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Oncoplastic Surgery (OPS)
Breast cancer Breast reconstruction

Oncoplastic Surgery  is the combination and integration of plastic surgery techniques with surgery for breast cancer to preserve the natural shape of the breast. The goal of OPS is to both improve oncology and aesthetic outcomes for breast cancer surgery as well as extending the indications to allow more patients the option of breast conservation over mastectomy. The conceptual idea of OPS is not new and the has proven to have equivalent efficacy compared to more traditional breast conservation approaches.Breast cancer treatment The safety of breast conservation surgery compared to mastectomy has been demonstrated in large clinical trials in both the United States and Europe over the past 20 years.NSABP Umberto Veronesi

The exact definition of OPS may vary from country to country and center to center as there are a number of different philosophic approaches to breast conservation and reconstruction. In the United Kingdom, emphasis is placed on volume replacement techniques for the management of partial mastectomy defects through autologous tissue transfers. The French have approached OPS through glandular redistribution of the remaining breast volume after tumor resection through simple glandular advancement flaps as well as more complex reduction mammoplasty techniques. Centers in the United States have also advanced the field through emphasis on breast reconstruction and unique reduction mammoplasty techniques such as the Batwing approach described by Mel Silverstein.

History
The first description of Oncoplastic surgery can be cited to Werner Audretsch, M.D. in Germany. Since his description the field of OPS has expanded at an exponential rate with now over 187 articles and books related to the topic and numerous centers focused on performing OPS in both Europe and the United States. Centers of OPS in Europe can be found in Italy, France, Germany and the United Kingdom.

France currently has an advanced certificate training program for qualified surgeons to learn OPS while there is a formal training program developed in the United Kingdom. There are surgical fellowships in the United States that also focus on OPS.

The acceptance of oncoplastic surgery in the academic fields of surgery as demonstrated by the explosion of articles published in peer-reviewed articles has now begun to surface in popular press releases providing more education for current and future patients.WSJ

Indications
The main indication for OPS is large lesions for which a standard excision with safe margins would either seem impossible or lead to a major deformity.

Selection Criteria
Appropriate patient selection is a critical element in the safe and effective use of oncoplastics in the treatment of breast cancer. The surgeon must focus on three key elements when choosing between the different oncoplastic treatment levels. The key elements include excision volume, glandular density and tumor location.

Level I
Oncoplastic surgery is based upon allowing wide excisions with free margins, not on minimizing incision length. Short incisions limit mobilization of the gland and do not permit creation of adequate glandular flaps to fill in excision defects.

Level II
Selection for level II procedures is based on an excision volume to breast volume ration that is greater then 20%.

Results
Oncoplastic surgery allows for wide resections with favorable cosmesis and integrates into a standard multidisciplinary approach for BCS. OPS enables the surgeon to avoid breast deformity for patients selected for breast conservation and also can extend the indications for breast conservation for patients that have been traditionally selected to undergo mastectomy.

Future
Although prospective randomized controlled studies (the highest level of evidence) are not available to measure the efficacy of OPS for the treatment of breast cancer there have been prospective studies from Europe with 5 years of follow-up that demonstrate equivalent results compared to traditional breast conserving surgery.

Training for OPS can be acquired gradually, and level I techniques do not require advanced training. One solution for the more complex oncoplastic procedures is to incorporate a dual-team approach with a plastic surgeon. However, OPS training for all future breast surgeons may be a more sustainable long-term solution. Training can be obtained either through formal OPS fellowships or more accessible courses offered through select institutes. Paris Breast CenterSchool of European Surgery