The American Journal of Surgery xxx (2017) 1e5

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The American Journal of Surgery

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Lateral Oncoplastic Breast Surgery (LOBS) - A new surgical technique

and short term results
Gurpreet Singh, MS *, Pavneet Singh Kohli, MS 1, Dinesh Bagaria, MS 2
Department of Surgery, Post Graduate Institute of Medical Education & Research (P.G.I.M.E.R.), Chandigarh, India

a r t i c l e i n f o a b s t r a c t

Article history: Background: We present a new approach for BCS which we have named as the Lateral Oncoplastic Breast
Received 3 August 2017 Surgery (LOBS) approach.
Received in revised form Methods: Patients with biopsy proven breast cancer or phyllodes tumors in the outer quadrants of the
30 August 2017
breast were selected. The patients were operated in the lateral position using the principles of a Level 1
Accepted 16 September 2017
oncoplastic technique.
Presented at the American Society of Breast Results: 106 patients (93 breast cancer; 13 phyllodes tumor) were operated using this technique. For
Surgeons 18th Annual Meeting, April 26 patients with breast cancer the mean tumor size was 2.7 cms. 3 patients had a positive margin. The mean
e30, 2017. tumor size for phyllodes tumors was 6.7 cms. Surgical site infections (15 patients), marginal skin necrosis
(2 patients) and superficial NAC necrosis (1 patient) were observed. Although the mean follow up was
Keywords: only 355.8 days there were no early detected recurrences.
Lateral oncoplastic breast surgery Conclusions: LOBS is a new approach for BCS which offers distinct advantages. The short term results,
Breast conserving surgery both oncological and aesthetic, are encouraging.
Level 1 oncoplasty
Summary: A new approach for performing oncoplastic breast conserving surgery (BCS) is described and
the short term results of our first 106 cases are presented. Advantages of this approach over conventional
techniques are reviewed.
© 2017 Elsevier Inc. All rights reserved.

1. Introduction
In October 2002, both Fisher et al.1 and Veronesi et al.2 pub-
lished the 20 year results of their trials comparing Breast
Conserving Surgery (BCS) and Mastectomy in the treatment of early
breast cancer. Both trials did not show any difference in terms of
survival in the two arms. In an accompanying editorial in the same
issue of the NEJM, Morrow3 wrote that “the failure to observe a
survival advantage of mastectomy after 20 years should convince even
the most determined skeptics that mastectomy is not superior to breast
conservation for the treatment of breast cancer”. BCS followed by
radiotherapy is now the standard of care for early breast cancer and
is recommended by all major guidelines as such.
* Corresponding author.
E-mail address: gsinghpgi@gmail.com (G. Singh).
1
Currently working as Senior Resident. Dept. of Surgical Oncology, JIPMER,
Puducherry, India.
2
Currently working as Assistant Professor, Dept. of Surgery, AIIMS, New Delhi,
India.
The focus has now moved away from this debate and other is-
sues related to BCS have come to the forefront. Expanding the scope
of BCS and improving the aesthetic quality of the retained breast
are issues which occupy the surgical mind. The fact that the
aesthetic result is not often perfect is acknowledged by the fact that
surgeons have reported on the classification of these deformities
and methods to correct them.4,5 The two factors often related to a
poor aesthetic outcome are the volume of the excised tissue and the
location of the primary tumor.6 Suboptimal aesthetic outcomes are
related to poor adjustment and inferior quality of life in breast
cancer survivors.7
At around the same time that BCS was being accepted as the
standard of care, attempts were being made to improve the
aesthetic outcome. The principles of plastic and reconstructive
procedures were being combined with the principles of breast
cancer surgery. The branch of Oncoplastic Breast Surgery (OPBS)
was a result of this amalgamation of techniques. The scope and
standards of OPBS were defined and it was quickly incorporated
into breast surgery.8 OPBS increases the scope of BCS as well as
improves the aesthetic outcome of such patients. OPBS techniques
can be broadly divided in volume displacement and volume

https://doi.org/10.1016/j.amjsurg.2017.09.016
0002-9610/© 2017 Elsevier Inc. All rights reserved.

Please cite this article in press as: Singh G, et al., Lateral Oncoplastic Breast Surgery (LOBS) - A new surgical technique and short term results, The
American Journal of Surgery (2017), https://doi.org/10.1016/j.amjsurg.2017.09.016
2 G. Singh et al. / The American Journal of Surgery xxx (2017) 1e5

replacement.9 Clough et al.10 have divided volume displacement

techniques into Level 1 and 2. A Level 1 technique can be easily
performed by general surgeons without much training and is the
easiest way to enhance the aesthetic outcome of standard BCS. We
believe that all straight forward BCS should be performed using
Level 1 oncoplasty. This is a paradigm shift from the NSABP
guidelines for performing BCS.11
New techniques are constantly being described in OPBS, the
only limiting factor possibly being the imagination of the surgeon.
We describe here a surgical technique and short term results of this
new approach to perform a Level 1, volume displacement OPBS,
which we call the Lateral Oncoplastic Breast Surgery (LOBS).

2. Methods

After institutional review board approval, a retrospective review

of patients treated with BCS by LOBS technique was undertaken and
includes patients with biopsy proven breast cancer or phyllodes
tumors with tumors in the outer quadrants of the breast (extension
into the medial quadrants was permitted for phyllodes tumors) and
with no contraindication to breast conserving therapy.

2.1. Surgical technique

The tumor outline is drawn with indelible ink with the patient in
lateral decubitus position. The incision is marked with the patient
in sitting position and arm abducted overhead. The incision starts
in the apex of the axilla and follows the anterior axillary fold
downwards, curves around the breast mound, terminating in the
lateral part of the inframammary crease.
The entire procedure is carried out with the patient in the lateral
position. The shoulder is abducted to 900 and the arm supported on
a rigid frame. The body is supported anteriorly and posteriorly at
the level of the hips and upper back in a way that the table can be
turned sideways without the patient moving. All pressure points
are well padded (Fig. 1).
The surgeon stands facing the back of the patient. The table is
rotated towards the surgeon to facilitate the lumpectomy part of
the procedure. The incision is deepened in the upper half and the
lateral border of the pectoralis major identified. The incision is
extended inferiorly as marked following the lateral border of the
pectoralis major muscle. The breast is then dissected of the pec-
toralis major well beyond the tumor margins. The anterior surface
of the breast is separated from the skin, in a plane similar to that
while performing mastectomy. If required, the retroareolar region
can also be mobilized after dividing the major lactiferous ducts.
Thus a biplanar mobilization is achieved (Fig. 2a).
The tumor can now be palpated “bimanually” and is resected
under bimanual guidance. Full thickness excision of the breast with
1 cm margins is performed. Radio opaque marker clips are placed in
the tumor bed and at the margins of excision. This is done as the
margins may move away from the tumor bed after closure of the
defect. Prior to suturing the defect, additional mobilization of flaps
may be required to avoid skin dimpling and NAC deviation.
If the tumor is close to the incision, the excision is usually in the
form of a wedge and the closure of the defect can be achieved by
direct approximation (LOBS 1) (Fig. 2). If the tumor is away from the
incision, an access cut is made perpendicular to the incision and
continued circumferentially around the tumor. The flaps of breast
tissue so created can be swung/crossed over to bridge the defect
produced (LOBS 2) (Fig. 3). The lateral edge of the fascia of the
breast which was lifted off from the pectoralis major is sutured back
to the lateral border of the muscle in order to prevent medial
displacement/rotation (Fig. 3d).
Axillary surgery, if required, is done through the same incision in
Fig. 1. Patient position for performing LOBS, Front (a) and Back (b).
the same position.
Lumpectomy specimens are oriented by the surgeon (short su-
ture as superior, long suture as lateral, and two sutures as anterior).
In the histopathology suite, all margins are painted and the spec-
imen is cut from the posterior surface as 1 cm thin slices. The tumor
is identified and accurate measurement (at least 2 larger di-
mensions) of tumour size and the tumor distance from all the
resection planes is noted. Sections from the tumor proper with
adjacent breast and from all the resection planes (preferably radial
section) are taken for microscopic examination.
All patients with breast cancer received whole breast radio-
therapy and adjuvant systemic therapy as per standard treatment
protocols followed in our hospital.
3. Results
Between January 1, 2013 and April 30, 2016, 106 females were
selected to undergo LOBS in the Department of Surgery, PGIMER,
Chandigarh, a tertiary health care centre in North India. Patients
with Breast Cancer (93 patients) and Phyllodes tumors (13 patients)
underwent this procedure.
Fifteen patients with breast cancer underwent neoadjuvant
chemotherapy to make them eligible for BCS. The mean age of
patients was 44.7 ± 11.7 years (range 18e74 years). The tumors
were located in the upper outer quadrant in 66 patients (62.2%) and
in the lower outer quadrant in 40 patients (37.8%). The left breast
was affected in 55 patients and the right breast in 51. All patients

Please cite this article in press as: Singh G, et al., Lateral Oncoplastic Breast Surgery (LOBS) - A new surgical technique and short term results, The
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 G. Singh et al. / The American Journal of Surgery xxx (2017) 1e5 3

Fig. 2. LOBS I. a) Biplanar mobilization performed. b) Status after tumor excision. c) Tissue approximation prior to suturing, x-x* d) Final status after suturing.

underwent tumor excision through the lateral approach. The post
excision defect was closed using LOBS 1 in 60 patients (56.6%) and
LOBS 2 in 46 patients (43.4%).
There were 41 patients (44.1%) with pT1, 50 patients (53.8%)
with pT2, and 2 patients (2.1%) with pT3 tumors. There were 40
patients (43.0%) with pN0, 47 patients (50.5%) with pN1, and 6
patients (6.5%) with pN2 status. The clinicopathologic features of
the patients are detailed in Table 1.
The mean follow up was 355.8 ± 199.5 days (range 124e1028
days). The median duration of follow up was 321 days. There were
no local or systemic recurrences in this period of follow up. A
formal aesthetic evaluation of the breast was not done but all pa-
tients were satisfied with the procedure and the outcome (Figs. 4
and 5).
3.1. Positive margins
Three patients (2.83%) with breast cancer had positive margins.
In 2 patients negative margins could be achieved after re-excision.
In one patient the margins were positive after re-excision and she

Fig. 3. LOBS II. a) Status after biplanar mobilization and tumor excision. B) Lower flap being swung upwards and inwards, x-x*. c) Upper flap being swung downwards and outwards,
y-y*. d) Final status after suturing.

Please cite this article in press as: Singh G, et al., Lateral Oncoplastic Breast Surgery (LOBS) - A new surgical technique and short term results, The
American Journal of Surgery (2017), https://doi.org/10.1016/j.amjsurg.2017.09.016
4 G. Singh et al. / The American Journal of Surgery xxx (2017) 1e5

Table 1
Clinicopathologic data of the patients in the study.

Breast Cancer (n ¼ 93) Phyllodes (n ¼ 13)

Age (years) 45.4 ± 11.5 (24e74) 39.8 ± 12.4 (18e66)

BMI (Kg/m2) 25.9 ± 3.63 (19.2e36.3) 24.7 ± 3.4 (20.2e30.2)
Post Menopausal (%) 33 (35.5%) 2 (15.4%)
Tumour Size (cm) 2.7 ± 1.2 (0.5e6.0) 6.7 ± 2.3 (3.0e11.0)
Lump weight (gm) 64.8 ± 34.5 (20.0e154.0) 299.9 ± 112.9 (143.0e452.0)

underwent mastectomy. No patients with phyllodes tumors had

involved margins.

Fig. 5. A 45 year female with a 9 cm phyllodes tumor underwent LOBS 2 procedure

(specimen weight 430 gm). Cosmetic appearance 1 year post-operative.

3.2. Complications

Surgical site infections were the commonest complication and

Fig. 4. A 38 year old female with a 3 cm infiltrating duct cancer underwent a LOBS 1
procedure (specimen weight 65 gm). Cosmetic appearance 2 years post-operative.
were seen in 15 patients. They delayed wound healing in 4 patients.
Marginal skin necrosis was seen in 2 patients. Superficial NAC
(nipple areola complex) necrosis was seen in 1 patient who un-
derwent this procedure for a large phyllodes tumor extending into
the medial quadrants. Fat necrosis was seen in 4 patients in the
follow up. It presented as a nodular hardness and was documented
on FNAC (fine needle aspiration cytology).

Please cite this article in press as: Singh G, et al., Lateral Oncoplastic Breast Surgery (LOBS) - A new surgical technique and short term results, The
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 G. Singh et al. / The American Journal of Surgery xxx (2017) 1e5
4. Discussion
The surgical approach described here follows the principles of
Level 1 oncoplasty. Wide biplanar mobilization, full thickness
excision of the breast bearing the tumor with clear margins, closure
of the defect by advancement of the local tissues and NAC mobili-
zation are all essential components of this approach as described in
Level 1 oncoplasty.10
Although suitable for outer quadrant tumors only, we believe
that this approach offers several distinct advantages. There is a
single scar in the lateral aspect of the chest wall which is not
visible when the patient is sitting in the normal position. This
results in avoiding scars over the breast and results in a superior
aesthetic result. Though the scar is longer than usual, it is not
visible. The tumor is excised under bimanual palpation guidance,
thus resulting in an increased chance of achieving negative mar-
gins and limiting tissue excision at the same time. Only 3 of our
106 patients had a positive margin. Larger tumors can be excised
using this approach as is evident from the size of the tumor and
the weight of the resected specimens in our patients. Large phyl-
lodes tumors can be excised and the breast reshaped using local
tissues with this approach. This technique has reduced the use of
Latissimus dorsi miniflaps for volume replacement in our hands.
The position adopted by us for this approach has been described by
Rainsbury12 in his technique for Latissmus dorsi miniflaps for
partial volume replacement. If after excision of the tumor, the re-
sidual defect is too large for being bridged by local breast tissue,
the procedure can be completed as a partial volume replacement
with latissimus dorsi miniflap without having to abandon the
operation or change the position of the patient. Patients with large
breasts and tumors in the upper outer quadrants tend to be sur-
gically difficult in the supine position, as the breasts flop laterally
and the tumor is displaced/rotated posteriorly. In the lateral
approach used by us the breasts flop medially and ‘unmask’ the
tumor, making the procedure technically easy. This technique can
easily be adapted for non-palpable tumors and sentinel lymph
node biopsy.
The average tumor size for patients with breast cancer was
2.7 cms in this series. With this kind of tumor size it is not sur-
prising that almost 60% of our patents have nodes positive in the
axilla. Axillary dissection continues to form an important part of
the surgical treatment of breast cancer in our setup. In our
approach the axillary dissection can be performed through the
same incision. The 90 abduction at the shoulder as adopted in the
position of the patient relaxes the pectoralis major muscle and
makes the axillary dissection easier.
Vascularity of the breast tissue advanced/rotated has not proven
a major issue. We have able to document fat necrosis in only 4 of
our patients so far.
Surgical site infection is our major morbidity. The American
Society of Breast Surgeons13 has issued a consensus guideline on
preoperative antibiotics and surgical site infections (SSI) in breast
surgery. They state that the rates for SSI are higher than those seen
in other clean cases (expected rate of less than 5%). The observed
rates in contemporary series are 2%e16%. All oncoplastic surgery
procedures are not the same. The extent of resection and dissection
varies with the kind of on colplastic procedure being done and it
will be very difficult to compare complications of such diverse
procedures. In a systematic review of oncoplastic breast surgery,
early complication rate (<2 months postoperative) of 20% has been
reported.14
The follow up of the patients is short but the initial results
appear to be encouraging as we have not seen any local recurrence
so far. We have not performed any formal aesthetic evaluation
Please cite this article in press as: Singh G, et al., Lateral Oncoplastic Breast Surgery (LOBS) - A new surgical technique and short term results, The
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5
but the initial results are very encouraging concerning patient
satisfaction.
5. Conclusion
Lateral Oncoplastic Breast Surgery (LOBS) is new approach
described for use in outer quadrant tumors. The approach offers
several distinct advantages and the short term results, both onco-
logical and aesthetic are very encouraging. This approach has
several advantages including the ability for patients to undergo a
single stage cancer and reconstructive surgery that is aesthetically
satisfactory utilizing a technique that is straight forward and
technically easily reproduced. It also provides alternatives for
practices that may be located in under sourced global regions or for
practices where formally trained plastic surgeons are not available.
Disclosures
No Disclosures.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest
No author has any conflict of interest.
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