Oncoplastic breast surgery: indications, techniques and perspectives

Publication Trends in Aesthetic Breast Surgery: A Bibliometric Analysis

Background

Aesthetic breast surgery (ABS) encompasses breast augmentation, breast reduction, mastopexy, and mastopexy augmentation. This topic has seldom been assessed as a bibliometric study. This analysis aims to address this gap and identify trends in ABS literature to guide future research areas. Bibliometrics, the quantitative analysis of publications, particularly scholarly literature, offers valuable insights into research trends and impact.

Objectives

This analysis aims to address this gap and identify trends in ABS literature to guide future research areas.

Methods

The 100 most-cited publications in ABS were identified on Web of Science (Clarivate Analytics, Philadelphia, PA), across all available journal years (from 1953 to 2024). Study details, including the citation count, main content focus, and outcome measures, were extracted and tabulated from each publication. The Oxford Centre for Evidence Based Medicine and levels of evidence (LOE) of each study were assessed.

Results

The 100 most-cited publications in ABS were cited by a total of 11,522 publications. Citations per publication ranged from 46 to 1211 (mean 115.2 ± 135.7), with the highest-cited study being the Pusic BREAST-Q paper (n = 1211). A majority of publications were LOE 4 (n = 30), representative of the large number of case series. The number of publications for LOE 5, 3, 2, and 1 was 12, 28, 21, and 9, respectively. The main content focus was "outcomes" in 52 publications, followed by "nonoperative management" (n = 12) and "surgical technique" (n = 12). Patient-reported outcome measures (PROMs) were used in 29 publications, and 53 publications reported aesthetic outcome measures.

Conclusions

This analysis highlights that research methodologies in ABS studies should be improved. This necessary improvement would be facilitated by vigorous, high-quality research, and the implementation of validated ABS-specific PROMs enhancing patient satisfaction, particularly in aesthetic procedures, such as BREAST-Q.

Level of Evidence 4

Chest wall perforator flap partial breast reconstruction: a retrospective analysis of surgical, cosmetic and survival outcome

Introduction

Oncoplastic breast surgery includes volume replacement as well as volume displacement. Autologous tissue is the preferred approach for volume replacement and includes chest wall perforator flaps (CWPF). Although described more than a decade ago, CWPFs have not been adopted widely in clinical practice till recently. We report the largest single-centre institutional data on CWPFs.

Patients and methods

The study includes all patients who underwent breast conservation surgery (BCS) using CWPFs from January 2015 to December 2022. Data were retrieved from the institutional electronic record and Redcap database. The analysis was done using SPSS 23 and STATA 14.

Results

150 patients were included in the study. The mean age was 48.8 years (SD 10.4), and the body mass index was (26.6 kg/m2, SD 4.3). >50% of patients had breasts with small cup sizes (A&B) and mild ptosis (Non-ptotic and Grade 1 ptosis). 44.7% of patients underwent lateral intercostal artery perforator flap (LICAP), anterior intercostal artery perforator flap in 31.3%, lateral thoracic perforator flap (LTAP) in 12%, LICAP + LTAP in 11.3% and thoracodorsal artery perforator flap in 1%. Post-operatively, haematoma was seen in 1.3%, complete flap necrosis in 1.3%, seroma in 7%, wound dehiscence in 12%, and positive margin in 6.7%. 92 patients responded to the satisfaction assessment, of which >90% were happy with the surgical scars, comfortable going out in a public place, satisfied with the symmetry of the breast, and no one chose mastectomy in hindsight. The 5-year predicted disease free survival and overall survival were 86.4% and 94.7%, respectively.

Conclusion

BCS with CWPF is an excellent option for reconstruction in small to medium-sized breasts. It is associated with minimal morbidity and comparable patient-reported cosmetic and survival outcomes.

Usefulness of nerve-sparing pedicled segmental latissimus dorsi muscle flap combined with lateral thoracic skin flap for partial volume reconstruction in laterally located breast cancer

Background

The latissimus dorsi muscle (LDM) is a flexible muscle that is frequently employed in various reconstructive operations. Breast-conserving surgery is widely acknowledged as an effective treatment for breast cancer, and the latissimus dorsi muscle flap is a straightforward, dependable technique for partial breast reconstruction.

Methods

A pedicled segmental latissimus dorsi muscle flap was employed in 20 patients with laterally situated breast cancer treated at our institution from January 2018 to December 2021. During a 6-month postoperative follow-up period, patients were polled on their overall satisfaction and cosmetic satisfaction. Plastic surgeons assessed the aesthetic and functional outcomes in terms of breast shape and symmetry, as well as muscular function.

Results

The mean operative time was 120 ± 35.2 min while the mean postoperative hospital stay was 2.5 days (range, 1.5–3 days). There were no donor site complications such as intraoperative bleeding, postoperative hematoma, or infection, and postoperative drain removal was done on average after 5 days. The average weight of specimens was 50–160 gm with a mean of 100 gm, and the locations of the masses were the upper lateral quadrant (n = 15), the lower lateral quadrant (n = 2), and the central lateral area (n = 3). Complications developed in 6 of the cases, hematoma in 2 cases, wound seroma developed in the donor site in 2 cases, and weakness in shoulder movement in 2 cases, and the majority of the patients were satisfied with their cosmetic outcomes. No tumor recurrence was reported.

Conclusion

Replacement of 20 to 40% of breast volume in the upper and the lower outer quadrants with a latissimus dorsi muscle flap as nerve-sparing pedicled segmental flap that can be harvested from the same axillary incision of lymphadenectomy is a good alternative reconstruction technique after partial mastectomy. This resulted in an acceptable postoperative scar, less pain, and early upper extremity movement, so this technique is considered a useful and reliable technique in correcting breast deformity after breast-conserving surgery, especially in laterally located breast cancer.

Level of evidence: Level IV, therapeutic study.

Interactive exploration of a global clinical network from a large breast cancer cohort

Despite unprecedented amount of information now available in medical records, health data remain underexploited due to their heterogeneity and complexity. Simple charts and hypothesis-driven statistics can no longer apprehend the content of information-rich clinical data. There is, therefore, a clear need for powerful interactive visualization tools enabling medical practitioners to perceive the patterns and insights gained by state-of-the-art machine learning algorithms. Here, we report an interactive graphical interface for use as the front end of a machine learning causal inference server (MIIC), to facilitate the visualization and comprehension by clinicians of relationships between clinically relevant variables. The widespread use of such tools, facilitating the interactive exploration of datasets, is crucial both for data visualization and for the generation of research hypotheses. We demonstrate the utility of the MIIC interactive interface, by exploring the clinical network of a large cohort of breast cancer patients treated with neoadjuvant chemotherapy (NAC). This example highlights, in particular, the direct and indirect links between post-NAC clinical responses and patient survival. The MIIC interactive graphical interface has the potential to help clinicians identify actionable nodes and edges in clinical networks, thereby ultimately improving the patient care pathway.

Subcutaneous Quadrantectomy Is a Safe Procedure in Management of Early-Stage Breast Cancer

Background

A less-invasive surgery is often required today for many tumors, when oncologic radicality is strictly ensured, both to minimize hospital stay and health costs and to guarantee aesthetical results. Breast surgery for cancer has been radically changed in the last years since conservative interventions are widely performed everywhere.

Methods

The authors present 75 cases of early breast cancer, randomly treated with standard quadrantectomy and subcutaneous quadrantectomy; the totally subcutaneous surgical technique implies only a short periareolar skin incision and a complete quadrant resection with skin and subcutaneous layer preservation. Continuous data were analyzed by unpaired Student's t-test. The Chi-square test was used to cumulate categorical variables. The Kaplan–Meyer method and log-rank test were used to compare the overall survival and disease-free survival.

Results

No difference was found among the two groups in terms of the type of tumor, overall survival (OS), disease-free survival (DFS), early complications, radicality, and mortality. The only significant differences were both found in the length of hospital stay and in postoperative breast deformity that required further intervention in some cases.

Conclusion

In the era of mini-invasive surgery and quality assurance, the authors conclude that subcutaneous quadrantectomy is a safe procedure that allows less health cost and a better aesthetical result.

Complications after breast reconstruction with alloplastic material in breast cancer patients submitted or not to post mastectomy radiotherapy

Background and purpose

Breast reconstruction following mastectomy is a relevant element of breast cancer treatment. The purpose of this study was to evaluate the influence of radiotherapy (RT) on local complications in patients with breast cancer that had undergone breast reconstruction with alloplastic material.

Materials and methods

Retrospective study of breast cancer patients submitted to mastectomy and breast reconstruction from 2009 to 2013. Clinical and treatment variables were correlated with early and late complications.

Results

251 patients were included; mean age was 49.7 (25 to 78) years. Reconstruction was immediate in 94% of the patients, with 88% performed with a temporary tissue expander. Postoperative radiotherapy (RT) was delivered to 167 patients (66.5%). Early complications were present in 26.3% of the patients. Irradiated patients presented 5.4% incidence of late complications versus 2.4% for non-irradiated patients (p = 0.327). Diabetes (OR = 3.41 95% CI: 1.23-9.45, p = 0.018) and high body mass index (BMI) (OR = 2.65; 95% CI: 1.60-4.37, p < 0.0001) were the main risk factors. The overall incidence of late complications was 4.4%, with predominance of severe capsular contracture (8/11). Arterial hypertension (OR = 4.78; 95% CI: 1.97-11.63, p = 0.001), BMI (OR = 0.170; 95% CI: 0.048-0.607, p = 0.006) and implant placement (OR = 3.55; 95% CI: 1.26-9.99, p = 0.016) were related to late complications.

Conclusions

The overall rate of complications was low in this population. Radiotherapy delivery translated into a higher but not statistically significant risk of late complications when compared with the non-irradiated patients. Already well-known clinical risk factors for complications after breast reconstruction were identified.

Advanced breast conservation and partial breast reconstruction - a review of current available options for oncoplastic breast surgery

Breast cancer is the most common cancer affecting one in three women with new cancer diagnosis in England. Breast-conserving surgery is the primary surgical option in a vast majority of these patients. Use of oncoplastic techniques in breast conservation surgery has significantly improved the aesthetic outcomes without compromising the oncological safety of cancer resections. Oncoplastic breast-conserving surgery (OPBCS) has transformed the specialty with a paradigm shift in ideology and the recognition that aesthetic and oncological resections are synonymous when planning surgical intervention for patients with breast cancer. The two main options for OPBCS are therapeutic mammoplasty and partial beast reconstruction using pedicle-based flaps. This review aims to highlight key concepts in OPBCS demonstrating an overview of these surgical techniques, their safety, outcomes and the emergence of extreme oncoplastic breast surgery.

Extreme Oncoplasty: Breast Conservation in Patients with Large, Multifocal, and Multicentric Breast Cancer

INTRODUCTION

Extreme Oncoplastic Breast Conservation Surgery (EOBCS) is offered in selected patients with multifocal or multicentric breast cancer (MFMC). Recent evidence has suggested that EOBCS may be a valuable resource for patients with MFMC who may avoid the risk associated with mastectomy in favour of the benefits of breast conservation without risking their oncological outcomes. Our study examined the practice of EOBCS in two regional breast units in Glasgow, United Kingdom.

MATERIALS AND METHODS

A prospectively collected database of 50 patients treated with EOBC in two breast units in Glasgow between 2007 and 2018 were evaluated, and clinical outcomes were observed.

RESULTS

Fifty patients (median age 55) underwent EOBCS, of which 43 (86%) had invasive disease. Median tumour size was 55mm (50-90) and multifocal disease was identified in 22 (44%) patients. Nine patients (18%) were found to have positive margins and underwent a second procedure, with 6 (12%) proceeding to mastectomy. Five-year disease free survival rate was 91.5%, while cancer-specific survival was 95.7%.

CONCLUSION

EOBCS is oncologically safe in short-term follow-up. Large scale studies are required to confirm these preliminary results, in order to offer EOBCS as a valid option to patients with advanced or multifocal breast cancer.

Chest wall perforator flaps for partial breast reconstruction: Surgical outcomes from a multicenter study

Background

Perforator artery flaps based on the branches of intercostal arteries and lateral thoracic artery can be used for reconstruction after breast-conserving surgery (BCS). Although described more than a decade ago, these have not been adopted widely in clinical practice. We report on short-term and long-term surgical outcomes of partial breast reconstruction using chest wall perforator flaps from a prospective multicenter audit.

Methods

All patients operated for BCS and partial breast reconstruction using intercostal artery perforator or lateral thoracic artery perforator flaps from January 2015 to October 2018 were included in the analysis. Oncoplastic breast surgeons with appropriate level of training performed all tumor excisions and reconstructions as a single-stage procedure. Patient characteristics, treatment details and surgical outcomes were noted. Specific outcomes recorded were margin re-excision and complication rates.

Results

One hundred and twelve patients underwent the procedure in the given study period. The median age was 54 years. Median specimen weight was 62.5 g and median volume of excision was 121.4 mL. Fifteen patients (13.39%) underwent a margin re-excision for close or positive margins without additional morbidity. One patient required a completion mastectomy. Eight patients (7.14%) had an early complication. None of the patients required a contralateral symmetrization procedure. The results were comparable across the participating centers.

Conclusions

Chest wall artery perforator-based flaps are an excellent option for lateral and inferior quadrant partial breast reconstructions. The short and long-term surgical outcomes are comparable across sites and can be performed with minimal morbidity. Patient-reported outcome measures need to be studied.

Oncoplastic Volume Replacement for Breast Cancer: Latissimus Dorsi Flap versus Thoracodorsal Artery Perforator Flap

Volume replacement oncoplastic breast techniques have become one of the standard lines in the treatment of early breast cancer. They have better cosmetic outcome and patient satisfaction. Latissimus dorsi (LD) flap is one of the most commonly used flaps for these techniques. Although it shows satisfactory surgical outcomes, postoperative shoulder dysfunction is an obvious drawback. The aim of this study was to compare LD flap with thoracodorsal artery perforator (TDAP) flap after breast-conserving surgery regarding surgical outcomes, patient satisfaction, and impact on shoulder function.

A Novel Level I Oncoplastic Surgery Technique for Tumors Located in UIQ of the Breast Far from the Nipple: The "Cross" Technique

Breast surgery was revolutionized with the use of oncoplastic reshaping techniques minimizing breast deformities and esthetic complications. However, the application of the current oncoplastic techniques becomes challenging in some situations such as small-size breasts and when the tumors are located in special locations of the breast, for example, upper inner quadrant. In this article, an optimized oncoplastic technique named the "Cross" technique is introduced to overcome the abovementioned problems in the surgery of breast tumors located in the upper inner quadrant far from the center of the breast. Nineteen oncoplastic surgeries were performed by the same breast surgeon. The mean diameter and weight of the excised specimens were 20 mm and 74 g. The mean age of the patients was 51 years. Clear surgical margins were obtained in all patients. There was no marked deformity in the breast after surgery. The optimized technique produced promising results in our hands when applied to a selected group of patients. Moreover, the technique was found to reduce the need for revision surgery in ptotic breasts, as the alteration in the shape of the breast undergoing surgery is not significant enough to introduce asymmetry to the breasts.

Investigation into breast cancer and partial breast reconstruction: A review

Growing increasingly in South America, Africa and Asia, breast cancer is known as the dominant type of cancer in women. Different treatments are available for breast cancer, among which surgery is the most widely used, but researchers are trying to develop new strategies. One of the most prominent surgical methods is referred to as oncoplastic surgery, that helps to remove segments of malignant breast tissue. This type of surgery aims to obtain vast surgical margins, while the remaining tissue is rearranged so that the better cosmetic outcome is obtained. This review will investigate the breast cancer and then discuss partial breast reconstruction. Before outlining the procedures, the different types of partial breast reconstruction will be discussed. Finally, advantages and disadvantages will be outlined. MEDLINE database was used to conduct the search. The main terms used were ‘Conservation Breast Surgery Reconstruction’ AND ‘Oncoplastic Surgery’, ‘Partial Mastectomy Reconstruction’ AND ‘Conservative Breast Surgery Reconstruction’, ‘oncoplastic’ [All Fields], ‘breast’ AND ‘surgery’ OR ‘surgery’ operative’, ‘oncoplastic’ (‘breast’)’. The bibliographies of relevant papers were manually searched up to October 2018, but more recent voices are also included.

Oncoplastic central quadrantectomies

Tumors localized in the central quadrant (centrally located breast tumors) have always represented a challenge for the surgeon because of the critical aesthetical matters related to the nipple-areola complex (NAC). Many years of experience with breast cancer patients treated by using various oncoplastic techniques, has allowed us to develop the modified hemibatwing for the treatment of central breast tumors, where the NAC is involved. Modified hemibatwing-along with the removal of the NAC-is a useful oncoplastic technique and it represents an ideal option for the treatment of central tumors because it assures oncological safety, a reduced surgical timetable and greater aesthetical results.

Conservative mastectomies and Immediate-DElayed AutoLogous (IDEAL) breast reconstruction: the DIEP flap

BACKGROUND

With the development of conservative mastectomies, there are an increasing number of women seeking immediate implant based and autologous breast reconstruction. Despite the oncologic safety of the procedures, the focus will be on the timing of reconstruction.

METHODS

Our plastic surgery unit is focused primarily on autologous breast reconstruction and is part of an interdisciplinary breast center. We offer immediate breast reconstruction (IBR) with autologous tissue for patients with positive BRCA 1 and 2, ductal carcinoma in situ (DCIS), invasive cancer without margin problems to the skin, as well as to correct poor oncologic and aesthetic breast conserving therapy (BCT) outcomes. In the majority of cases we prefer an Immediate-DElayed AutoLogous (IDEAL) breast reconstruction concept with a two-stage procedure.

RESULTS

Over the last 10 years we performed more than 1,600 breast reconstructions with free flaps, performing the deep inferior epigastric perforator (DIEP) flap as our first choice for autologous tissue. We recommend IDEAL breast reconstruction, however approximately 15% of our cases are immediate one stage conservative mastectomies and breast reconstruction with the DIEP flap.

CONCLUSIONS

For immediate reconstruction, the aesthetic outcome should not take precedence over oncologic considerations. Immediate one-stage, breast reconstruction with autologous tissue can be offered to the suitable patients which is most likely a healthy women with a small-to-medium sized non ptotic breast receiving a conservative mastectomy. In all other cases, we recommend an IDEAL breast reconstruction approach in order to achieve a final result that is both satisfyingly pleasing and oncologically safe.