A Head-to-Head Comparison of Quality of Life and Aesthetic Outcomes following Immediate, Staged-Immediate, and Delayed Oncoplastic Reduction Mammaplasty [Outcomes Article]:

Crowdsourced Assessment of Aesthetic Outcomes of Dorsal Preservation Rhinoplasty

BACKGROUND

The inherent subjectivity in aesthetic outcomes presents a unique challenge in assessing rhinoplasty. Crowdsourcing has provided a new metric for objective analysis. The authors designed a retrospective study to compare the aesthetic outcomes of dorsal preservation rhinoplasty vs structural rhinoplasty.

OBJECTIVES

We aimed to objectively quantify the relative aesthetic advantages of performing a dorsal preservation technique. Additionally, we aimed to demonstrate the efficacy of crowdsourcing as an efficient and reliable method for evaluating any plastic surgery aesthetic outcome.

METHODS

Patients' preoperative and postoperative photographs were divided into 2 cohorts. Photographs were evaluated by crowdworkers on a secure online rating platform based on the overall nasal appearance, dorsal profile, dorsal aesthetic line symmetry, and dorsal contour, and rated their confidence about whether a patient had undergone surgery. A delta was calculated by comparing preoperative to postoperative states to represent an absolute value of improvement after surgery. Each cohort was compared with non-paired t tests.

RESULTS

The structural rhinoplasty cohort included 34 patients. The dorsal preservation cohort included 30 patients. Both cohorts demonstrated improved aesthetic outcomes (dorsal preservation 0.300, 95% CI 0.047; structural 0.377, 95% CI 0.055). When raters were asked to predict whether a patient had surgery, the correlation coefficient of the structural cohort (0.74) suggested that a crowdworker was better able to identify whether a patient had surgery in those patients. The correlation coefficient in the dorsal preservation cohort (-0.0554) suggested that the raters were unable to identify which patients had surgery.

CONCLUSIONS

We found significant improvements in overall aesthetic outcomes with both techniques, although a more natural "unoperated" outcome was achieved when performing a dorsal preservation technique. We also provide evidence of the efficacy of crowdsourcing as an efficient and reliable method for evaluating aesthetic outcomes.

LEVEL OF EVIDENCE: 4 (THERAPEUTIC)

Enhancing breast cancer surgery outcomes: A comprehensive review of oncoplastic techniques, surgical planning, and aesthetic considerations

Breast cancer is one of the most common types of cancer among women in Western countries. Historically treated with radical and modified radical surgeries, breast cancer is now primarily managed with breast-conserving surgery combined with postsurgical radiotherapy. Oncoplastic breast surgery, a technique that integrates aesthetic breast reduction methods with cancer surgery, has been developed as a tumor-specific approach to facilitate breast conservation while removing the tumor. This method allows for higher excision volumes with minimal aesthetic compromise. The main components of oncoplastic surgery are volume displacement and volume replacement techniques. This review discusses the essential role of oncoplastic techniques in breast-conserving surgery (BCS), which has evolved into the standard of care for early-stage breast cancer. Understanding these techniques is critical for all breast surgeons to optimize both aesthetic and oncologic outcomes.

Does Prior Breast Irradiation Increase Complications of Subsequent Reduction Surgery in Breast Cancer Patients? A systematic Review and Meta-Analysis

BACKGROUND

Reduction mammoplasty and mastopexy are potentially complicated by prior breast irradiation as part of breast conserving therapy. Associated tissue changes with therapeutic irradiation have led to surgeons deciding the risks may outweigh potential benefit for those patients. A systematic review of the existing literature was performed to explore surgical outcomes of patients undergoing delayed bilateral reduction mammoplasty or mastopexy following unilateral breast irradiation as part of breast conserving therapy.

METHODS

Medline, PubMed and EMBASE were searched from 1990 to 2023 according to PRISMA guidelines. Studies were combined by the generic inverse variance method on the natural logarithms of rate ratios (RR) using a random effect model in Review manager 5.4.1.

RESULTS

Fifteen studies reported outcomes in 188 patients who underwent breast reduction (BR) following unilateral breast conserving surgery and radiotherapy. The median age at BR was 51.5 years (range 39-60), and median time since radiotherapy was 48 months (range 11.7-86). We compared outcomes for irradiated breast (IB) versus non-irradiated breast (NIB). Pooled results showed higher rate of major complications in the IB (RR 2.52, 95%CI 0.96-6.63, p=0.06), but not statistically significant. However, rate of minor complications was significantly higher in the IB (RR 3.97 95%CI 1.86-8.50, p<0.0004). Incidence of fat necrosis as a discrete complication was 2× higher in IB (RR 2.14 95%CI 0.85-5.35, p-value 0.10) compared to the NIB, but not significant.

CONCLUSION

We found breast reduction to be safe with acceptable risk of major complications. However, the overall complication rate remains higher in IB compared to NIB.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of contents or the online Instructions to Authors www.springer.com/00266 .

Oncoplastic Techniques and Tricks to Have in Your Toolbox

SUMMARY

Oncoplastic breast reconstruction seeks to address partial mastectomy defects in the setting of breast-conserving surgery to achieve superior aesthetic outcomes with comparable oncologic safety compared with traditional breast conservation surgery. As such, oncoplastic breast-conserving surgery has grown in popularity in recent years. Several techniques have been used to displace the volume with the remaining breast tissue or replace it with local soft-tissue options, with decision-making guided by patient and tumor characteristics, additional treatment requirements, patient preference, and available tissue resources. The purpose of this review is to provide an overview of considerations in oncoplastic breast reconstruction with a focus on techniques and tips to achieve optimal outcomes.

Immediate or delayed oncoplastic surgery after breast conserving surgery at the Netherlands Cancer Institute: a cohort study of 251 cases

PURPOSE

Oncoplastic surgery (OPS) after breast conserving surgery is preferably performed during the same operation. Offering delayed OPS instead of mastectomy to patients with a high risk of tumor-positive margins allows breast conservation with the option of margin re-excision during OPS, without having to dismantle the reconstruction. We aimed to evaluate surgical outcomes after immediate and delayed OPS.

METHODS

We included early-stage breast cancer patients who underwent OPS at the Netherlands Cancer Institute between 2016 and 2019. Patients were selected for delayed OPS after multidisciplinary consultation if the risk of tumor-positive margins with immediate OPS was considered significant (> 30%). Groups were compared on baseline characteristics and short-term surgical outcomes.

RESULTS

Of 242 patients with 251 OPS, 130 (52%) OPS had neoadjuvant chemotherapy. Immediate OPS was performed in 176 (70%) cases and delayed OPS in 76 (30%). Selection for delayed OPS was associated with tumor size (OR 1.03, 95% CI 1.01-1.04), ILC (OR 2.61, 95% CI 1.10-6.20), DCIS (OR 3.45, 95% CI 1.42-8.34) and bra size (OR 0.76, 95% CI 0.62-0.94). Delayed and immediate OPS differed in tissue weight (54 vs. 67 g, p = 0.034), tissue replacement (51% vs. 26%, p < .001) and tumor-positive margins (66% vs. 18%, p < .001). Re-excision was performed in 48 (63%) delayed OPS and in 11 (6%) immediate OPS. Groups did not differ in complications (21% vs. 18%, p = 0.333). Breast conservation after immediate and delayed OPS was 98% and 93%, respectively.

CONCLUSION

Performing delayed OPS in selected cases facilitated simultaneous margin re-excision without increasing complications, and resulted in an excellent breast conservation rate.

Revisiting Reduction Mammaplasty: Complications of Oncoplastic and Symptomatic Macromastia Reductions

BACKGROUND

Oncoplastic breast reduction has been shown to be an effective and safe approach to breast conservation surgery in women with macromastia. However, there remains a paucity of data investigating the comparative outcomes. This study seeks to delineate the complication profiles for oncoplastic and symmetrizing breast reductions versus mammaplasty for benign macromastia.

METHODS

A retrospective review was conducted of all consecutively performed reduction mammaplasty cases at a single institution by two plastic surgeons over a 2-year period.

RESULTS

A total of 632 breasts were analyzed: 502 reduction mammaplasties, 85 symmetrizing reductions, and 45 oncoplastic reductions in 342 patients. Mean age was 43.9 ± 15.93 years, mean body mass index was 29.15 ± 5.66 kg/m2, and mean reduction weight was 610.03 ± 313.13 g. Regarding surgical technique, a medial pedicle was used in 86% of cases. There were similar postoperative complication outcomes for nipple necrosis, wound healing, scar revision, fat necrosis, seroma, hematoma, and overall complication rates for all procedures. However, the rate of postoperative revision among reduction mammaplasty (2%), oncoplastic reduction (6.7%), and symmetrizing reduction (5.9%) was significantly different (P = 0.027). In univariate analysis, diabetes (P = 0.011), smoking (P = 0.007), higher body mass index (P = 0.003), larger reduction weight (P = 0.011), longer nipple-to-inframammary fold measurement (P = 0.014), and longer sternal notch-to-nipple measurement (P = 0.039) were all significant risk factors for a surgical complication in reductions performed for any indication. Using a multivariate logistic regression model, diabetes (P = 0.047), smoking (P = 0.025), and higher body mass index (P = 0.002) were all retained as statistically significant risk factors.

CONCLUSION

The complication profiles for both oncoplastic breast reductions and breast reductions for symptomatic macromastia are similar and acceptably low.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Safety of Reduction Mammaplasty and Mastopexy After Breast Conservation Therapy and Radiation Therapy: A Case Series

BACKGROUND

Conservative surgery and radiotherapy (CS + RT) have become the standard of care for early-stage breast cancer as an alternative to mastectomy. With the increasing rate of obesity and incidence of macromastia, surgeons increasingly encounter patients with a history of breast radiation desiring breast reduction. However, elective breast surgery after irradiation remains to be controversial due to known adverse effects of radiation, especially on wound healing, and unknown effects of lumpectomy on traditional pedicle choices. Herein, we present our experiences and outcomes of reduction mammaplasties and mastopexies in patients with breast cancer previously treated with CS + RT.

METHODS

Between 2009 and 2020, 13 patients undergoing reduction mammaplasty or mastopexy, who have previously underwent CS + RT with or without axillary surgery, were included in this study. Surgical techniques and complications, including delayed wound healing, infection, fat necrosis, and nipple-areolar necrosis, were recorded and analyzed based on the irradiated versus nonirradiated sides.

RESULTS

Of the 13 patients, delayed wound healing occurred in 7% on the irradiated side and 15% on the nonirradiated sides (P > 0.05). No significant correlation was observed between the number of complications and time of elective breast surgery from the last radiation therapy. Complications between irradiated and nonirradiated breasts did not significantly differ in both the reduction mammaplasty and mastopexy groups.

CONCLUSIONS

Reduction mammaplasty and mastopexy in patients with a history of lumpectomy and breast irradiation can be safely performed and should be considered in those experiencing macromastia or asymmetry post-CS + RT.

The Use of Validated Visual Scales in Plastic Surgery: Where Are We Now?

BACKGROUND

The assessment of the human body, whether for aesthetic or reconstructive purposes, is an inherently visual endeavor. Ideally, reproducible, prompt, and cost-effective systems of visual evaluation would exist that can provide validated assessments of the aesthetic endpoints of treatment. One method to accomplish a standardization of the appreciation of visual endpoints is the use of visual scales. The goal of this systematic review is to summarize and evaluate the use of validated visual scales within aesthetic medicine, dermatology, and plastic and reconstructive surgery.

METHODS

A literature search was performed with a defined search strategy and extensive manual screening process. The Medical Outcomes Trust guidelines for visual scales in medicine were used, with special attention paid to each study's validation metrics. The review process identified 44 publications with validation data of sufficient quality from an initial survey of 27,745 articles. All rating scales based on imaging other than standardized clinical photographs were excluded.

RESULTS

The review demonstrates that validated visual assessment in plastic surgery is incomplete. Within specific subfields of aesthetic medicine and dermatology, many of the ( n = 20) facial aging scales were well-validated and demonstrated high reliability. Publications ( n = 8) focused on the evaluation of facial clefts demonstrated heterogeneity in the methods of validation and in overall reliability. Within the areas of breast surgery ( n = 9), body contouring ( n = 2), and scarring ( n = 5), the scales were variable in the methods used and the validation procedures were diverse. Scales using a visual guide tended to have better interrater (kappa = 0.75) and intrarater reliability (kappa = 0.78), regardless of the specific area of interest.

CONCLUSIONS

The fields of aesthetic medicine, and aesthetic and reconstructive plastic surgery require assessment of visual states over time and between many observers. For these reasons, the development of validated and reliable methods of visual assessment are critical. Until recently, the use of these tools has been limited by their time-consuming nature and cost.

Comparing costs of standard Breast-Conserving Surgery to Oncoplastic Breast-Conserving Surgery and Mastectomy with Immediate two-stage Implant-Based Breast Reconstruction

BACKGROUND

Conventional breast-conserving surgery (C-BCS) has equal oncological outcomes and superior cosmetic and patient-reported outcomes compared to mastectomy with immediate two-stage implant-based breast reconstruction (M-IBR). Oncoplastic breast-conserving surgery (OP-BCS) is increasingly being used, as it often has better cosmetic results and it enables larger tumour resection. However, OP-BCS and M-IBR compared to C-BCS lengthens operative time and might lead to more complications and consequently to additional costs. Therefore, this study aimed to compare costs and complication rates of C-BCS, OP-BCS and M-IBR.

METHODS

This single-centre, retrospective cohort study, calculated costs for all patients who had undergone breast cancer surgery between January 2014 and December 2016. Patient-, tumour- and surgery-related data of C-BCS, OP-BCS and M-IBR patients were retrieved by medical record review. Treatment costs were calculated using hospital financial data. Differences in costs and complications were analysed.

RESULTS

A total of 220 patients were included: 74 patients in the C-BCS, 78 in the OP-BCS and 68 in the M-IBR group. From most expensive to least expensive, differences in total costs were found between C-BCS vs. OP-BCS and C-BCS vs. M-IBR (p=<0.01 and p=0.04, respectively). Costs of OP-BCS and M-IBR were comparable. Complication rates were 5.5% for C-BCS, followed by 17% for OP-BCS, and 34% for M-IBR (p<0.01).

CONCLUSION

Considering total treatment costs, OP-BCS was financially non-inferior to M-IBR, whereas complication rates were higher following M-IBR. Therefore, when considering other benefits of OP-BCS, such as higher patient-reported outcomes and similar oncological outcomes, a shift from M-IBR to BCS using oncoplastic techniques seems justified.

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.

Psychological and Aesthetic Outcomes in Breast Cancer Patients

Background:

Patients who undergo breast cancer treatment require psychosocial and aesthetic rehabilitation. Advantages of breast reconstruction in-patient rehabilitation are well known. Oncoplastic organ-preserving surgery offers aesthetically better results, yet is often considered less safe than more radical procedures. We compared the aesthetic and psychological outcomes in patients undergoing breast reconstruction and oncoplastic breast cancer treatment.

Methods:

In total, 1130 patients who received either breast reconstruction or oncoplastic breast cancer surgery were included in the study. Patients were classified into two groups. Group 1 included 510 patients who received breast reconstruction surgery. Group 2 included 620 patients who received oncoplastic surgery. The following aspects were compared between the two groups: demographics, tumor progression, and immunohistochemical aspects, complications, hospitalization stay, and psychological and aesthetic outcomes.

Results:

Patients in the oncoplastic group showed statistically significant higher psychosocial and aesthetic outcomes, as well as lower incidence of complications, revision rate, disease progression, and recurrence. The majority of oncoplastic patients were treated in early stages of breast cancer.

Conclusion:

Offering superior treatment results, oncoplastic organ-preserving surgery should be favored in patients with earlier stages of cancer progression.

Improving Results in Oncoplastic Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the risks, benefits, and safety profile of oncoplastic procedures for partial breast reconstruction, and how they compare to breast conservation-therapy alone. 2. Have a working knowledge of oncoplastic techniques and how they are addressed from the multidisciplinary perspective. 3. Understand the limitations of oncoplastic techniques and how to avoid unfavorable results.

SUMMARY

Oncoplastic surgical techniques have expanded indications for breast conservation and have improved both oncologic and reconstructive outcomes. This article will focus on some of the barriers to adoption and discuss ways to improve safety through streamlining the process, understanding the oncologic concerns, and evaluating unfavorable outcomes that might interfere with the appropriate delivery of breast cancer care.

Crowdsourced Assessment of Aesthetic Outcomes after Breast Reconstruction

BACKGROUND

Evaluating the aesthetic success of breast reconstruction can be difficult. Patients, surgeons, and the general population may differ in what constitutes a successful outcome. Recently, crowdsourcing has emerged to accumulate and analyze data on a massive scale. The authors propose that crowdsourcing can be a useful tool to reliably rate aesthetic outcomes of breast reconstruction.

METHODS

One hundred one deidentified photographs of patients at various stages of breast reconstruction were gathered. Assessment tools included a five-point Likert scale and the transverse rectus abdominis myocutaneous (TRAM) visual assessment scale. Anonymous crowd workers and a group of expert reconstructive surgeons rated an identical set of photographs on the Likert scale. Crowd workers also rated the set of photographs on the TRAM scale.

RESULTS

The authors obtained 901 anonymous, layperson evaluations on both Likert and TRAM scales. Crowdsourced assessment data collection took 28.6 hours. Expert assessment took 15 months. Expert and crowdsourced scores were equivalent on the Likert scale (overall interrater reliability, κ = 0.99; 95 percent CI, 0.98 to 0.99). Intrarater reliability among each subcomponent was highly reproducible for the crowd (r = 0.98; 95 percent CI, 0.97 to 0.99) and experts (r = 0.82; 95 percent CI, 0.77 to 0.87). Breast contour and positioning were most predictive of overall aesthetic result. Skin patch and scar were least predictive of overall aesthetic appearance.

CONCLUSIONS

Aesthetic outcomes rated by crowds were reliable and correlated closely with those by expert surgeons. Crowdsourcing can be a rapid, reliable, and valid way to assess aesthetic outcomes in the breast reconstruction patient.

How to Optimize Aesthetics for the Partial Mastectomy Patient

Aesthetic concern is one of the main driving forces behind the popularity of the oncoplastic approach to breast conservation therapy. Oncoplastic options at the time of lumpectomy include volume replacement techniques such as flaps and volume displacement techniques such as the oncoplastic reduction. These techniques can be employed to ensure preservation of breast shape and contour, size and symmetry, inframammary fold position, and position of the nipple-areola complex. The importance of aesthetic outcomes is not only to improve overall patient satisfaction but also to minimize the need for revisional surgeries for shape and symmetry. The purpose of this review is to discuss ways to optimize the aesthetic result and to review the evidence behind aesthetic outcomes.

A Cost-Utility Analysis Comparing Immediate Oncoplastic Surgery with Delayed Oncoplastic Surgery in Smoking Breast Cancer Patients

BACKGROUND

Oncoplastic reduction mammoplasty for smoking breast cancer patients committed to smoking cessation may be performed immediately (increasing smoking-related risk) or in a delayed fashion (increasing radiation-related risk).

OBJECTIVE

Our aim was to examine the cost utility of immediate versus delayed oncoplastic reconstruction when operating on a smoking patient with breast cancer and macromastia with a long-term commitment to smoking cessation.

METHODS

A literature review determined the probabilities and outcomes for the treatment of unilateral breast cancer with immediate or delayed oncoplastic surgery. Reported utility scores were used to estimate quality-adjusted life-years (QALYs) for varying health states. A decision analysis tree was constructed with rollback analysis to highlight the more cost-effective strategy, and an incremental cost-utility ratio (ICUR) was calculated. Sensitivity analyses were performed to validate the robustness of the results.

RESULTS

Immediate oncoplastic surgery is associated with a higher clinical effectiveness (QALY) of 33.3 compared with delayed oncoplastic surgery (33.26), with a higher increment of clinical effectiveness of 0.07 and relative cost reduction of $3458.11. This resulted in a negative ICUR of -50,194, which favored immediate reconstruction, indicating a dominant strategy. In one-way sensitivity analyses, delayed reconstruction was the more cost-effective strategy if the probability of successful immediate reconstruction falls below 29% or its cost exceeds $29,611. Monte-Carlo analysis showed a confidence of 99% that immediate oncoplastic surgery is more cost effective.

CONCLUSIONS

Despite the risk of postoperative complications associated with smoking, immediate oncoplastic surgery is more cost effective compared with delayed oncoplastic surgery in which reconstructive surgery would occur after radiation.

The Public's Perception on Breast and Nipple Reconstruction: A Crowdsourcing-Based Assessment

BACKGROUND

Breast reconstruction outcomes have traditionally been measured by evaluating the opinions of patients and surgeons.

OBJECTIVES

Our goal was to assess the views of the general public.

METHODS

A survey was designed and distributed through a crowdsourcing website called Amazon Mechanical Turk. Questions assessed participant demographics, personal experience with breast reconstruction, perceptions on breast reconstruction, and opinions regarding aesthetics results. Responses were analyzed using chi-square test.

RESULTS

A total of 992 responses were collected. Most participants were female (56.1%), white (32.1%), aged 30 to 39 years (40.4%), and had a bachelor's degree (42.0%). A total of 44.2% had personal experience with breast reconstruction and 25.8% with nipple reconstruction. Several aesthetic and reconstructive factors were significantly favored over others across sex, ethnicity, age group, education level, and personal experience with breast reconstruction. For instance, women were more likely to prefer reconstructed nipples (P < 0.0001), view a breast without a nipple as complete (P = 0.024) and place less importance on nipple shape (P = 0.002). Additionally, those who personally experienced nipple reconstruction were willing to undergo more procedures for a complete nipple-areola complex (P < 0.0001), to increase aesthetic results (P = 0.018), and to increase chances of nipple survival (P = 0.002).

CONCLUSIONS

Crowdsourcing can be useful in plastic surgery and has helped identify several key findings. The importance of the nipple in reconstruction has been validated; almost three-quarters of respondents did not view a breast without a nipple as complete. The aesthetic preferences seem to support bilateral nipple-sparing reconstruction when possible. Most importantly, the respondents helped elucidate key differences in perception of aesthetic outcomes.

Breast Reduction and Mastopexy for Repair of Asymmetry After Breast Conservation Therapy: Lessons Learned

BACKGROUND

Breast conservation therapy (BCT) can cause breast distortion and asymmetry. Repair of this asymmetry by means of breast reduction or mastopexy procedures can be challenging and harbor considerably high rates of complications.

METHODS

In this retrospective study, we describe our experience in repairing post-BCT breast asymmetry by performing breast reduction or mastopexy. The surgical protocol we followed consisted of stringent patient selection, thorough surgical planning, basic surgical refinements, and patient education for enhancing the likelihood of achieving a good outcome with minimal surgical complications.

RESULTS

Our search of the departmental database identified 25 patients with breast asymmetry who had undergone breast reduction or mastopexy between 2009 and 2017. Corrective surgery was performed 4 years on average after the completion of radiotherapy, and those patients included eleven who had undergone breast reduction and fourteen who had undergone mastopexy on the radiated side. Two patients (8%) had major complications that required further surgery (major fat necrosis, wound infection, and breast deformation), and five patients (20%) had minor complications (infection, minor fat necrosis, wound dehiscence, and nipple congestion). All complications developed on the radiated breast. There was no correlation between the occurrence of complications and patients' demographics, tumor type, tumor location, and breast tissue resection (p > 0.05).

CONCLUSION

Only two of our 25 patients had major complications following breast reduction and mastopexy for the repair of asymmetry post-BCT. Following our four-step protocol was instrumental in leading to the successful performance of these procedures.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Long term effects of modern breast cancer surgery

Breast cancer surgery includes a wide array of surgical treatment options. Not only does it involve the oncologic excision of the breast cancer disease but it also involves the reconstruction of the breast. Surgical treatment options vary with regards to the size of the tumor relative to the size of the breast further complicated by the preferences of the patient and the ability of the available surgeon(s). The goal of this paper is to highlight major long-term effects, positive and negative, of modern breast cancer surgery.

Oncoplastic approach to excisional breast biopsies: a randomized controlled, phase 2a trial

BACKGROUND

Oncoplastic surgery has been used in breast cancer patients for better cosmetic outcome over the last decades. The aim of this prospective randomized study is to show its place in excisional breast biopsy.

METHODS

An oncoplastic approach excision was compared with conventional excisional breast biopsies. The study included 80 patients, of whom half received oncoplastic intervention and half received the conventional. The primary endpoint was the cosmetic result. Patient, surgeon and independent observers rated the results on a four-point scale. Scores other than self-perceived were based on third-month medical photographs.

RESULTS

Between May 20, 2015 and April 27, 2016, 40 patients were randomly assigned to oncoplastic biopsy and 40 patients were assigned to conventional excisional biopsy. Median follow-up was 5.6 months (IQR 3.0-6.0). Self-perceived perfect scoring for general cosmetic outcome was found significantly higher after oncoplastic biopsy (73 0.5%) comparing with control group (32.4%) (p = 0.001). This impact did not change after adjusting patients for potential confounders. Margin clearance rates in malignant cases were comparable in both arms (p = 0.999); four patients in oncoplastic biopsy group (40%) and three patients in control group (33%) had positive margins.

CONCLUSIONS

The oncoplastic biopsy achieved better cosmetic results with similar surgical margin positivity rates when compared with conventional breast biopsy. It may be a better biopsy option used for patients requiring excisional breast biopsy.

Updated Evidence on the Oncoplastic Approach to Breast Conservation Therapy

The oncoplastic approach to breast conservation therapy has become a useful and popular option for women with breast cancer who wish to preserve their breast. The initial driving forces were aimed at minimizing the potential for a breast conservation therapy deformity; however, various other benefits have been identified that include broadening the indications for breast conservation therapy in some patients and improved margin control. The various techniques can be categorized into glandular rearrangement techniques such as breast reductions usually in patients with larger breasts or flap reconstruction such as the latissimus dorsi muscle usually in patients with smaller breasts. As the acceptance continues to increase, we are starting to see more outcomes evidence in terms of patient satisfaction, quality of life, complications, and recurrence, to further support the safety and efficacy of the oncoplastic approach.

Patient-Reported Outcomes Are Better after Oncoplastic Breast Conservation than after Mastectomy and Autologous Reconstruction

Supplemental Digital Content is available in the text.

Oncoplastic breast-conserving surgery (OBCS) avoids mastectomy for larger tumors, but patient-reported outcomes are unknown.

Oncoplastic reduction mammoplasty for breast cancer in women with macromastia: long term aesthetic, functional and satisfaction outcomes

AIM OF THE STUDY

Despite the increase in studies concerning oncoplastic reduction mammoplasty (ORM), data showing long-term aesthetic and patient satisfaction for ORM in patients with macromastia remain limited. Therefore, this study evaluated the long-term results of tumorectomy and concomitant bilateral ORM for early-stage breast cancer patients with macromastia in terms of cosmesis, patient satisfaction, and functional outcomes.

MATERIAL AND METHODS

Retrospective data of patients with macromastia undergoing ORM for breast cancer between 1996 and 2011 were examined and evaluated regarding the aesthetic results, patient satisfaction, and functional outcomes.

RESULTS

The median age of the 82 patients was 50 years. The median follow-up was 120 months (range: 28-212 months). The median breast volume was 1402 cm(3), and the median weight of the excised breast material was 679 g. A good or excellent evaluation of the cosmetic outcome was as follows: self-evaluation: 84.1% at the early-stage, 80.3% at the later stage; panel evaluation: 75.4% at the late-stage. Median patient satisfaction rates were 9.1% for early-stage disease and 8.8% for late-stage disease. Reduced mobility and intertrigo improved by three-fold during the post-operative period.

CONCLUSIONS

ORM for early-stage breast cancer in women with macromastia results in good cosmesis in both the early-stage and long-term, and is quite acceptable for use in patients. Patients reacted favorably to the prospect of having their breast cancer and macromastia treated in a single session, and positive results continued over the long-term.

Oncoplastic surgery and radiation therapy for breast conservation: early outcomes

PURPOSE

To analyze a multidisciplinary community experience with oncoplastic breast surgery (OBS) and postoperative radiation therapy (RT).

METHODS

The records of 79 patients with localized breast cancer who underwent OBS+RT were reviewed. OBS included immediate reconstruction and contralateral mammoreduction. All patients had negative surgical margins. Whole-breast RT was delivered without boost. A subset of 44 patients agreed to complete a validated quality of life survey pre-RT, post-RT, 6 months after RT, and at final follow-up assessing cosmesis and treatment satisfaction.

RESULTS

Sixty-seven patients (85%) were white. Median age was 62 years. Median interval between OBS and RT start was 9.6 weeks. Median RT dose was 46 Gy. Fourteen patients (18%) developed surgical toxicities before RT. Five patients (6%) developed RT toxicities. Physician rating of cosmesis post-RT was: 3% excellent, 94% good, and 4% fair. Cosmesis was rated as excellent or good by 87% of patients pre-RT, 82% post-RT, 75% at 6 months, and 88% at the final follow-up. Treatment satisfaction was rated as "total" or "somewhat" by 97% of patients pre-RT, 93% post-RT, 75% at 6 months, and 96% at final follow-up. No significant relation was found between patient or treatment-related factors and toxicity. Local control is 100% at median follow-up of 2.9 years.

CONCLUSIONS

OBS followed by RT resulted in acceptable toxicity and favorable physician-rated cosmesis in this large community series. Patients' ratings of cosmesis and treatment satisfaction were initially high, decreasing at 6 months, returning near baseline at final follow-up.

Factors to Consider in Breast Reconstruction

Women considering breast ablative therapy are confronted with a variety of decisions that include the type of mastectomy (partial, total, skin sparing, nipple areolar sparing), the type of reconstruction (prosthetic, autologous, oncoplastic) and the need for adjuvant therapy (chemotherapy, radiation). The parameters for each are multifactorial and require significant thought and counseling. Therapeutic options are essentially individualized and dependent upon a variety of factors such as tumor size and location, lymph node involvement, comorbidities, expectations and body characteristics. The role of reconstructive surgery is now well appreciated and an integral component of the multidisciplinary care of the patient and is influenced by the opinions and recommendations of surgical, medical and radiation oncologists. This manuscript will review the role of reconstructive surgery and the many factors to consider.

Patient-reported outcome measures in reconstructive breast surgery: is there a role for generic measures?

BACKGROUND

Patient-reported outcomes provide an invaluable tool in the assessment of outcomes in plastic surgery. Traditionally, patient-reported outcomes have consisted of either generic or ad hoc measures; however, more recently, there has been interest in formally constructed and validated questionnaires that are specifically designed for a particular patient population. The purpose of this systematic review was to determine whether generic measures still have a role in the evaluation of breast reconstruction outcomes, given the recent popularity and push for use of specific measures.

METHODS

A systematic review was performed to identify all articles using patient-reported outcomes in the assessment of postmastectomy breast reconstruction. Frequency of use was tabulated and the most frequently used tools were assessed for success of use, using criteria described previously by the Medical Outcomes Trust.

RESULTS

To date, the most frequently used measures are still generic measures. The 36-Item Short-Form Health Survey was the most frequently used and most successfully applied showing evidence of responsiveness in multiple settings. Other measures such as the Hospital Anxiety and Depression Scale, the Hopwood Body Image Scale, and the Rosenberg Self-Esteem Scale were able to show responsiveness in certain settings but lacked evidence as universal tools for the assessment of outcomes in reconstructive breast surgery.

CONCLUSIONS

Despite the recent advent of measures designed specifically to assess patient-reported outcomes in the breast reconstruction population, there still appears to be a role for the use of generic instruments. Many of these tools would benefit from undergoing formal validation in the breast reconstruction population.

The Role of Oncoplastic Breast Surgery in Breast Cancer Treatment

The aim of this study is to discuss indications, advantages, disadvantages, oncologic and aesthetic results of Oncoplastic Surgery (OBS). Pubmed and Medline database were searched for articles published between 1998 and 2014 for keywords: oncoplastic breast surgery, therapeutic mammoplasty, oncoplastic breast reduction, synchrenous reconstructions. Role of OBS in breast cancer surgery, its aspects to be considered, its value and results have been interpreted. This technique has advantages by providing more extensive tumourectomy, yielding better aesthetic results compared with breast conserving surgery, allowing oncoplastic reduction in breast cancer patients with macromastia, with higher patient satisfaction and quality of life and by being inexpensive due to single session practice. As for its disadvantages are: re-excision is more difficult, risk for mastectomy is higher, it is depent on the Surgeron's experience, it has a risk for delay in adjuvant therapies and its requirement for additional imaging studies during management. Main indications are patients with small tumour/breast volume, macromastia, multifocality, procedures which can disrupt breast cosmesis such as surgeries for upper inner breas tquadrient tumours. Contraindications are positive margin problems after wide excision, diffuse malign microcalsifications, inflammatory breast cancer, history of radiotherapy and patients' preferences. Despite low evidence level, Oncoplastic Breast Surgery seems to be both reliable and acceptable in terms of oncologic and aesthetic aspects. Oncoplastic Breast Surgery increase the application rate of breast conserving surgery by obviating practical limitations and improve the results of breast conserving surgery. Correct patient and technique choice in OBS is vital for optimization of post surgical.

A meta-analysis comparing breast conservation therapy alone to the oncoplastic technique

When immediate reconstruction is applied to breast conservation therapy (BCT), the benefits extend well beyond the minimization of poor cosmetic results. The purpose of this analysis was to compare literature outcomes between BCT alone and BCT with the oncoplastic approach.

METHODS

A meta-analysis was performed in PubMed using key words "oncoplastic," "partial breast reconstruction," and "breast conservation therapy." Case reports, series with less than 10 patients, and those with less than 1-year follow-up were excluded from the analysis. The 3 comparative groups included BCT with oncoplastic reduction techniques (Group A), BCT with oncoplastic flap techniques (Group B), and BCT alone (Group C).

RESULTS

Comparisons were made on 3165 patients in the BCT with oncoplastic group (Groups A and B, 41 papers) and 5494 patients in the BCT alone group (Group C, 20 papers). Demographics were similar, and tumor size was larger in the oncoplastic group (2.7 vs 1.2 cm). The weight of the lumpectomy specimen was 4 times larger in the oncoplastic group. The positive margin rate was significantly lower in the oncoplastic group (12% vs 21%, P < 0.0001). Reexcision was more common in the BCT alone group (14.6% vs 4%, P < 0.0001), however, completion mastectomy was more common in the oncoplastic group (6.5% vs 3.79%, P < 0.0001). The average follow-up was longer in the BCT alone group (64 vs 37 months). Local recurrence was 4% in the oncoplastic group and 7% in the BCT alone group. Satisfaction with the aesthetic outcome was significantly higher in the oncoplastic group (89.5% vs 82.9%, P < 0.001).

CONCLUSIONS

The oncoplastic approach to BCT allows a generous resection with subsequent reduction in positive margins. The true value on local recurrence remains to be determined. Patients are more satisfied with outcomes when the oncoplastic approach is used.

Reduction mammaplasty and mastopexy in previously irradiated breasts

BACKGROUND

Little data exist on the safety of elective breast surgery following breast conservation therapy.

OBJECTIVES

The authors evaluate their experience performing reduction mammaplasties and mastopexies in previously irradiated breasts.

METHODS

A retrospective chart review was conducted of all reduction mammaplasties and mastopexies in previously irradiated breasts performed by the 2 senior authors (MYN and SLS) from 1995 to 2012 (n = 18). Patient records were analyzed for demographics, perioperative and postoperative details, and complications.

RESULTS

During the study period, 12 reduction mammaplasties and 6 mastopexies were performed on breasts previously treated with breast conservation therapy. The average study participant age was 49.5 years, and average body mass index was 29. Average preoperative bra cup size was D/DD. One patient was a former smoker; 17 were nonsmokers. Eleven of the 18 patients had been previously treated with chemotherapy; average time between radiation therapy and surgery was 2.5 years. Average specimen weight in the 12 reduction mammaplasties was 623 g. Twenty-two percent (n = 4) of patients experienced a total of 5 minor complications; none required a return to the operating room. One patient (6%) experienced a major complication resulting in approximately 50% loss of breast tissue, which was reconstructed with a latissimus dorsi musculocutaneous flap. Seventeen patients (94%) had successful outcomes with preoperative goals achieved.

CONCLUSIONS

In the previously irradiated breast, reduction mammaplasty and mastopexy should be approached with extra caution, but the surgeries may still be safely and successfully performed.

LEVEL OF EVIDENCE

4.

Quality of information reporting in studies of standard and oncoplastic breast-conserving surgery

The aim of this systematic review was to establish the completeness of reporting of key patient, tumour, treatment, and outcomes information in the randomized-controlled trials (RCTs) of standard breast-conserving surgery (sBCS) considered to be the 'gold-standard', and to compare this with the reporting of the same key criteria for all published studies of oncoplastic breast-conserving surgery (oBCS). Pubmed (1966 to 1st April 2013), Ovid MEDLINE (1966 to 1st April 2013), EMBASE (1980 to 1st April 2013), and the Cochrane Database of Systematic Reviews (Issue 4, 2013) were searched separately for the following terms: (i) 'oncoplastic AND breast AND surgery'; and (ii) 'therapeutic AND mammaplasty'. Only English language and full text articles were reviewed. Following a pilot evaluation of all studies, key reporting criteria were identified. 16 RCTs of sBCS (n = 11,767 patients) were included, and 53 studies met the inclusion criteria for oncoplastic BCS (n = 3236 patients), none of which were RCTs. No study reported all of the criteria identified, with a mean of 64% of key criteria (range, 55-75%) reported in studies of sBCS, and 54% of criteria (range, 10-85%) reported in studies of oBCS. It is therefore evident that there is much room for improvement in the quality of reporting is BCS studies. Standards are proposed to give future studies of BCS a framework for reporting key information and outcomes.

Using therapeutic mammoplasty to extend the role of breast-conserving surgery in women with larger or ptotic breasts

INTRODUCTION

The equivalence of breast-conserving surgery followed by postoperative radiotherapy against mastectomy is now firmly established in patients with early breast cancer. The results of surgery in large-breasted women can be poor, with radiation-induced fibrosis, chronic pain and poor cosmesis contributing to long-term psychological and physical morbidity. Therapeutic mammoplasty offers an alternative management strategy to both enhance the role of breast-conserving surgery and provide better outcomes.

METHODS

A retrospective note review was undertaken of all patients undergoing therapeutic mammoplasty for breast malignancy between 2007 and 2011. All cases were performed using a Wise pattern-reduction technique. Histology and pathological outcomes were assessed. Postoperative outcomes reviewed included wound infection, seroma and need for further intervention.

RESULTS

During the study period, 20 patients underwent therapeutic mammoplasty with a mean follow-up duration of 36 months. The mean weight of the lumpectomy specimen was 330g. The average cancer size was 34mm, with a mean margin clearance of 7mm. There was one episode of wound infection and three of delayed wound healing at the T-junction. One patient required a mastectomy for involved margins. There were no recurrences at the most recent follow-up visit.

CONCLUSIONS

Therapeutic mammoplasty offers a tailored approach to women with larger breasts and early breast cancers with good cosmetic results and oncological outcomes.

From radical mastectomy to breast-conserving therapy and oncoplastic breast surgery: a narrative review comparing oncological result, cosmetic outcome, quality of life, and health economy

Surgical management of breast cancer has evolved considerably over the last two decades. There has been a major shift toward less-invasive local treatments, from radical mastectomy to breast-conserving therapy (BCT) and oncoplastic breast surgery (OBS). In order to investigate the efficacy of each of the three abovementioned methods, a literature review was conducted for measurable outcomes including local recurrence, survival, cosmetic outcome, quality of life (QOL), and health economy. From the point of view of oncological result, there is no difference between mastectomy and BCT in local recurrence rate and survival. Long-term results for OBS are not available. The items assessed in the QOL sound a better score for OBS in comparison with mastectomy or BCT. OBS is also associated with a better cosmetic outcome. Although having low income seems to be associated with lower BCT and OBS utilization, prognosis of breast cancer is worse in these women as well. Thus, health economy is the matter that should be studied seriously. OBS is an innovative, progressive, and complicated subspeciality that lacks published randomized clinical trials comparing surgical techniques and objective measures of outcome, especially from oncologic and health economy points of view.

Use of boost radiotherapy in oncoplastic breast-conserving surgery - a systematic review

BACKGROUND

The use of local boost radiotherapy to the tumour bed has been demonstrated in randomised-controlled trials to reduce local recurrence rates following breast-conserving surgery (BCS) and is the standard of care. Oncoplastic BCS techniques with parenchymal rearrangement present new challenges to the localisation of the tumour bed and therefore delivery of local boost radiotherapy. The aim of this review was to evaluate the reporting of boost radiotherapy in the oncoplastic BCS literature.

METHODS

Pubmed, Ovid MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews were searched for studies reporting oncoplastic BCS using volume displacement techniques.

RESULTS

24 studies met the inclusion criteria (n = 1933 patients). Use of boost radiotherapy was reported in 11 studies, in 2 of which it was for the treatment of incomplete or close margins, and marking of the tumour bed was only reported in 8 studies. None of the studies reported the number of patients where the tumour bed could not be localised.

CONCLUSIONS

The use of local boost radiotherapy and tumour bed marking was not reported in the majority of studies of oncoplastic BCS. Future studies need to provide detailed information regarding the use of boost radiotherapy and difficulties determining the target volume so that current radiotherapy approaches can be reviewed and improved for these advanced techniques.

[Intraoperative, postoperative and long-term oncosurgical safety of therapeutic mammaplasty]

INTRODUCTION

(Pre)malignant lesion in the breast requiring mastectomy conventionally may be treated with breast conservation by using oncoplastic breast surgical techniques, which is called therapeutic mammaplasty. However, no reliable data has been published so far as regards the oncological safety of this method.

AIM

The aim of the authors was to analyse the oncological safety of therapeutic mammaplasty in a series of patients.

METHOD

99 patients were treated with therapeutic mammaplasty and data were collected in a breast surgical database prospectively. Results were analysed with respect to intraoperative, postoperative and long-term oncological safety.

RESULTS

Incomplete resection rate was 14.1%, which correlated with tumour size (p = 0.023), and multifocality (p = 0.012). Time between surgery (therapeutic mammaplasty) and chemotherapy was similar to time between conventional breast surgeries (wide excision, mastectomy, mastectomy with immediate reconstruction) and chemotherapy (mean 29-31 days; p<0.05). Overall recurrence rate was 6.1%, locoregional recurrence rate was 2% during 27 month (1-88) mean follow-up.

CONCLUSIONS

Since literature data are based on relatively short follow-up and low patient number, it is highly important that all data on therapeutic mammaplasty is collected in a prospectively maintained breast surgical database in order to determine true recurrence after long-follow-up.

Alternatives for optimizing outcomes in oncoplastic breast surgery

BACKGROUND

Breast conservation treatment (BCT) is an accepted option for the treatment of breast malignancies. However, as suboptimal surgical techniques result in poor cosmetic outcomes, a plethora of operative approaches to prevent potential deformity has emerged in contemporary literature. Many of these procedures, referred to as oncoplastic breast surgery (OBS), depend on complex mammoplasty-type procedures, often with contralateral symmetrisation, and the frequent use of volume replacement techniques with implants or autologous tissue flaps. However, there have been reports of moderately high rates of complications for these types of procedures.

OBJECTIVE

To propose surgical approaches that reduce tissue manipulation and lower complication rates without sacrificing local control and survival.

METHODS

A description of methods is presented, involving closely coordinated collaboration with members of the interdisciplinary team to enable accurate resection with minimal tissue loss for appropriate margins, allowing adequate retained tissue for acceptable cosmesis.

RESULTS

Using these techniques, more women with breast malignancies may undergo BCT without elaborate mammoplasty procedures or volume replacement operations with implants or autologous flaps.

CONCLUSIONS

The approaches described are alternatives to the conventional volume displacement techniques for optimising outcomes with OBS. They allow a greater proportion of women to undergo BCT with less tissue manipulation and lower complication rates.