REVIEW Oncoplastic Breast Conservation Surgery: The New Paradigm MELVIN J. SILVERSTEIN, MD, 1,2 * TAM MAI, MD, 1,2 NIRAV SAVALIA, MD, 1,2 FAAIZA VAINCE, MD, 1,2 AND LISA GUERRA, MD 1,2 1 Hoag Memorial Hospital Presbyterian, Newport Beach, California 2 Keck School of Medicine, University of Southern California, Los Angeles, California Oncoplastic surgery combines plastic surgical techniques with sound surgical oncologic principles. The goal is to completely excise the cancer, with wide surgical margins while maintaining or improving cosmesis. For large, poorly defined, or unfavorably situated tumors, standard lumpectomies may lead to unacceptable cosmetic results in addition to close or involved resection margins. Similar problems may occur for smaller tumors in small breasts. Integration of the two surgical disciplines avoids or minimizes poor cosmetic results after wide excision. It increases the number of women who can be treated with breast‐conserving surgery by allowing larger breast excisions with more acceptable cosmetic results. Oncoplastic surgery requires a multidisciplinary approach and thorough preoperative planning. It is absolutely necessary to enlist the cooperation and coordination of surgical oncology, plastic surgery, radiology, pathology, medical oncology, and radiation oncology. Oncoplastic surgery requires a philosophy that the appearance of the breast after tumor excision is important. J. Surg. Oncol. ß 2014 Wiley Periodicals, Inc. KEY WORDS: oncoplastic breast surgery; oncoplastic breast conservation; reduction excision; breast cancer oncoplastic surgery INTRODUCTION Traditionally, surgical oncologists are trained to remove the cancer at all costs, with little emphasis placed on the importance of cosmesis. Oncoplastic breast preservation surgery is a new paradigm. Oncoplastic breast conservation surgery combines oncologic principles with plastic surgical techniques. But it is much more than a combination of two disciplines. It is a philosophy that requires vision, passion, knowledge of anatomy, an appreciation and understanding of aesthetics, symmetry and breast function. It is a philosophy that the appearance of the breast after tumor excision is important. The oncoplastic surgeon must be constantly thinking: “How can I remove this cancer with adequate margins while at the same time make the patient look as good, or better than she looks now?” The goals of oncoplastic breast conservation surgery include: 1. Complete removal of the lesion 2. Clear margins 3. Good to excellent cosmetic result 4. Operating one time to perform the definitive procedure. When treating a patient with biopsy proven breast cancer, surgeons have generally made a small, curvilinear incision over the area to be removed. They excised no skin, took a relatively small piece of breast tissue, accepted non‐transection as the definition of a clear margin, did not require complete and sequential tissue processing, and used radiation therapy routinely to deal with tumor cells that might have been left behind. This was generally successful if the tumor was small. However, if the tumor was large relative to the size of the breast, or if the tumor was located in a cosmetically unfavorable position, the excision might lead to significant deformity as well as involved margins. This in turn could ultimately lead to a mastectomy. During the last 30 years, we have developed a comprehensive multidisciplinary oncoplastic approach for the excision of breast cancer [1–3]. It requires a multidisciplinary approach, including coordination with the surgical oncologist, radiologist, plastic surgeon, medical oncologist, and pathologist. Oncoplastic surgery combines sound surgical oncologic principles with plastic surgical techniques. It is defined as immediate reshaping of the remaining breast tissue, using various forms of remodeling mammoplasty after wide excision of the primary lesion. This can range from simple flap advancement with multi‐layered undermining and closure to reduction mammoplasty. Almost always, a contralateral mammoplasty or mastopexy is required for symmetry due to the loss of volume from removal of the cancer. The combination of these two surgical disciplines helps to avoid poor cosmetic results after wide excision and increases the number of women who can be treated with breast‐conserving surgery, by allowing larger breast excisions with more acceptable cosmetic results [4]. These techniques are applicable to patients with both noninvasive (DCIS) and invasive breast cancer. Furthermore, now that excision without radiation therapy is an accepted method of treatment for patients with favorable DCIS, widely clear margins are of even greater importance than previously appreciated [5,6]. *Correspondence to: Melvin J. Silverstein, MD, Hoag Memorial Hospital Breast Center, One Hoag Drive, Newport Beach, CA 92663. Fax 949‐764‐ 8236. E‐mail: melsilver9@gmail.com Received 5 December 2013; Accepted 5 April 2014 DOI 10.1002/jso.23641 Published online in Wiley Online Library (wileyonlinelibrary.com). Journal of Surgical Oncology ß 2014 Wiley Periodicals, Inc.