programs for oncoplastic surgery, including the CAST program, Breast Fellowship and Annual Breast Cancer Summit.

Prior to surgery, the breast and plastic surgeons see the patient together and place markings on the breast. “The closer the two of us work, the better our outcomes at both ends — oncological and cosmetic. The tumor is treated better because a larger and therefore safer margin can be obtained while still achieving an ideal appearance,” says Dr. Bernard.

“We learn from each other and come up with new ways to improve both procedures,” he adds.