Improving Results in Oncoplastic Surgery

A Cost-Utility Analysis of the Use of -125 mm Hg Closed-incision Negative Pressure Therapy in Oncoplastic Breast Surgery

Background

Closed-incision negative pressure therapy (ciNPT) decreases the rate of wound complications in oncoplastic breast surgery (OBS) but at a fiscal cost. Our aim was to examine the cost-utility of ciNPT in OBS.

Methods

A literature review was performed to obtain the probabilities and outcomes for the treatment of unilateral breast cancer with OBS with ciNPT versus without. Reported utility scores in the literature were used to calculate quality-adjusted life years (QALYs) for each health state. A decision analysis tree was constructed with rollback analysis to determine the more cost-effective strategy. An incremental cost-utility ratio was calculated. Sensitivity analyses were performed.

Results

OBS with ciNPT is associated with a higher clinical effectiveness (QALY) of 33.43 compared to without (33.42), and relative cost increase of $667.89. The resulting incremental cost-utility ratio of $57432.93/QALY favored ciNPT. In one-way sensitivity analysis, ciNPT was the more cost-effective strategy if the cost of ciNPT was less than $1347.02 or if the probability of wound dehiscence without was greater than 8.2%. Monte Carlo analysis showed a confidence of 75.39% that surgery with ciNPT is more cost effective.

Conclusion

Despite the added cost, surgery with ciNPT is cost-effective. This finding is a direct result of decreased overall wound complications with ciNPT.

Efficacy of Closed-Incision Negative Pressure Wound Therapy in Reducing Postoperative Complications in Breast Reconstruction After Radiotherapy: A Propensity Score Analysis

Background

Implant-based breast reconstruction following radiotherapy can lead to significant postoperative complications. Closed-incision negative pressure wound therapy (ciNPWT) has emerged as a potential intervention to reduce these complications.

Objectives

To assess the effectiveness of ciNPWT in reducing postoperative complications in patients undergoing implant-based breast reconstruction after radiotherapy.

Methods

A retrospective single-center cohort study was conducted, including patients who underwent implant-based breast reconstruction after mastectomy and radiotherapy between January 1, 2015, and December 31, 2022. We utilized a procedure-level analysis model with patients contributing distinct observations for multiple procedures. Our primary outcome measures included fluid collection, infection, and wound complications. Propensity score analysis was employed to adjust for potential confounders, such as BMI, smoking history, and diabetes history, creating a balanced comparison between the ciNPWT-treated and untreated groups.

Results

In our study of 301 breast reconstructions postradiotherapy from 2015 to 2022, encompassing 218 unique patients, we found significant benefits of ciNPWT. During an average of 2.2-year follow-up, the ciNPWT group demonstrated no infections, contrasting with a 10.4% rate in the non-ciNPWT group (P < .0001). Wound complications were also significantly lower in the ciNPWT group (1.9% vs 11.2%; P = .00848). Demographic differences were adjusted using inverse probability of treatment weights. The findings suggest ciNPWT's promising role in enhancing postoperative outcomes in breast reconstruction postradiotherapy.

Conclusions

Our study suggests that the use of ciNPWT in implant-based breast reconstruction postradiotherapy can potentially reduce postoperative complications. This intervention can improve patient outcomes and may offer cost-saving benefits in the long run.

Level of Evidence 3 Therapeutic

Oncoplastic Surgery Outcomes in the Older Breast Cancer Population: A Matched-Cohort Comparison Study

BACKGROUND

Oncoplastic breast surgery (OBS) is a form of breast conservation surgery (BCS) that involves a partial mastectomy followed by immediate volume displacement or volume replacement surgical techniques. To date, there are few studies evaluating OBS in older patients. Therefore, we sought to determine if outcomes differed between patients 65 years and older versus younger patients who underwent oncoplastic surgical procedures.

METHODS

A retrospective chart review was performed for all oncoplastic breast operations within a single health system from 2015 to 2021. Patients were stratified by age, with patients 65 years and older (OBS65+) identified and then matched with younger patients (OBS <65) based on BMI. Primary outcomes were positive margin rates and overall complication rates; secondary outcomes were locoregional recurrence (LR), distant recurrence (DR), disease-free survival (DFS), overall survival (OS), and long-term breast asymmetry.

RESULTS

A total of 217 patients underwent OBS over the 6-year period, with 22% being OBS65+. Preoperatively, older patients experienced higher American Anesthesia (ASA) scores, Charlson Co-morbidity index (CCI) scores, and higher rates of diabetes mellitus, hypertension, and grade 3 breast ptosis. Despite this, no significant differences were found between primary or secondary outcomes compared to younger patients undergoing the same procedures.

CONCLUSIONS

Oncoplastic breast reconstruction is a safe option in patients 65 years and older, with overall similar recurrence rates, positive margin rates, and survival when compared to younger patients. Although the older cohort of patients had greater preoperative risk, there was no difference in overall surgical complication rates or outcomes. Supporting the argument that all oncoplastic breast reconstruction techniques should be offered to eligible patients, irrespective of age.

Local practice variations and payer differences underlie state-wide disparities in oncoplastic breast surgery

BACKGROUND

Little is known about disparities in oncoplastic breast surgery delivery.

METHODS

The Massachusetts All-Payer Claims Database was queried for patients who received lumpectomy for a diagnosis of breast cancer. Oncoplastic surgery was defined as adjacent tissue transfer, complex trunk repair, reduction mammoplasty, mastopexy, flap-based reconstruction, prosthesis insertion, or unspecified breast reconstruction after lumpectomy.

RESULTS

We identified 18 748 patients who underwent lumpectomy between 2016 and 2020. Among those, 3140 patients underwent immediate oncoplastic surgery and 436 patients underwent delayed oncoplastic surgery. Eighty-one percent of patients who underwent oncoplastic surgery did so in the same county as they underwent a lumpectomy. However, the relative frequency of oncoplastic surgery varied significantly among counties. In multivariable regression, public insurance status (odds ratio: 0.87, 95% confidence interval: 0.80-0.95, p = 0.002) was associated with lower odds of undergoing oncoplastic surgery, even after adjusting for macromastia, other comorbidities, and county of lumpectomy. Average payments for lumpectomy with oncoplastic surgery were more than twice as high from private insurers ($840 vs. $1942, p < 0.001).

CONCLUSION

Disparities in the receipt of oncoplastic surgery were related to differences in local practice patterns and the type of insurance patients held. Expanding services across counties and considering billing reform may help reduce these disparities.

Extreme oncoplasty: past, present and future

Breast surgery has evolved from mastectomy to breast-conserving surgery (BCS). Breast oncoplastic surgery later emerged with the inclusion and development of techniques used in plastic surgery for breast neoplasms. Recently, a new paradigm has been considered for mastectomy candidates with large multifocal and multicentric tumours, designated extreme oncoplasty (EO), which has allowed new techniques to be applied to tumours that would have been ineligible for BCS before. There are few publications and no uniform descriptions grouping all the technical possibilities and new indications together. We performed this a review with the objective of evaluating the indications and surgeries performed in the EO context, representing a new perspective for BCS. We observed new indications as extensive microcalcifications, locally advanced breast carcinoma with partial response to chemotherapy, small to moderate-sized non-ptotic central tumours and extreme ptosis. Small breasts are able for EO since the presence of ptosis. New surgeries are reported as disguised geometric compensation, perforators flaps, local/regional flaps, latissimus dorsi miniflap and partial breast amputation. It is important to decrease barriers to oncoplastic surgery if we want to increase the use of EO and BCS rates.

Localization of Central Breast Lymphatics and Predefined Separation of Lobes along the Horizontal Septum

BACKGROUND

The predictable localization of the neurovascular supply along the ligamentous suspension, composed of the horizontal septum, vertical ligaments, and superficial fascia, has increased safety in breast reduction. Lymphatic drainage of the breast has always been described as running close to vascular supply. However, the correlation between the lymphatic course and ligamentous suspension has not yet been considered. This study aimed to visualize the relationship, direction of lymphatic flow, and predefined separation of lobes along the horizontal septum.

METHODS

To investigate central drainage, methylene blue was injected subareolarly in five breasts of female cadavers before blunt preparation of the horizontal septum in anatomical studies. To visualize central and peripheral drainage, lymphographin was injected into one of the three different sites in 14 breasts; the dynamic flow of drainage was observed during subsequent septum-based breast reductions in clinical settings.

RESULTS

In all anatomical studies, a predefined section of the glandular layers allowed access to central clearance along the stained horizontal septum. Clinical investigations similarly showed clearance along the corresponding part of the ligamentous suspension, most reliably along the horizontal septum. The affected quadrant of the breast, its relation to the nipple-areola complex, and the anterior-posterior axis toward the thoracic wall mainly determine the direction of lymphatic flow. Interconnections along the ligaments may explain the unpredictability of final clearance directions.

CONCLUSIONS

This study shows the horizontal septum as a guiding structure for central mammary drainage. This may encourage a septum-based approach for refinement of procedures such as oncoplastic, irradiation, and lymphedema treatments.

The impact of body mass index on oncoplastic breast surgery: A multicenter analysis

BACKGROUND

Obesity has nearly tripled in the last 50 years. During the last decades, oncoplastic breast surgery has become an important choice in the surgical treatment of breast cancer. An association exists between higher body mass index (BMI) and wound complications for major operations, but there is scarce literature on oncoplastic surgery. Hence, our aim was to compare the complication rates among patients who underwent oncoplastic surgery, stratified by BMI.

METHODS

Patient data were analyzed from the National Surgical Quality Improvement Program database (NSQIP) for oncoplastic breast procedures (2005-2020). Patients were stratified according to World Health Organization obesity classifications. Multivariate logistic regression was performed to assess risk factors for complications (overall, operative, and wound-related).

RESULTS

From a total of 6887 patients who underwent oncoplastic surgery, 4229 patients were nonobese, 1380 had Class 1 obesity (BMI: 30 to <35 kg/m2 ), 737 Class 2 obesity (BMI: 35 to <40 kg/m2 ), and 541 Class 3 obesity (BMI: ≥ 40 kg/m2 ). Greater operative time was found according to higher BMI (p < 0.001). Multivariate analysis adjusted for baseline characteristics showed that patients with obesity Class 2 (odds ratio [OR] = 1.51, 95% confidence interval [CI]: 1.03-2.23, p = 0.037) and 3 (OR = 1.87, 95% CI 1.24-2.83, p = 0.003) had increased risk of overall and wound complications compared with Nonobese patients. Comparing obese with nonobese patients, there were no differences in rates of deep SSI, organ/space SSI, pneumonia, reintubation, pulmonary embolism, deep vein thrombosis, urinary tract infection, stroke, bleeding, postoperative sepsis, length of stay, and readmission.

CONCLUSIONS

Oncoplastic surgery is a safe procedure for most patients. However, caution should be exercised when performing oncoplastic surgery for patients with Class 2 or 3 obesity (BMI ≥ 35 kg/m2 ), given there was a higher rate of overall and wound-specific complications, compared with patients who were not obese or had Class 1 obesity.

Oncoplastic surgery for breast cancer: Global perspectives and trends

Oncoplastic surgery (OPS) is a form of breast conservation that combines definitive oncologic resection with optimal aesthetic outcomes. Various definitions exist, with most focusing on volume displacement techniques to close the lumpectomy defect and redistribute the remaining breast volume over the preserved breast. Although its oncologic safety has been well demonstrated, uptake into practice varies globally. This article details the definition, safety, training opportunities, and practice patterns of OPS on a global scale.

The Free Superficially Based Low-Abdominal Mini Flap for Oncoplastic Breast Reconstruction

SUMMARY

Volume replacement in oncoplastic breast reconstruction most commonly uses pedicled flaps. In thin patients with small breasts, free-tissue transfer may be better suited to preserve breast size. Evidence on microvascular oncoplastic reconstruction is limited, and reconstruction has often required sacrifice of potential future donor sites. The free superficially based low-abdominal mini (SLAM) flap uses a narrow strip of lower abdominal tissue based on superficial perfusion of the abdominal wall that is anastomosed to chest wall perforators to preserve the ability to perform future abdominally based autologous breast reconstruction. Five patients underwent reconstruction with SLAM flaps for immediate oncoplastic reconstruction. Their mean age was 49.8 years, and their mean body mass index was 23.5. Tumor location was most commonly in the lower outer quadrant (40%). Average lumpectomy weight was 30 g. Two flaps were based on the superficial inferior epigastric artery, and three, on the superficial circumflex iliac artery. Recipient vessels included internal mammary perforators (40%), serratus branch (20%), lateral thoracic vessel branch (20%), and lateral intercostal perforators (20%). All patients underwent radiation therapy without delay and maintained volume, symmetry, and contour at an average period of 11.7 months after surgery. There were no cases of flap loss, fat necrosis, or delayed wound healing. The free SLAM flap allows for immediate oncoplastic breast reconstruction in thin, small-breasted patients with limited regional tissue without sacrificing future potential donor sites for autologous breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Aesthetic results were more satisfactory after oncoplastic surgery than after total breast reconstruction according to patients and surgeons

INTRODUCTION

Patient satisfaction after breast cancer surgery has an impact on body image, sexual function, self-esteem, and quality of life and may differ from the perception of the attending physician. This study aimed to compare the aesthetic outcomes and satisfaction with conservative oncoplastic surgeries, mastectomies, and total breast reconstruction.

METHODS

We included 760 women diagnosed with invasive breast carcinoma or phyllodes tumors who returned at least 6 months after surgery or radiotherapy at two public hospitals and a private clinic between 2014 and 2022. Data was collected prospectively from patients and retrospectively from their medical records using a specific form after obtaining their informed consent. Aesthetic outcomes and quality of life were assessed using the BREAST-Q©, Harris Scale, and BCCT.core software. Data were evaluated using the SPSS statistical software. Statistical significance was set at p < 0.05. This study was approved by the hospital ethics committees.

RESULTS

A total of 405 (53.29%) partial and 355 (46.71%) total reconstructions were included. Patients who underwent partial reconstruction were older and had higher body mass index. Patients who underwent total reconstruction had larger tumors with advanced clinical and pathological stages. Clinical and surgical complications occurred more frequently in the total reconstruction group. A greater number of reparative surgeries and lipofilling procedures were required for total reconstruction. According to the BREAST-Q, the partial reconstruction group showed significantly higher levels of women's satisfaction with their breasts, the surgical outcomes, psychosocial and sexual well-being, provision of information, and the reconstructive surgeon. Only physical well-being was slightly higher in the total reconstruction group. In most cases, the results were rated good or excellent. Physicians considered partial reconstructions to have better results than total reconstructions, although this difference was not perceived by the BCCT.core software.

CONCLUSION

Women who underwent partial breast reconstruction had higher levels of satisfaction in several domains, lower frequency of complications, and required fewer surgeries to complete their reconstruction than women who underwent total reconstruction. Physicians were also more satisfied with the results of partial reconstructions.

The adoption of oncoplastic surgery: Is there a learning curve?

INTRODUCTION

Oncoplastic surgery (OPS) is a form of breast conservation surgery involving partial mastectomy followed by volume displacement or replacement surgery. As the field of OPS is growing, we sought to determine if there was a learning curve to this surgery.

METHODS

A retrospective chart review was conducted of all patients who underwent OPS over a 6-year period with a single surgeon formally trained in both Plastic Surgery and Breast Oncology. Cumulative summation analysis (CUSUM) was performed on mean operative time to generate the learning curve and learning curve phases. Outcomes were compared between phases to determine significance.

RESULTS

Mean operative time decreased significantly across the 6-year period, generating three distinct learning curve phases: Learner phase (cases 1-23), Competence phase (24-73), and Mastery phase (74 and greater). The overall positive margin rate was 10.9% and there was no significant difference in rates between phases (p = 0.49). Overall complication rates, reoperation rates, and locoregional recurrence remained the same across all phases (p = 0.16; p = 0.65; p = 0.41). The rate of partial nipple loss decreased between phases (p = 0.02).

CONCLUSION

As with many complex operations, there does appear to be a learning curve with OPS, as the operative time and the rates of partial nipple loss decreased over time.

Closed Incision Negative Pressure Therapy in Oncoplastic Breast Surgery: A Comparison of Outcomes

We aim to discern the impact of closed incision negative pressure therapy (ciNPT) on wound healing in the oncoplastic breast surgery population.

Methods

A retrospective analysis was conducted on patients who underwent oncoplastic breast surgery with and without ciNPT in a single health system over 6 years. Oncoplastic breast surgery was defined as breast conservation surgery involving partial mastectomy with immediate volume displacement or replacement techniques. Primary outcomes were rates of clinically significant complications requiring either medical or operative intervention, including seroma, hematoma, fat necrosis, wound dehiscence, and infection. Secondary outcomes were rates of minor complications.

Results

ciNPT was used in 75 patients; standard postsurgical dressing was used in 142 patients. Mean age (P = 0.73) and Charlson Comorbidity Index (P = 0.11) were similar between the groups. The ciNPT cohort had higher baseline BMIs (28.23 ± 4.94 versus 30.55 ± 6.53; P = 0.004), ASA levels (2.35 ± 0.59 versus 2.62 ± 0.52; P = 0.002), and preoperative macromastia symptoms (18.3% versus 45.9%; P ≤ 0.001). The ciNPT cohort had statistically significant lower rates of clinically relevant complications (16.9% versus 5.3%; P = 0.016), the number of complications (14.1% versus 5.3% with one complication, 2.8% versus 0% with >2; P = 0.044), and wound dehiscence (5.6% versus 0%; P = 0.036).

Conclusions

The use of ciNPT reduces the overall rate of clinically relevant postoperative complications, including wound dehiscence. The ciNPT cohort had higher rates of macromastia symptoms, BMI, and ASA, all of which put them at increased risk for complications. Therefore, ciNPT should be considered in the oncoplastic population, especially in those patients with increased risk for postoperative complications.

Sometimes it is better to just make it simple. De-escalation of oncoplastic and reconstructive procedures

Simple breast conservation surgery (sBCS) has technically advanced onto oncoplastic breast procedures (OBP) to avoid mastectomy and improve breast cancer patients' psychosocial well-being and cosmetic outcome. Although OBP are time-consuming and expensive, we are witnessing an increase in their use, even for cases that could be managed with sBCS. The choice between keeping it simple or opting for more complex oncoplastic procedures is difficult. This review proposes a pragmatic approach in assisting this decision. Medical literature suggests that OBP and sBCS might be similar regarding local recurrence and overall survival, and patients seem to have higher satisfaction levels with the aesthetic outcome of OBP when compared to sBCS. However, the lack of comprehensive high-quality research assessing their safety, efficacy, and patient-reported outcomes hinders these supposed conclusions. Postoperative complications after OBP may delay the initiation of adjuvant RT. In addition, precise displacement of the breast volume is not effectively recorded despite surgical clips placement, making accurate dose delivery tricky for radiation oncologists, and WBRT preferable to APBI in complex OBP cases. With a critical eye on financial toxicity, patient satisfaction, and oncological outcomes, OBP must be carefully integrated into clinical practice. The thoughtful provision of informed consent is essential for decision-making between sBCS and OBP. As we look into the future, machine learning and artificial intelligence can potentially help patients and doctors avoid postoperative regrets by setting realistic aesthetic expectations.

Single Versus Dual Surgeon Approaches to Oncoplastic Surgery: A Comparison of Outcomes

INTRODUCTION

Oncoplastic surgery (OPS) is traditionally performed using a dual surgeon (DS) approach that involves both a breast surgeon and a plastic surgeon. It is also performed using a single surgeon (SS) approach with a surgeon trained in both breast surgical oncology and plastic surgery. We sought to determine if outcomes differed between SS versus DS OPS approaches.

METHODS

A retrospective chart review was conducted of all OPS performed in a single health system over a 6-y period by either an SS or a DS approach. Primary outcomes were rates of positive margins and the overall complication rate; secondary outcomes were loco-regional recurrence, disease-free survival, and overall survival.

RESULTS

A total of 217 patients were identified; 117 were SS cases and 100 were DS cases. Baseline preoperative patient characteristics were similar between the two groups as there was no difference in mean Charlson Comorbidity Index scores (P = 0.07). There was no difference in tumor stage (P = 0.09) or nodal status (P = 0.31). Rates of positive margins were not significantly different (10.9% (SS) versus 9% (DS); P = 0.81), nor were rates of complications (11.1% (SS) versus 15% (DS); P = 0.42). Rates of locoregional recurrence were also not significantly different (1.7% (SS) versus 0% (DS); P = 0.5). Disease-free survival and overall survival were not significantly different at 1-y, 3-y, and 5-y time points (P = 0.20 and P = 0.23, respectively) although follow-up time was not sufficient for definitive analysis regarding survival.

CONCLUSIONS

Both SS and DS approaches to OPS have similar outcomes with regards to positive margin rates and surgical complication rates and are comparably safe.

The Use of Hemostatic Agents to Decrease Bleeding Complications in Breast Cancer Surgery

INTRODUCTION

Following breast cancer surgery, patients often require adjuvant radiation and chemotherapy for locoregional and systemic disease control. These procedures may result in postoperative complications, which may delay adjuvant therapy. To potentially decrease these complications, hemostatic agents may be used. This study evaluated the rate of postoperative bleeding complications and duration of Jackson-Pratt (JP) drain use in oncologic breast surgery with and without hemostatic agents.

METHODS

After obtaining institutional review board approval, a retrospective chart review was performed. Patients who underwent oncoplastic breast surgery, mastectomy with or without expander/implant-based reconstruction, and subsequent reconstruction with expander to implant exchange were included. Data collected included indication for surgery, type of operation, use of hemostatic agent, specifically fibrin sealant (FS, EVICEL^®, Ethicon, USA) or combination powder (CP, HEMOBLAST^™ Bellows, biom'up, France), length of follow-up, time to JP drain removal, and post-operative complications (seroma, hematoma, or operating room (OR) takeback). This was a consecutive experience where initially no hemostatic agent was used, followed by use of FS, and then CP.

RESULTS

The use of a hemostatic agent resulted in fewer bleeding complications and significantly decreased time until JP drain removal. Although not significant, subgroup analysis demonstrated that this was more pronounced in the CP group. JP drain duration was decreased among all procedures for CP compared to FS.

CONCLUSIONS

The use of hemostatic agents in oncologic breast surgery may result in decreased postoperative complications and significantly reduce time to JP drain removal.

Comparing oncoplastic breast reduction with immediate symmetry surgery to standard breast reduction surgery: Are postoperative complications worse?

INTRODUCTION

Oncoplastic breast reduction mammoplasty (ORM) is an excellent treatment option for women with breast cancer and macromastia undergoing breast conservation therapy. Here, we aim to better understand the risks associated with ORM compared to standard reduction mammoplasty (SRM).

METHODS

A retrospective chart review was performed of patients undergoing ORM or SRM from 2015 to 2021. Primary outcomes included the occurrence of major or minor postoperative complications in the two groups and delays to adjuvant therapy (>90 days) among the women undergoing ORM.

RESULTS

Women in the ORM group (n = 198) were significantly older (p < 0.001) with a higher prevalence of smoking (p < 0.001), diabetes mellitus (p < 0.01), and a Charlson comorbidity index ≥ 3 (p < 0.001) compared to women undergoing SRM (n = 177). After controlling for potential confounders, there were no significant between-group differences in the odds of developing postoperative complications (odds ratio = 0.80, 95% confidence interval: 0.36-1.69). Only 3% (n = 4) of the 150 women undergoing adjuvant radiation or chemotherapy experienced delays related to postoperative complications.

CONCLUSION

ORM has a similar safety profile as SRM, despite the older age and higher number of comorbidities often seen in patients undergoing ORM, and is a safe option for achieving contralateral symmetry at the time of partial mastectomy without delays to adjuvant therapy.

Oncoplastic breast reconstruction: Principles, current techniques, and future directions

Oncoplastic breast reconstruction has improved esthetic results after breast-conserving surgery with low complication rates and stable oncologic outcomes. Basic principles can be applied across different volume displacement and replacement techniques including restoration of breast shape and symmetry through esthetic incisions while eliminating dead space. Technique selection is guided by several factors including breast size, resection-to-breast ratio, and patient desires. A surgeon familiar with all techniques will allow individualization of treatment and optimization of outcomes.

Innovative Standards in Oncoplastic Breast Conserving Surgery: From Radical Mastectomy to Extreme Oncoplasty

BACKGROUND

Oncoplastic breast conserving surgery (OBCS), which is the current procedure of choice for eligible BC patients, describes a philosophy that prioritizes oncologic and cosmetic outcomes. However, knowledge gaps regarding training, acceptance, and practice preclude standardization and make it difficult to design algorithmic guidelines to optimize individualized management in the era of precision medicine.

SUMMARY

The harmony between patient expectations and oncologic goals creates the state of the art of OBCS. Nevertheless, to achieve these goals, multidisciplinary approach is a must. Surgical decisions require a comprehensive evaluation including patient factors, tumor biology, genetics, technical considerations, and adjunct therapies. Moreover, the quality-of-life (QOL) issues should be considered as the highest level of priority with a shared decision making instituted on realistic discussions with the patient.

KEY MESSAGES

The standardization in OBCS should be initiated via defining a breast surgeon who should gain theorical and practical competence on techniques via national or international educational programs. The algorithmic patient assessment with appropriate documentation before and after surgery should be established. A simple and safe global lexicon should be designed regarding techniques to be proposed and quality metrics to be considered. Additionally, international multicenter prospective trials should be instituted to overcome knowledge gaps. It is evident that OBCS is the perfect union of science with art. Nevertheless, at the very end, the question is not the nature of the surgeon/artist who would be the extremist, the innovator, or the conservative, but the patient's satisfaction, prognosis, and QOL that conclude the cascade of state of the art of OBCS.

Oncoplastic Mammoplasty with disguised geometric compensation

OBJECTIVE

To evaluate the results of a cohort of patients submitted to a new technique of oncoplastic mammoplasty, referred to as Disguised Geometric Compensation Mammoplasty (GCM), which is suitable for tumours involving the glandular tissue in the pillars of the mammoplasty.

MATERIALS AND METHODS

Twenty-five breast tumours involving the pillars of the mammoplasty were included, 20 (80.0%) invasive ductal carcinomas, 3 (12.0%) phyllodes tumours, 1 (4.0%) invasive lobular carcinoma, and 1 (4.0%) in situ ductal carcinoma. Preoperative markings followed the "Wise-pattern" technique. The resection of the tumour in the pillar, preserving the overlying skin, was geometrically compensated with a corresponding area coming from the lower poles, which folded over itself and maintained the skin vascularity in the pillar. One patient was converted to classic GCM due to a positive skin margin in the frozen section. Another patient combined a Classic GCM for the inner quadrants and a Disguised GCM for the outer quadrants on the same breast. One patient decided to undergo a bilateral mastectomy after some months because of a BRCA 1 mutation. Immediate fat grafting was done in one case. Approval from the ethics committee: n. 2.322.212.

RESULTS

Mean age was 47.0 ± 9.5 years. Mean clinical tumour size was 47.2 ± 22.2mm before chemotherapy and 36.7 ± 22.5mm, after. There were 11 (44.0%) locally advanced and 1 (4.00%) multicentric tumours. Nine (36.0%) were submitted to neoadjuvant chemotherapy. Adjuvant treatment was indicated according to the necessity. Ptosis was corrected in all cases. The aesthetic results were rated as excellent or good in 21 (95.5%) cases, by the Harris scale and the BCCT.core. The BREAST-Q scores for the satisfaction with the breasts and satisfaction with outcomes were 81.5 (±15.0) and 90.4 (±11.7), respectively. Intraoperative frozen sections were done in 12 (48%) cases. There was 1 (4.0%) focus of DCIS in the skin margin treated with radiotherapy. Minor complications occurred in 6 (24.0%) patients. There was 1 (4.0%) local recurrence treated with radical mastectomy, and 1 (4.0%) metastasis after 3 months. No deaths were observed within a mean follow-up time of 16.3 ± 11.4 months.

CONCLUSIONS

The disguised geometric compensation mammoplasty allowed breast conservation in situations requiring large resection in the pillars of the mammoplasty, with a high rate of free margins, correction of ptosis, satisfactory symmetry, and few complications.

Breast reconstruction during the COVID-19 pandemic in resource-limited settings

The coronavirus disease 2019 (COVID-19) is a novel, rapidly changing pandemic. It has affected specialized medical services in unprecedented ways. Surgical decision making, always the most important aspect of care has taken on an added layer of complexity in the face of the COVID-19 pandemic. Therefore, recommendations for breast reconstruction during COVID-19 remain challenging and unclear. This article reviews the impact of the COVID-19 pandemic and suggests potential approaches that could be considered in the absence of validated strategies in breast reconstruction.

A comprehensive literature review of patient-reported outcome measures (PROMs) among common breast reconstruction options: What types of breast reconstruction score well?

PURPOSE

Breast cancer continues to be the most prevalent cancer affecting women. Many reconstructive options exist after oncologic resection. Breast reconstruction can have a lasting impact on many areas of the patient's life, and therefore, a high consideration for patient satisfaction is crucial. Patient-reported outcome measures (PROMs) provide an important tool in the evaluation of different surgical methodologies. The aim of this comprehensive systematic review is to look at various surgical modalities in breast reconstruction as they relate to patient satisfaction.

METHODS

A PubMed PRISMA search was performed. Criteria for inclusion included nipple-sparing or skin-sparing mastectomy with autologous or implant-based reconstruction, level 2 volume displacement or volume replacement oncoplastic surgery, and measurement of patient-reported outcomes using the BREAST-Q or other validated PROMs. From the data set, weighted proportions were generated and analyzed using the Kruskal-Wallis rank sum test and a post hoc Dunn's test.

RESULTS

After obtaining 254 full text copies, 43 articles met inclusion criteria and were included. Analysis of BREAST-Q data showed oncoplastic breast surgery was significantly preferred over mastectomy regardless of the type of reconstruction. Nipple-sparing was significantly preferred over skin-sparing mastectomy, autologous reconstruction was significantly preferred over implant-based reconstruction, and prepectoral implant placement was preferred over subpectoral implant placement. Validated PROMs other than BREAST-Q showed similar trends in all but type of mastectomy.

CONCLUSIONS

In this comprehensive systematic review, oncoplastic surgery showed the most favorable PROMs when compared to other reconstructive modalities. Autologous was preferred over implant-based reconstruction, and prepectoral was preferred over subpectoral implant placement.