Minimalist breast conserving surgical approaches for inferiorly sited cancers

Contemporary data suggests that breast conservation treatment (BCT) may confer a survival advantage when compared to mastectomy. Hence, it would be logical to adopt strategies which increase eligibility of successful BCT without compromising oncologic principles or cosmetic outcome. With respect to achieving good aesthetics, inferiorly sited breast cancers pose a particular technical challenge. A vast array of techniques, collectively referred to as oncoplastic breast surgery (OBS) have been developed to minimise post treatment distortion. The purported advantages of these approaches are the acquisition of wider margins and reduced re-excision rates. However, to date, there is a lack of data demonstrating significant reduction in local recurrence and overall survival when compared with less extensive procedures. In this review, "minimalist" procedures are described where strict oncologic criteria of clear margins are fulfilled and acceptable cosmesis are simultaneously achieved. These techniques offer less tissue loss, less extensive parenchymal mobilisation and shorter operating times without compromising margin status and aesthetics. They involve the combination of innovative incision designs and certain parenchymal resection patterns. Incision designs include the boomerang, golf-tee, anchor and arrowhead incisions which have been previously described but not widely used. Parenchymal resection patterns follow the "sick lobe hypothesis". These techniques, termed "reductionist", or "minimalist" comprising approaches where breast conserving surgery is condensed to its irreducible elements, offer alternatives which align with contemporary objectives of surgery where optimal survival outcomes are achieved through individualised procedures resulting in reduced iatrogenic impact. This logically allows scope for de-escalation of surgical therapy for breast cancer.