Oncoplastic mammaplasty with geometric compensation: Evolution of the technique, outcomes and follow‐up in a multicentre retrospective cohort

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.

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.

Factors associated with unsatisfactory cosmetic results in oncoplastic surgery

INTRODUCTION

Oncoplastic surgery (OS) has expanded the indications for breast-conserving surgery associated with an adequate aesthetic result. However, few studies have described the factors associated with unsatisfactory cosmetic outcomes from this surgical modality.

MATERIALS AND METHODS

This is a cross-sectional prospective study that included patients undergoing breast-conserving surgery (BCS) with or without OS. The patients self-evaluated the cosmetic results of the breasts posttreatment and had them photographed. The photos were analyzed by BCCT.core. Individual and treatment factors (local and systemic) for all patients were evaluated. These factors were dichotomized according to the use of OS and to the cosmetic result (satisfactory and unsatisfactory). Categorical variables were tested for association with surgical outcome using the chi-square test while numerical variables using the Mann-Whitney U test. Variables with p <0,2 were selected for multivariate analysis.

RESULTS

Of the 300 patients evaluated, 72 (24,0%) underwent OS. According to the patient self-evaluations, an unsatisfactory cosmetic result from OS was significantly associated with younger age at diagnosis, higher body mass index (BMI) at the time of evaluation, larger tumor size and greater weight of the surgical specimen. According to the BCCT.core, only the laterality of the tumor (left) was significantly associated with an unsatisfactory cosmetic result. In logistic regression, considering OS as a control variable, the risk of an unsatisfactory outcome according to patient self-evaluation was related to the tumor ≥ T2 odds ratio (OR) 1,85 (1,027-3,34) and age at diagnosis < 40 [OR 5,0 (1,84-13,95)]. However, according to the software, the variables were associated with an increased risk of an unsatisfactory outcome were the time interval between surgery and evaluation [OR 1,27 (1,16-1,39)], the presence of lymphedema [OR 2,97 (1,36-6,46)], surgical wound infection [OR 3,6 (1,22-11,16)], tumor location on the left side [OR 3,06 (1,69-5,53)], overweight [OR 2,93 (1,48-5,8)] and obesity [OR 2,52 (1,2-5,31)].

CONCLUSION

There is no standard methodology for breast cosmesis evaluation, which influences the factors associated with unsatisfactory results. Younger patients and those with increased BMI, left breast cancer and extensive resections tend to present with unsatisfactory cosmetic results when OS is performed.

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.

Dermoglandular advancement-rotation flap for conservative treatment of breast cancer - description of technique, objective and subjective assessments

Objective

to describe and evaluate the dermoglandular advancement-rotation flap with no contralateral surgery as a technique for the conservative treatment of breast cancer when skin or a large proportion of gland requires resection.

Patients/Methods

14 patients with breast tumors with a mean size of 4.2 cm and need for skin resection. The resection area is included within an isosceles triangle, with its apex located on the areola, which is the pivot for rotation of a dermoglandular flap released through a lateral extension along that triangle base. Symmetry before and after radiotherapy was objectively assessed by authors using the BCCT.core software, as well as subjectively by three experts and patients themselves using the Harvard scale.

Results

Experts considered the breast symmetry results to be excellent/good for 85.7% of patients in the early post-operative period and 78.6% in the late post-operative period. Excellent/good ratings provided by BCCT.core software amounted to 78.6% of cases in the early post-operative period and 92.9% in the late post-operative period. Symmetry was rated as excellent/good by 100% of patients.

Conclusion

Dermoglandular advancement-rotation flap technique with no contralateral surgery provides good symmetry when a large proportion of skin or gland requires resection on breast conservative cancer treatment.

Breast-conserving surgery with the geometric compensation/split reduction technique. Indications, oncologic safety and cosmesis. A cohort series and systematic review of the literature

BACKGROUND

The Geometric Compensation Technique (GCT) and the Split Reduction Technique (SRT) enables breast conserving surgery (BCS) in selected patients with breast cancer initially candidates to mastectomy.

METHODS

Observational study of patients with breast cancer who underwent GCT consecutively treated. Evaluated retrospectively: indications, clinical characteristics, surgical features and recurrences. Cosmesis were evaluated prospectively by the BCCT.core software, Harris/Harvard and Garbay scales. Descriptive statistics were performed, chi-square test was used to compare aesthetic outcomes; Kappa and Weighted Kappa test was used to assess agreement between the postoperative evaluations; Kaplan-Meier model for follow-up and recurrence. A systematic review was carried out using PRISMA methodology.

RESULTS

Thirty-six patients were evaluated, 26 (72.2%) with medium/large breasts with or without ptosis, seven (19.4%) with small breasts with or without ptosis, a profile undergoing GCT not previously identified in the literature. The mean tumor clinical size was 3.65 ± 1.59 cm. 34 (94.4%) patients underwent GCT. Mean follow-up time was 36.6 ± 16.8 months, with no local recurrences. According to BCCT.core, the postoperative aesthetic was good in 17 (51.5%) patients and 11 (33.3%) was reasonable. In the systematic review, 3.584 articles were evaluated, 20 articles were selected, 243 patients undergoing GCT were found, with several indications for BCS instead of mastectomy, with high rates of free margins, low recurrence and good aesthetic outcomes.

CONCLUSION

GCT, an oncologically safe and aesthetically satisfactory option, has been extended to patients with small and medium breasts with ptosis, large tumors to breast volume or in unfavorable resection sites, initially candidates for mastectomy.

The iTOP trial: Comparing immediate techniques of oncoplastic surgery with conventional breast surgery in women with breast cance - A prospective, controlled, single-center study

INTRODUCTION

Oncoplastic techniques allow resection of larger tumors, permitting breast conservation in cases otherwise requiring mastectomy. We sought to prospectively compare quality of life (QoL) in patients undergoing oncoplastic surgery as compared to conventional breast conservation (CBC) or mastectomy is lacking.

METHODS

Patients diagnosed with BIRADS IV-VI lesion were eligible if resection of ≥10% of the breast volume was planned. Patients were allowed to decide whether they wanted to undergo CBC or oncoplastic breast conservation (OBC). Patients who underwent mastectomy and immediate breast reconstruction (IBR) were also included for comparison. The primary endpoint was breast self-esteem using the Breast Image Scale (BIS) at 12 months, secondary endpoints were perioperative morbidity and QoL using the BREAST-Q questionnaire.

RESULTS

From 2011 to 2016, 205 patients were included in the study. 116 patients (56.6%) received CBC, 46 (22.4%) OBC and 43 (21%) MIBR. Women in the OBC group were more likely to have tumors ≥ 2cm than those in the CBC group (34.7% vs. 17.5%, respectively). Women who underwent MIBR were more likely to have tumors > 5cm than those in the CBC and OBC groups (23% vs 1% and 10%, respectively). The BIS and BREAST-Q improved in each group after 12 months but did not differ significantly between groups at any time point. Surgical complications (seroma, bleeding, infection, necrosis) were numerically more likely in the OBC and MIBR groups.

CONCLUSION

OBC and the MIBR allow for resection of larger tumors with a similar quality of life as CBC.

Inverted-T pattern reduction mammoplasty in bilateral breast ptosis: cosmetic and oncological outcomes

Background

Breast ptosis is directly caused by Cooper's ligament laxity, with the decline of nipple areola complex (NAC) and mammary parenchyma. Breast cancer with ptosis is always a knotty problem that can hardly be repaired by classic breast conservation surgery (BCS) ending up with a pleasing appearance. We analyzed our 12 years' experience of performing inverted-T pattern techniques to treat bilateral breast ptosis, with or without breast cancer.

Methods

One hundred forty-eight breasts in 74 patients undergoing inverted-T pattern reduction mammoplasty were included in this study. Information about patients' clinical and surgical characteristics, complications, NAC sensitivity, cosmetic and oncological outcomes were collected and retrospectively analyzed.

Results

In the cohort of 57 patients with pure breast ptosis, the mean body mass index (BMI) was 25.2 kg/m², and the mean weight of resected tissue from the left and right breast reductions were 744.9 and 756.7 g. In the cohort of 17 patients diagnosed as breast cancer with ptosis, the mean BMI was 25.1 kg/m², and the mean weight of resected tissue were 504.1 g for left and 535.6 g for right side. The majority of repairs were performed for tumors located in the upper outer (58.8%), mostly with inferior or superomedial pedicles (90%). All the upper inner tumors were repaired with inferior pedicles. Minor complications such as seroma (8.1%), NAC epidermolysis (8.1%), delayed wound healing (4.1%) were detected postoperatively. Partial NAC necrosis occurred in one patient (1.4%). 82.4% of all the patients rated "very satisfied" or "satisfied" as the final cosmetic outcomes. NAC sensitivity was "very high" and "high" in 82.4% patients. No local occurrence, distant metastasis and mortality occurred in tumor patients.

Conclusions

The inverted-T pattern reduction mammoplasty is a reliable technique to treat bilateral breast ptosis with a low complication rate. For cases with breast cancer, this technique can achieve both satisfying cosmetic outcomes and oncological safety.

Outcome reporting in therapeutic mammaplasty: a systematic review

Background

Therapeutic mammaplasty (TM) is an oncological procedure which combines tumour resection with breast reduction and mastopexy techniques. Previous systematic reviews have demonstrated the oncological safety of TM but reporting of critically important outcomes, such as quality of life, aesthetic and functional outcomes, are limited, piecemeal or inconsistent. This systematic review aimed to identify all outcomes reported in clinical studies of TM to facilitate development of a core outcome set.

Methods

Medline, EMBASE, CINAHL and Web of Science were searched from inception to 5 August 2020. Included studies reported clinical outcomes following TM for adult women. Two authors screened articles independently for eligibility. Data were extracted regarding the outcome definition and classification type (for example, oncological, quality of life, etc.), time of outcome reporting and measurement tools.

Results

Of 5709 de-duplicated records, 148 were included in the narrative synthesis. The majority of studies (n = 102, 68.9 per cent) reported measures of survival and/or recurrence; approximately three-quarters (n = 75, 73.5 per cent) had less than 5 years follow-up. Aesthetic outcome was reported in half of studies (n = 75, 50.7 per cent) using mainly subjective, non-validated measurement tools. The time point at which aesthetic assessment was conducted was highly variable, and only defined in 48 (64.0 per cent) studies and none included a preoperative baseline for comparison. Few studies reported quality of life (n = 30, 20.3 per cent), functional outcomes (n = 5, 3.4 per cent) or resource use (n = 28, 18.9 per cent).

Conclusion

Given the oncological equivalence of TM and mastectomy, treatment decisions are often driven by aesthetic and functional outcomes, which are infrequently and inconsistently reported with non-validated measurement tools.

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.