Good surgical management is the cornerstone of breast cancer treatment and the restoration of self for patients. With surgical advancements in oncoplastic breast surgery, minimally invasive breast surgery and breast reconstruction, patients can now look forward to better cosmetic outcomes and quality of life.
Breast cancer is the most common cancer affecting
women in Singapore and the world. Much thanks to
the international community’s efforts driving advancements
in innovation and research, breast cancer
therapy is one of the most rapidly evolving fields in
medical and surgical practice, and personalised
tailored treatment is the prioritised concept in the modern day.
Oncological surgical resection, safety, function and
aesthetics are now viewed as integral components
of comprehensive breast surgical care. As the field of
breast surgical oncology has evolved, surgeons have
largely abandoned extensive disfiguring resections as
In its stead, modernised techniques now favour:
This means respecting the value of scar minimisation, cosmetic optimisation and preservation of function in our surgical planning.
Today, breast cancer surgery that optimises quality of life can be better achieved by principle of two broad
groups of surgical skills that surgeons have embraced in a complementary manner:
1. Oncoplastic breast surgery
2. Minimally invasive breast surgery
Breast conservation concerns in the past
Oncoplastic breast surgery (oBCS) was revolutionary
in the efforts towards breast conservation.
Before the evolution of oBCS, it was believed that the
upper limit of reasonable resection was a mere 10%
before a cosmetic deformity would result. That made
for a very low threshold that pushed a good proportion
of patients away from a breast conservation surgery
(BCS) and towards mastectomy.
When BCS was introduced, the average five-year
survival rate was about 65% (1940s to 1980s). Survival
was the primary goal of treatment at the time, and it
was commonly believed that cosmetic breast preservation
was unachievable with what was considered an
adequate cancer operation.
The emotional impact of losing a breast can be
overwhelming. It induces trauma, disrupts the sense-of-self and sexual functioning (Figure 1).
Breast conservation today
The five-year age-standardised survival rate for breast
cancer in Singapore is now 82.1%, and there is a
definite expectation of long-term survival.
In addition, we are now certain that both aesthetic
and functional outcomes contribute towards overall
patient satisfaction, and are considered major determinants
of quality of life.
oBCS increases the proportion of patients eligible
for BCS, and considers cosmetic outcomes individualised
to patient-tumour morphology, cancer
biology and patient choice.
What is oBCS?
By definition, oBCS is a ‘tumour-specific, partial and
immediate breast reconstruction method that applies
aesthetically derived volume displacement, volume
replacement or volume reduction techniques to the
field of breast cancer surgery, to allow for higher
volume excision with minimal aesthetic compromise’.1
Types of oBCS
As an overview, the types of oncoplastic breast procedures
can be thought of as:
Conventional BCS, but with thoughtful and favourable scar placement and orientation. Examples include incisions placed discretely at the edge of the areolar (periareolar), through the nipple base, in the bra line (inframammary fold) or underarm (axillary).
Volume displacement oBCS or reshaping procedures
that transpose a dermoglandular flap of
breast tissue into the defect site (e.g., mastopexy
and mammoplasty) (Figure 2).
Volume reduction oBCS techniques when the
removal of excessive parenchyma can result in an
aesthetic or quality of life benefit (i.e., the reduction
mammoplasty) (Figure 2).
Volume replacement oBCS which includes autologous
tissue flaps or implants to correct the
partial mastectomy defect (e.g., intercostal artery
perforator flap, thoracodorsal artery perforator flap,
latissimus dorsi flap or omental flap reconstruction)
Complimentary contralateral breast symmetrisation,
fat grafting (lipofilling), nipple-areolar
tattoo or reconstruction and other cosmetic
corrections are now regarded as vital components
of our repertoire.
‘Levels’ have also been assigned to describe the
spectrum of oncoplastic surgical techniques, according to the volume of tumour removed and to reflect the
complexity of the reconstructive procedure required
(i.e., level 1 comprises resection volumes less than 20%
and level 2 around 20% to 50%).
Benefits of oBCS
Surgical safety: The oncological safety of oBCS has been widely
established in terms of disease-free outcomes and
overall survival. Complication rates were once
thought to be higher, but with experience and time
are now recognised to be comparable to BCS, and
preferable to a mastectomy.
Good cosmetic outcomes:
Good cosmetic outcomes, reported in more than
80% to 90% of patients, have contributed to quality survivorship. Complementing this is a strong collective of studies reinforcing the importance of
quality of life in terms of vitality, self-esteem, social
functioning and emotional and mental health.
The place of oBCS today
The lessons we have learnt as a community practicing
oBCS have been invaluable. Ultimately, one can say
that regardless of whether specialised techniques are
indicated or otherwise, all breast surgeries ought to
be oncoplastic in nature, permeating our practice right
down to a cosmetically-optimised simple mastectomy.
What it is
Minimally invasive breast surgery (MIBS) evolved in
tandem with oBCS to push conventional boundaries of
aesthetic outcomes. It utilises endoscopic-laparoscopic
instruments or robotic surgical platforms.
On this journey towards the holy grail of discrete
resection-restoration, the fundamentally unshakable
tenets of practice are:
En-bloc resection (as opposed to fragmentation
of the specimen which compromises oncological
Beyond this, there is no ceiling to creativity and artistry.
Initially utilised mainly for mastectomy (whole breast
resection), more surgeons have been moving towards
the application of MIBS in BCS (partial breast resection).
Benefits of MIBS
For the surgeon, the use of a camera and endorobotic
instruments allows for improved visualisation,
agility and precision in dissection and
But the most obvious advantage of the minimally
invasive endoscopic or robotic techniques is
that the surgeon is empowered to make smaller inconspicuous incisions that can even be sited off
the main mound of the breast.
Planning an off-the-breast scar placement is not just
purely aesthetic. Smaller inconspicuous incisions
cause minimal scarring, less postoperative pain
and greater patient satisfaction, and wound
complications are said to be rare events.
Because the breast skin and nipple-areolar complex
(NAC) remain surgically unaltered and a scar is
potentially not found on the breast itself in a direct
face-on manner, we have had patients who were
very happy to report that the resultant natural effect
could even allow them to forget that breast surgery,
or even breast cancer, was once a part of their lives (Figures 4 and 5).2
For any patient facing a mastectomy, skin and NAC
preservation and consideration of breast reconstruction
are requisite therapeutic components. The
NAC represents a geometric and aesthetic focal point
of the breast, and the breast itself retains significant
psychoemotional importance to most women.
Although we were once more conservative, there
is increasing community consensus that the nipple-sparing mastectomy (NSM) can now be performed for
any tumour of any size that does not involve the skin
or NAC directly, independent of axillary status.
The main remaining contraindications to nipple and/or
areola preservation are:
The community also recognises that autologous
reconstruction establishes enduring natural aesthetics
and tactile results.
The abdominal-based free perforator flap (e.g., deep
inferior epigastric perforator [DIEP] flap), has edged
itself as the preferred reconstruction method. It allows
close to ideal breast defect restoration, while also
minimising abdominal donor site morbidity since the
‘free’ DIEP flap spares the underlying rectus abdominis
muscle (Figure 6).
Alternative flaps such as those listed below continue
to provide the suitable individual niche benefits:
Superficial inferior epigastric artery
Profunda artery perforator
Transverse rectus abdominis myocutaneous
Latissimus dorsi (back)
Gluteal artery (buttock)
Upper gracilis (thigh)
Omental (intra-abdominal adipose) flap
Prosthetics and other procedures
Prosthetics (breast implants) and adjunctive procedures
continue to provide options for patients who present
with challenging clinical scenarios or unavailable or
inadequate abdominal donor sites, or as a component
of patient choice.
Breast cancer is a complex disease that is multifactorial
in aetiology and threatens life, function and identity. While therapy is ultimately multidisciplinary, good
surgical management remains the cornerstone of
locoregional management and restoration of self.
Multidisciplinary collaborative efforts and more
effective treatments are continually evolving through
research and clinical trials. As breast surgeons, we
hold ourselves responsible for the guidance of decision
making, coordination, communication, widening
our collaborative efforts and seeking continual self-improvement
in order to reach the ultimate goal of
optimal recovery for every patient.
Assistant Professor Sabrina Ngaserin, a Consultant Breast Surgical Oncologist, is the Head
of Breast Surgery at Sengkang General Hospital’s Breast Service. Her main interest
lies in cutting-edge breast cancer surgical techniques that consider the patient’s disease
alongside their need for aesthetic surgical solutions. She is particularly passionate about oncoplastic and minimally invasive breast surgery, tailoring ‘off-the-breast’ and ‘minimal-access’
incisions to provide the illusion of ‘nearly scarless’ breast resections. These practice
principles prioritise not only disease eradication but also physical restoration, and optimise
mental wellbeing and overall quality of life for cancer survivors.
GPs can call the SingHealth Duke-NUS Breast Centre for appointments at the
following hotlines or click here to visit the website:
Singapore General Hospital: 6326 6060Changi General Hospital: 6788 3003
Sengkang General Hospital: 6930 6000
KK Women’s and Children’s Hospital: 6692 2984
National Cancer Centre Singapore: 6436 8288
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