In performing a wide local excision (WLE) for a breast tumour, sometimes it is necessary to use so-called oncoplastic techniques to achieve a better cosmetic outcome while still being able to adequately remove the tumour. “Onco” refers to cancer as these techniques are used most often in removing a tumour from the breast while “plastic” refers to borrowing from plastic surgical techniques for breast reduction (mammaplasty) and breast lift (mastopexy).
The most common techniques used are highlighted below. It is important to note, however, that the technique of choice depends on multiple factors including breast size and density, degree of ptosis (how far down the breast sags), tumour size and surgical expertise. Below is a list of the most commonly used techniques:
This involves making two circular incisions around the areola, dissecting under the skin towards the tumour. It is a versatile technique for all breast quadrants.
This involves making two radial incisions from the areola which meet towards the upper outer quadrant of the breast. The incision may be extended into two circular incisions similar to the doughnut mastopexy. Suitable for tumours located in the upper outer breast.
This involves a circular incision at the top of the areola with an extended incision around this in the shape of two wings. It is suitable for central upper breast tumours.
The incision is J-shaped along the lower outer part of the breast extending into the infra-mammary crease (the skin crease under the breast). This is suitable for lower central breast tumours.
A vertical scar mammaplasty is a versatile breast reduction technique which involves two circular incisions around the areola with a V-shaped incision extending from this areolar incision towards the tumour.
This is where a typical breast reduction (Wise) pattern is used. It is a versatile technique but involves the most tissue rearrangement. It may require a post-operative drain and is usually performed together with a similar reduction pattern on the opposite side for symmetry.
Fast from midnight for a morning procedure OR from 7am for an afternoon procedure.
If your procedure includes a sentinel node biopsy, you will be booked for a lymphoscintigram – on the morning of surgery for an afternoon procedure, or the afternoon before for a morning procedure.
If you require placement of a guidewire, this will be done one to two hours before your procedure. It will be co-ordinated with your lymphoscintigram if you require both.
You will be informed of your admission time which will depend on the above procedures.
The surgeon will draw markings over your breast in the holding bay or anaesthetic room. These markings are sometimes best drawn with you standing up or sitting upright which is why it is done before you are put under anaesthetic.
Risks of surgery
There is a small risk of bleeding which usually settles spontaneously.
There is also a small risk of infection which is further reduced by the administration of antibiotics at the time of surgery.
Up to 10% of patients may have a positive margin when examined under the microscope.
This usually requires further surgery – either removing more tissue or sometimes a mastectomy.
You can usually go home the same day unless the technique used involved a breast reduction or symmetrizing surgery to the opposite breast. This may require you to stay overnight.
Pain is usually minimal following a wide local excision but may be more significant after more extensive oncoplastic surgery.
You should take regular Panadol (as long as there are no medical reasons for you not to take it such as an allergic reaction or liver disease).
Non-steroidal anti-inflammatory medication such as Neurofen and Voltaren can also help with pain and inflammation but should be taken on a full stomach. Take these for the first 3-5 days as required.
Stronger pain killers such as opioid anaelgesics (Endone, Codeine) are usually not required and should be taken sparingly as they can cause constipation.
The wound is dressed with Dermabond glue which is waterproof. The glue feels hard which is normal. It sheds off over the 2-3 weeks.
Most wide local excisions do not require drainage. However, some patients may require placement of a drain tube following more extensive oncoplastic techniques such as a breast reduction.
You will be followed up within 1-2 weeks of your surgery to review the wound and discuss your pathology results.
Your follow up appointment is usually made for you prior to discharge.