Oncoplastic lumpectomy combines plastic surgery techniques with lumpectomy surgery to give you a better cosmetic outcome after the cancer is removed.
You can think of oncoplastic lumpectomy — also called oncoplastic surgery or oncoplasty — as a reconstructive surgery aimed at preventing problems with the breast’s appearance that can be caused by the lumpectomy. It is usually done at the same time as lumpectomy.
There are many different oncoplastic approaches that surgeons can use to reshape the breast after removing the cancer. These choices are tailored to the cancer’s location and size, as well as an individual woman’s breasts, body, and preferences.
Oncoplastic surgery techniques are generally used to either:
rearrange nearby breast tissue to fill in the space left behind after the cancer is removed to prevent “dents” and place the scar where it is less visible
remove the breast tissue containing the cancer and combine this procedure with a breast reduction, a breast lift, or both
If necessary, the surgeon can make adjustments to the other breast to create a balanced appearance.
Although oncoplastic surgery has been used in Europe and Latin America for some time, it has become more common in the United States, especially since the early to mid-2010s. If you’re eligible for lumpectomy, you may want to ask your surgeon if an oncoplastic approach makes sense for you.
What is oncoplastic lumpectomy?
The two main options for breast cancer surgery are lumpectomy and mastectomy. Breast reconstruction is routinely offered with mastectomy, but you might not know that oncoplastic surgery could be a reconstructive option if you’re eligible for lumpectomy.
Lumpectomy — also called partial mastectomy or breast-conserving surgery — removes the breast cancer and a rim of healthy tissue called a margin, preserving most of the breast. The surgeon then closes the incision and, over time, fluid fills in the space where the cancer was removed (this is called a seroma).
If the cancer is small, in a not very obvious location, and you have large or mid-sized breasts, you may have a cosmetic result you are happy with after lumpectomy. But many women aren’t satisfied with their appearance after traditional lumpectomy.
In some cases, a divot or dent forms and causes visible indentation in the breast, a tight scar, or distortions in the nipple’s appearance. Any radiation therapy given after lumpectomy can worsen the treated breast’s appearance, and it also can affect the treated breast’s size and shape. A breast that looked fine on the operating table might not look the same as time passes.
Oncoplastic lumpectomy combines plastic surgery techniques with lumpectomy to both remove the cancer and reconstruct and reshape the breast. It can be useful for achieving a good cosmetic outcome in many women who choose lumpectomy, such as those who have:
smaller breasts, where removing even a small tumor is likely to have a visible impact
breast cancer in an especially visible place, such as high on the chest wall, on the inner portion of the breast, or close to the nipple
mid- to large-sized breasts and the need to have a large amount of tissue (20% to 50%) removed from the affected breast
chemotherapy before surgery (called neoadjuvant chemotherapy) that shrinks the cancer enough to make lumpectomy possible
existing issues with their breasts, such as excessive sagging (ptosis), very large size (macromastia), or obvious lack of symmetry (balance), which could be addressed at the same time the cancer is removed
Oncoplastic lumpectomy is not a good option for inflammatory breast cancer or for cancers that are so widespread they can’t be completely removed with a good aesthetic result. The procedure also may not be possible if there are multiple tumors throughout the breast, unless the breast is quite large.
There are many different approaches to oncoplastic lumpectomy. Here in the United States, they are categorized as Level 1 or Level 2, depending on how complex they are.
With all of these approaches, the surgeon pays attention to the position of the nipple and areola, adjusting its location as needed while maintaining its blood supply.
Level 1 procedures include:
Volume displacement, rearrangement, and aesthetic scar placement:This is the simplest form of oncoplastic lumpectomy. The surgeon first removes the cancer and a margin of healthy tissue. The surgeon then loosens nearby tissue beneath the breast skin and uses it to fill in the space left behind. The surgeon can hide the scar by placing it under the arm, around the areola, or in the area under the breast (the inframammary fold).
There are many different types of incisions a surgeon can use, depending on the location of the tumor.
Generally, breast surgeons and general surgeons who frequently treat breast cancer are able to perform Level 1 procedures.
Level 2 procedures include:
Volume reduction with breast lift (mastopexy): The surgeon removes the section of the breast that contains the cancer and then performs a breast lift. This procedure can address sagging breasts (ptosis) or excess skin. To make the breasts symmetrical, the surgeon can also perform a breast lift on the other side.
Significant breast reduction (reduction mammaplasty): If a woman has very large breasts, the surgeon can remove the cancer and a larger amount of surrounding tissue as part of a breast reduction. The surgeon would also reduce the size of the other breast to match.
Volume replacement using nearby tissue flaps: Flaps of tissue from the side of the body (near the breast) or the upper back can be moved into the breast area while still attached to their blood supply (this is called a pedicled flap). The surgeon may use flaps if there is not enough nearby tissue to fill in space left behind after the lumpectomy (in a smaller-breasted woman, for example) or if a woman wants to maintain her breast size.
Volume replacement with fat grafting: Surgeons can use this technique later on, after you complete radiation therapy, to fill in areas of the breast as needed or to ensure the breasts are symmetrical (balanced).
Level 2 procedures require a plastic surgeon working together with the cancer surgeon. However, oncoplastic breast lifts and reductions also can be performed by breast cancer surgeons with extensive training and experience in oncoplastic techniques. Flaps and fat grafting require a plastic surgeon.
Any surgeons you consider must be able to demonstrate that they have done many of these procedures in the past, with good outcomes and an established safety record.
Other things to know about oncoplastic lumpectomy
Just as with a regular lumpectomy, the surgeon performing oncoplastic lumpectomy sends the removed cancer for pathology testing. The pathologist makes sure that the surgeon achieved clean — or negative — margins. When margins test negative, it means that no cancer is present at the edges of the rim of healthy tissue the surgeon removed along with the cancer. When margins test positive, it means that cancer is present on the edges of the removed healthy tissue and that another surgery is needed to remove more tissue. Positive margins are less of a concern if you are having a significant breast reduction, which removes a much larger amount of tissue along with the cancer.
Surgeons who rearrange breast tissue to fill the space left behind after removing the cancer must mark the original tumor site. They can use metal clips; a flexible radiopaque suture (a permanent type of suture that can be seen on X-rays); or a “bioabsorbable” marker (a small spiral-shaped device that dissolves over time but leaves the clips behind permanently). These devices ensure that, even after the breast tissue is rearranged, your doctors are still able to see the cancer’s original location. This is helpful for planning radiation treatments and for future breast cancer screenings. It’s also important in the small percentage of cases where the pathologist finds positive margins.
In most cases, surgeons perform oncoplastic surgery at the same time as lumpectomy. However, there are situations when surgeons can perform oncoplastic procedures a couple of weeks later, before radiation therapy is given, such as:
when the general surgeon or breast surgeon is not skilled or comfortable enough to perform the oncoplastic technique and a plastic surgeon who can perform it is not available. In this case, the cancer surgeon can coordinate with the plastic surgeon and perform the lumpectomy on one day, and the plastic surgeon can perform the oncoplastic surgery at a later date.
when the surgeon is concerned about the possibility of positive margins and wants to wait for pathology results before performing oncoplastic surgery. In most cases, though, surgeons can use shave margins to reduce the chances of positive margins and still proceed to oncoplastic surgery. A “shave margin” involves shaving the walls of the lumpectomy cavity after removing the cancer.
Sometimes, a surgeon may perform immediate oncoplastic surgery on the breast that has cancer and then wait between a few months and a year after radiation therapy to perform surgery on the healthy breast to bring it into balance, if needed. That’s because it can be hard to predict what effect radiation therapy might have on the breast. In general, whenever possible, most surgeons choose to operate on both breasts at once. Some surgeons leave the breast affected by cancer a little bit bigger to account for the 10% to 20% shrinkage that can occur with radiation therapy. Your surgeon can help you decide what’s right for your situation.
Making decisions about oncoplastic lumpectomy
If you’re having a lumpectomy, it’s understandable to want the cancer out as quickly as possible. But it may be worth taking time to explore your options for oncoplastic surgery.
“It is hard because your mind is reeling, you are thinking of your family and maybe your kids, and the last thing on your mind is where your scars are going to be and what your breasts will look like,” says Monique Gary, DO, MSc, FACS, a breast surgical oncologist and director of the breast program at Grand View Health in Sellersville, Pa. “But most women with early-stage breast cancer can expect to live a long time, and how you look is important. Cancer takes so much from you already — a surgeon might do the standard lumpectomy and tell you to go out and love your body, but you might not like it. This is not about vanity: You should know your options and look for surgeons who can perform these procedures or do them with plastic surgeons.”
If your surgeon focuses only on removing the cancer without considering the longer-term appearance of the breast, you might not be happy with the result. Many women report looking misshapen, disfigured, or imbalanced after radiation therapy. They find it difficult to have a visible reminder of the cancer when they look in the mirror or to see their clothes don’t fit correctly. Some choose to have reconstruction after lumpectomy to address these concerns. However, it’s more difficult for surgeons to work with skin that has been affected by radiation therapy.
The goal of oncoplastic lumpectomy is to avoid any issues up front, as long as it is a safe alternative to mastectomy. You and your surgeon can start by asking a key question: Can the tumor (or tumors) be removed with clean margins while giving you a cosmetic result and breast size that you’re happy with? This means considering the five S's:
Site: Where is the cancer located? Is there cancer in multiple places?
Size: What is your breast size relative to the cancer? Will there be enough tissue left to rearrange and fill the space left by lumpectomy? Are you interested in breast reduction?
Skin: Do you have excess skin or sagging that could be addressed by a breast lift during oncoplastic surgery?
Shape: Is it necessary and/or possible to relocate the nipple and areola to give you the desired shape?
Symmetry: Is surgery needed on the other breast to bring them into balance? Are your breasts already asymmetrical — an issue that could be addressed with oncoplastic surgery? 1
Another consideration is whether the breasts are mostly fatty tissue or mostly dense (this means the tissue is more glandular and connective rather than fat). With extremely fatty tissue, there is the possibility of fat necrosis, in which areas of tissue harden over time after surgery — a possibility your surgeon takes into account when considering the type of oncoplastic surgery technique that is best for you.
Here are some other things to think about:
Your personal preferences
Does keeping most of your natural breast tissue (versus having a mastectomy) appeal to you?
How do you feel about your breasts? Do you have issues that could be addressed by oncoplastic surgery? Examples include having very large breasts that cause discomfort or interfere with activity or exercise, excess skin or sagging (ptosis), one breast that’s bigger than or positioned differently from the other (asymmetry).
Are smaller breasts acceptable to you in the event you need to have a large amount of tissue removed relative to your breast size?
Do you want to avoid mastectomy with reconstruction, which can be a complex process requiring multiple procedures over time? And would you rather not go flat after mastectomy?
Likely aesthetic outcome of traditional lumpectomy
Ask your surgeon what your outcome is likely to be if you have lumpectomy and radiation without oncoplastic surgery. Have them mark the location of the cancer so you know exactly where it is. Is the treated breast’s shape and appearance likely to be affected after treatment? How large is the cancer relative to your breast size?
“I have a camera, a ruler, and a marker — those are the tools I use,” says Dr. Monique Gary. “We measure where the nipples are, we measure the overall length and width so that a woman can understand how her breasts look currently. I show her where the tumor is and the likely impact of radiation therapy and whether oncoplastic surgery might benefit her. It has to be a collaborative conversation.”
Advantages of oncoplastic lumpectomy
Oncoplastic lumpectomy offers a number of advantages:
The surgeon pays attention to the shape and appearance of the breast.
Since you keep much of your natural breast tissue, your breasts usually retain feeling. Although there may be some changes in sensation, you avoid the numbness that is common with full mastectomy and breast reconstruction (if you chose to have reconstruction). 2
The surgeon often can remove more tissue than with lumpectomy alone, which is more likely to result in clean margins.
It gives you and your surgeon the opportunity to address issues such as sagging, excess skin, very large breasts, and/or asymmetry.
For larger-breasted women who undergo a breast reduction as part of oncoplastic surgery, having less breast tissue may lower the risk of the cancer coming back (called recurrence) 3and makes future screenings easier.
In many cases, the surgery can be done in one day as an outpatient procedure.
Disadvantages of oncoplastic lumpectomy
You may likely still need to have radiation therapy.
Radiation treatments can affect the size and shape of the breast. Your surgeon may try to account for this change during oncoplastic surgery, but there may be a need for additional procedures (such as fat grafting) to balance the breasts.
The incisions with Level 2 oncoplastic surgeries are usually larger than the incisions with traditional lumpectomy. Those scars do fade over time, though. (However, if you’re not having a breast reduction and/or lift, the incisions are typically hidden.)
With more complex procedures such as a breast reduction or lift, the recovery time is longer than it would be with traditional lumpectomy.
As with traditional lumpectomy, there is a small chance of positive margins, but your surgeon won’t know for certain until the pathology report comes back a few days later. With positive margins, you would need additional surgery to remove more tissue (re-excision) or, possibly, the entire breast (mastectomy).
If you live in a remote area, it may be more difficult to find surgeons with the training and expertise needed to perform oncoplastic lumpectomy.
Choosing and working with an oncoplastic surgeon/surgical team
In Europe and Latin America, many breast cancer surgeons have been trained to use oncoplastic techniques. The United States and Canada are training more surgeons to perform oncoplastic surgery, but many are not yet familiar with these procedures. 1 So it’s important to ask about training and experience if your breast surgeon doesn’t work closely with a plastic surgeon.
If you’re in a larger metropolitan area or at a larger medical center, your breast cancer surgeon should be able to put together the right team for you. If not, you might need to do some research on your own. Even if there aren’t many plastic surgeons in your immediate area, your breast surgeon should be able to refer you to someone outside your area who can collaborate. Nurse navigators who work with people who have been diagnosed with breast cancer can also be a good resource. You also can network with other people who are being treated for breast cancer, whether in person or online, to get recommendations.
Level 1 vs. Level 2 oncoplastic surgery: Who performs what?
Level 1: In the United States, breast surgeons and general surgeons are considered qualified to perform Level 1 oncoplastic surgery. This involves rearranging the tissue to fill the space left behind by lumpectomy and placing the scar so that it is not obvious (aesthetic scar placement). Still, you should ask about your surgeon’s experience with these techniques and whether anything about your case may make the surgery more challenging.
If your surgeon is more comfortable performing traditional lumpectomy, ask if a plastic surgeon can be brought in to assist. Also, if your situation requires a major tissue rearrangement, you can ask for a plastic surgeon to be involved.
Level 2: For complex Level 2 procedures, which can involve a breast reduction or lift, adjustments to the healthy breast, and/or repositioning the nipple, you would need either:
A general surgeon or breast surgeon as well as a plastic surgeon. The general or breast surgeon focuses on removing the cancer, while the plastic surgeon focuses on the appearance of the breast.
A breast surgeon with extensive training and experience in performing oncoplastic lumpectomy. In especially complex cases — for example, if a person is obese, the cancer is close to the nipple, or there are concerns about wound healing — that surgeon still may need to call in a plastic surgeon. More breast surgeons are taking courses in oncoplastic surgery, but one course over a few days is generally not enough to master these techniques. Make sure your surgeon has done many of these procedures successfully and is open to bringing in a plastic surgeon if needed.
If your oncoplastic surgery requires using a nearby tissue flap (from the sides of your body or your upper back), you need a plastic surgeon to be involved.
Elisabeth Potter, MD, a plastic surgeon in Austin, Texas, says that she is sometimes asked to partner with breast surgeons who have oncoplastic surgery expertise: “If it’s a complicated case, I can be there to help. I can do the rearrangement of tissue and close the incisions if they need me to. Or they might call me if the defect is really big, they are worried about nipple viability, or the breasts are really large and are going to require a major change.”
If your general or breast surgeon isn’t experienced in oncoplastic surgery and a plastic surgeon cannot be present for your lumpectomy, you can ask for an in-person or virtual visit with a plastic surgeon. The plastic surgeon can review the surgical plan and consult with the breast surgeon about the best approach. You could then have oncoplastic surgery within a few weeks, before starting radiation therapy.
If you get any pushback from your surgeon about the need for oncoplastic surgery with lumpectomy, or if you get the sense that the surgeon does not seem comfortable advising you, seek a second opinion from another surgeon.
Questions to ask your surgeon
Here are some suggested questions you can ask your surgeon:
Considering the size/position of the cancer and my breast size, am I a good candidate for oncoplastic lumpectomy?
Can you mark where the cancer is and show me what incisions and surgical approach you would recommend?
If I have traditional lumpectomy, what are my long-term cosmetic results likely to be after radiation therapy?
Do you have before and after photos of your patients who have had oncoplastic lumpectomy?
Can I expect any changes in feeling/sensation?
If my surgical margins come back positive for cancer, what would the next steps be?
Can this be done as an outpatient procedure? If not, how long will my hospital stay be?
What is the recovery process like? Are there any issues to watch out for? What are my activity limitations after surgery?
What do you recommend for future breast cancer screenings? Would I have mammograms or do I need additional imaging, such as MRI or ultrasound? What should I tell the radiologist about the surgery I had?
Additional questions for a general surgeon or breast surgeon:
Are you experienced with Level 1 oncoplastic lumpectomy? How are you able to prevent dents when performing oncoplastic lumpectomy? How many of these surgeries do you perform on average each month?
If you’re more comfortable performing traditional lumpectomy without oncoplastic surgery, can you bring in a plastic surgeon for the oncoplastic procedure or refer me to someone for a consultation before my lumpectomy?
Additional questions for a breast surgeon who has more advanced oncoplastic surgery training:
What formal training in oncoplastic surgery have you completed?
How many Level 1 and Level 2 procedures do you perform on average each month?
What surgical approach would you recommend for my situation? Where will my scars be?
Can you address preexisting issues during oncoplastic surgery, such as very large breasts, sagging, or asymmetry?
What procedure would you recommend for my healthy breast to bring both breasts into balance?
Does my nipple need to be repositioned? If so, how would you do that?
How does radiation therapy affect the breast with cancer? Would you recommend leaving extra volume in that breast to account for the effects of radiation? Or do you prefer to perform any balancing procedures later?
How likely is it that I will need a second procedure later on, after completing radiation therapy?
Is there anything that makes my case especially complex? If so, would it be a good idea for you to bring in a plastic surgeon? If so, whom do you recommend?
Oncoplastic lumpectomy outcomes: Survival and recurrence
In the past several years, there has been a well-documented trend of women with early-stage breast cancers choosing mastectomy over lumpectomy. 4 5 For those with a known gene mutation that increases breast cancer risk and/or a strong family history of breast or ovarian cancer, doctors often recommended mastectomy to reduce the risk of a new breast cancer.
Many women diagnosed with breast cancer who don’t have these risk factors are still choosing mastectomy when they are eligible for lumpectomy. Many say they want to lower their future risk of breast cancer and eliminate the stress of breast cancer screenings. Certainly, every woman has the right to choose what’s best for her mental and emotional health and life situation.
It’s important to consider the latest research so you can make an informed decision about your care. Research studies have shown that, for early-stage cancers, lumpectomy with radiation has equivalent outcomes to mastectomy. In 2002, the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-06 trial found that, after 20 years of follow-up, total mastectomy did not offer an advantage over lumpectomy in terms of how long women lived (overall survival), how long they remained free of the cancer coming back (disease-free survival), and whether the cancer spread beyond the breast (metastatic disease). 6
A 2021 study of nearly 49,000 women with early-stage breast cancer in Sweden found that women who had lumpectomy plus radiation had better survival rates than those who had mastectomy with or without radiation.
Studies also have found that oncoplastic lumpectomy is as safe as traditional lumpectomy and total mastectomy with regard to cancer outcomes. For example, a 2016 study of nearly 10,000 people at the University of Texas MD Anderson Cancer Center found that overall survival (how long people lived) and recurrence-free survival (how long they remained free of recurrence) were similar among these groups. At 3 years, overall survival was roughly 96 to 98% for those who had oncoplastic lumpectomy, traditional lumpectomy, or mastectomy with reconstruction. Recurrence-free survival was also similar. Women who had oncoplastic lumpectomy had lower rates of positive or close margins than those who had lumpectomy alone. 7
Other studies have reached similar conclusions about the safety of oncoplastic lumpectomy. For example:
A 2020 analysis of studies involving more than 18,000 people found no significant differences in recurrence rates after oncoplastic lumpectomy, traditional lumpectomy, or mastectomy. There also was no significant difference in the need for reoperation. 8
A 2016 analysis of studies on oncoplastic lumpectomy found there were high rates of overall survival (95%) and disease-free survival (90%) after an average of 4 years of follow-up. About 90% of people had clean margins and did not need further surgery for their cancer. 9
More studies comparing oncoplastic lumpectomy and traditional lumpectomy have found that women in the former group were less likely to have positive margins requiring another surgery. They also had a lower rate of complications and local recurrences, and they were more satisfied with the appearance of their breasts. 10
Research is ongoing, but so far oncoplastic lumpectomy has been shown to be as safe as traditional lumpectomy and mastectomy for women with early-stage cancers. As with other surgeries, there is a risk of side effects such as infection, problems with wound healing, and fluid filling in the space where the cancer was removed (seroma).
Over time, some women can develop fat necrosis, meaning that damaged fatty tissue is replaced by a cyst or scar tissue. It’s not dangerous, but it may be viewed as suspicious by a radiologist when you resume your breast cancer screenings after surgery. Some women experience more callbacks for additional imaging after their first few cancer screenings.
Insurance coverage for oncoplastic lumpectomy
Oncoplastic lumpectomy should be covered by health insurance. However, it’s always a good idea to ask your surgeon and your medical team whether people have ever faced challenges with getting coverage. You also can do the following:
Make sure the practice describes your surgery as reconstructive when submitting it to the insurance company. The Women’s Health and Cancer Rights Act of 1998 requires insurance companies that cover mastectomy to also cover reconstruction, including any procedures that are needed on the remaining healthy breast.
If you’re having a procedure on the healthy breast (such as reduction or lift), make sure it is described as being necessary for symmetry. This can ensure that the insurance company does not classify it as cosmetic surgery.
Kaufman CS. Increasing Role of Oncoplastic Surgery for Breast Cancer. Curr Oncol Rep. 2019. Available at: https://doi.org/10.1007/s11912-019-0860-9
Casaubon JT, et al. Breast-Specific Sensuality and Appearance Satisfaction: Comparison of Breast-Conserving Surgery and Nipple-Sparing Mastectomy. J Am Coll Surg. 2020. Available at: https://doi.org/10.1016/j.jamcollsurg.2020.02.048
Yazar SK, et al. Oncoplastic Breast Conserving Surgery: Aesthetic Satisfaction and Oncological Outcomes. Eur J Breast Health. 2018. Available at: http://doi.org/10.5152/ejbh.2017.3512
CNN. Why more women are choosing double mastectomies. Available at: https://www.cnn.com/2013/03/13/health/double-mastectomy-rates-up/index.php
Dr. Deanna J. Attai. Increasing Mastectomy Rates – Science vs. Personal Choice. Available at https://drattai.com/increasing-mastectomy-rates-science-vs-personal-choice/
Fisher B, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002. Available at https://doi.org/10.1056/NEJMoa022152
Carter SA, et al. Operative and Oncologic Outcomes in 9861 Patients with Operable Breast Cancer: Single-Institution Analysis of Breast Conservation with Oncoplastic Reconstruction. Ann Surg Oncol. 2016. Available at: https://doi.org/10.1245/s10434-016-5407-9
Kosasih S, et al. Is oncoplastic breast conserving surgery oncologically safe? A meta-analysis of 18,103 patients. Am J Surg. 2020. Available at:https://doi.org/10.1016/j.amjsurg.2019.12.019
De La Cruz L, et al. Outcomes After Oncoplastic Breast-Conserving Surgery in Breast Cancer Patients: A Systematic Literature Review. Ann Surg Oncol. 2016. Available at: https://doi.org/10.1245/s10434-016-5313-1
UpToDate. Oncoplastic Breast Surgery. Last updated March 25, 2020. Available at: https://www.uptodate.com/contents/oncoplastic-breast-surgery
— Last updated on June 29, 2022, 3:16 PM