Is Oncoplastic Surgery Safe in High-Risk Breast Cancer Phenotypes?

BACKGROUND: Oncoplastic surgery (OPS) has increased in popularity over the recent years. It is a form of breast conservation surgery allowing for larger partial mastectomy (PM) resections followed by either volume displacement or volume replacement reconstruction techniques. However, there is a lack of evidence on the effectiveness and safety of OPS with radiotherapy (OPS + RT) in high-risk breast cancer phenotypes, such as triple negative breast cancer (TNBC) and HER2 positive (HER2+) patients. Our aim was to compare the breast cancer-specific survival (BCSS) and postoperative surgical complications in OPS + RT compared to PM alone with radiation (PM + RT) and total mastectomy (MTX) without radiotherapy (MTX-RT). METHODS: Patient data were analyzed from the Surveillance, Epidemiology, and End Results (SEER) cancer registries from January 1, 2012 to December 31, 2020. Patients were stratified according to the type of surgery. Cox regression analysis was performed to assess prognostic factors of BCSS. RESULTS: A total of 24 621 patients with high-risk breast cancer phenotypes were identified, 180 underwent OPS + RT; 13 402, PM + RT; and 11 039 MTX-RT. OPS + RT was more frequently performed in younger (mean age of 65.53 years, SD: 9.29, p < 0.001), non-Hispanic White (90.5% vs. 77.7% vs. 76.3%) and single women (17.9% vs. 12.1% vs. 13.3%). MTX-RT was usually performed in patients with high histological grade, TNBC, and higher stages. Overall complication rates were higher in the MTX-RT, compared to OPS + RT and PM + RT, 2%, 1.1%, and 0.7%, respectively, p < 0.001. Rates of hematoma and surgical site infections were higher in the MTX-RT group. With a median follow-up of 46 months, OPS + RT had better BCSS rates at 5 years compared to PM + RT and MTX-RT (97.1% vs. 94.7% vs. 89.8%, p < 0.001). MTX-RT was found to be an independent prognostic factor of worse BCSS compared to OPS + RT (hazard ratio [HR] = 2.584; 95% confidence interval [CI]: 1.005-7.171), while PM + RT had no difference compared to OPS + RT (HR = 1.670, 95% CI: 0.624-4.469). CONCLUSIONS: OPS is a safe breast surgical option in patients with HER2+ and TNBC. Patients with high-risk phenotypes who underwent OPS + RT and have similar BCSS and complication rates compared to standard breast surgical options. As such, OPS should be considered as an option whenever breast conservation surgery is being discussed.

Laparoscopically harvested omental flap for immediate breast reconstruction: a retrospective single-center study of 300 cases.

BACKGROUND: The laparoscopically harvested omental flap (LHOF) has been used in partial or total breast reconstruction, but most studies on LHOF were case reports or small case series. However, the clinical feasibility and oncological safety of LHOF in oncoplastic breast surgery remains controversial. This study reported our experience applying LHOF for immediate breast reconstruction. METHODS: Between June 2018 and March 2022, 300 patients underwent oncoplastic breast surgery using LHOF at our institution. Their clinicopathological data, complications, cosmetic outcomes, and oncologic outcomes were evaluated. RESULTS: All patients underwent total breast reconstruction using LHOF after nipple-sparing mastectomy. The median operation time was 230 min (ranging from 155 to 375 min). The median operation time for harvesting the omental flap was 55 min (ranging from 40 to 105 min). The success rate of the laparoscopically harvested pedicled omental flap was over 99.0%. Median blood loss was 70 ml, ranging from 40 to 150 ml. The volume of the flap was insufficient in 102 patients (34.0%). The overall complication rate was 12.3%. Subcutaneous fluid in the breast area (7%) was the most common reconstruction-associated complication, but most cases were relieved spontaneously. The incidence rate of omental flap necrosis was 3.3%. LHOF-associated complications occurred in two cases, including one case of incisional hernia and one case of vascular injury. Cosmetic outcomes were satisfactory in 95.1% of patients on a four-point scale by three-panel assessment and 97.2% using the BCCT.core software. Two local and one systemic recurrence were observed during a median follow-up period of 32 months. CONCLUSIONS: The LHOF for immediate breast reconstruction is a safe and feasible method that involves minimal donor-site morbidity, satisfactory cosmetic outcomes, and promising oncologic safety.

Implant-Based Breast Reconstruction with Bovine Pericardium: Our Approach Using Tutopatch® and Review of Literature.

OBJECTIVES: To describe the usage and advantages of bovine pericardium mesh (Tutopatch®) in breast reconstruction and to compare different mesh materials used in immediate breast reconstruction. METHODS: Our study involved a single-center, retrospective analysis of 103 patients (comprising 114 breasts) who underwent immediate implant-based breast reconstruction using bovine pericardium bovine matrix. The procedures were performed by the same surgical team between April 2018 and May 2023. RESULTS: The rates of early and late complications were examined after a median follow-up period of 30.2 ± 5.5 months. The results revealed that the rates of early complications stood at 9.7%, while late complications were observed in 14.5% of the cases. The most common late complication was seroma formation (7.7%) which six were resolved without any surgical intervention. CONCLUSION: Tutopatch® can be used as an extension of the muscle to cover the prosthesis. It forms an extra layer over the silicone implant that helps to decrease the complications as capsular contracture and implant exposure. It also represents a significant 85 % reduction in cost when compared to a similar-sized mesh materials. 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 .

Outcomes of oncoplastic breast surgery compared to breast-conserving surgery in breast cancer patients in a developing country: a retrospective cohort study.

Background and Objective: Breast-conserving surgery (BCS) with adjuvant radiotherapy remains the standard of care for early breast cancers in Pakistan. We sought to compare the outcomes of BCS with oncoplastic surgery (OPS), a relatively infrequent approach to breast cancer treatment in the country. Methods: This retrospective cohort study was conducted at Aga Khan University Hospital and Ziauddin Hospital in Karachi. Patients who had biopsy-proven Stage-I to III breast cancer and underwent either OPS or BCS between August 1, 2016, and December 31, 2021, were identified and followed for 30 days. Data were collected by reviewing patient files and electronic records. Results: A total of 481 patients were included in the study, where 204 (42.4%) underwent BCS and 277 (57.6%) underwent OPS. Mean tumor volume (146.8 vs. 90.4 cm3), and postoperative complications (2.2 % vs. 0%) were higher in OPS while the frequency of positive margins was greater in the BCS group (15.7 % vs. 2.2 %). There were no significant differences in the histologic type of tumor between the two groups. Conclusion: OPS is a valid alternative approach to breast cancer treatment that can be offered to women with early stage, locally advanced, multifocal or tumors at complex locations owing to the reduced occurrence of positive margins and thus lowered re-excision rates.

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.

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

INTRODUCTION: Oncoplastic surgery (OPS) is traditionally performed using a dual surgeon (DS) approach that involves both a breast surgeon and a plastic surgeon. It is also performed using a single surgeon (SS) approach with a surgeon trained in both breast surgical oncology and plastic surgery. We sought to determine if outcomes differed between SS versus DS OPS approaches. METHODS: A retrospective chart review was conducted of all OPS performed in a single health system over a 6-y period by either an SS or a DS approach. Primary outcomes were rates of positive margins and the overall complication rate; secondary outcomes were loco-regional recurrence, disease-free survival, and overall survival. RESULTS: A total of 217 patients were identified; 117 were SS cases and 100 were DS cases. Baseline preoperative patient characteristics were similar between the two groups as there was no difference in mean Charlson Comorbidity Index scores (P = 0.07). There was no difference in tumor stage (P = 0.09) or nodal status (P = 0.31). Rates of positive margins were not significantly different (10.9% (SS) versus 9% (DS); P = 0.81), nor were rates of complications (11.1% (SS) versus 15% (DS); P = 0.42). Rates of locoregional recurrence were also not significantly different (1.7% (SS) versus 0% (DS); P = 0.5). Disease-free survival and overall survival were not significantly different at 1-y, 3-y, and 5-y time points (P = 0.20 and P = 0.23, respectively) although follow-up time was not sufficient for definitive analysis regarding survival. CONCLUSIONS: Both SS and DS approaches to OPS have similar outcomes with regards to positive margin rates and surgical complication rates and are comparably safe.

Oncoplastic surgery for breast cancer: Global perspectives and trends.

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

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

INTRODUCTION: Oncoplastic surgery (OPS) is a form of breast conservation surgery involving partial mastectomy followed by volume displacement or replacement surgery. As the field of OPS is growing, we sought to determine if there was a learning curve to this surgery. METHODS: A retrospective chart review was conducted of all patients who underwent OPS over a 6-year period with a single surgeon formally trained in both Plastic Surgery and Breast Oncology. Cumulative summation analysis (CUSUM) was performed on mean operative time to generate the learning curve and learning curve phases. Outcomes were compared between phases to determine significance. RESULTS: Mean operative time decreased significantly across the 6-year period, generating three distinct learning curve phases: Learner phase (cases 1-23), Competence phase (24-73), and Mastery phase (74 and greater). The overall positive margin rate was 10.9% and there was no significant difference in rates between phases (p = 0.49). Overall complication rates, reoperation rates, and locoregional recurrence remained the same across all phases (p = 0.16; p = 0.65; p = 0.41). The rate of partial nipple loss decreased between phases (p = 0.02). CONCLUSION: As with many complex operations, there does appear to be a learning curve with OPS, as the operative time and the rates of partial nipple loss decreased over time.

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

BACKGROUND: Obesity has nearly tripled in the last 50 years. During the last decades, oncoplastic breast surgery has become an important choice in the surgical treatment of breast cancer. An association exists between higher body mass index (BMI) and wound complications for major operations, but there is scarce literature on oncoplastic surgery. Hence, our aim was to compare the complication rates among patients who underwent oncoplastic surgery, stratified by BMI. METHODS: Patient data were analyzed from the National Surgical Quality Improvement Program database (NSQIP) for oncoplastic breast procedures (2005-2020). Patients were stratified according to World Health Organization obesity classifications. Multivariate logistic regression was performed to assess risk factors for complications (overall, operative, and wound-related). RESULTS: From a total of 6887 patients who underwent oncoplastic surgery, 4229 patients were nonobese, 1380 had Class 1 obesity (BMI: 30 to <35 kg/m2 ), 737 Class 2 obesity (BMI: 35 to <40 kg/m2 ), and 541 Class 3 obesity (BMI: ≥ 40 kg/m2 ). Greater operative time was found according to higher BMI (p < 0.001). Multivariate analysis adjusted for baseline characteristics showed that patients with obesity Class 2 (odds ratio [OR] = 1.51, 95% confidence interval [CI]: 1.03-2.23, p = 0.037) and 3 (OR = 1.87, 95% CI 1.24-2.83, p = 0.003) had increased risk of overall and wound complications compared with Nonobese patients. Comparing obese with nonobese patients, there were no differences in rates of deep SSI, organ/space SSI, pneumonia, reintubation, pulmonary embolism, deep vein thrombosis, urinary tract infection, stroke, bleeding, postoperative sepsis, length of stay, and readmission. CONCLUSIONS: Oncoplastic surgery is a safe procedure for most patients. However, caution should be exercised when performing oncoplastic surgery for patients with Class 2 or 3 obesity (BMI ≥ 35 kg/m2 ), given there was a higher rate of overall and wound-specific complications, compared with patients who were not obese or had Class 1 obesity.

Examining a decade of racial disparity in partial mastectomy and oncoplastic surgery.

BACKGROUND AND OBJECTIVES: Understanding racial disparity is crucial to addressing health equity and access to care. Our study aims to examine racial differences in breast conserving surgery (BCS) utilization rates and determine how these rates have changed over time. METHODS: This retrospective cohort analysis utilized the NSQIP database to identify women diagnosed with breast cancer who underwent BCS procedures between 2008 and 2019. Racial utilization trends were analyzed using a Cochran-Armitage test and Index of Disparity analysis. RESULTS: In the 12-year period, 202 492 women underwent a breast cancer surgery, of which 47% underwent BCS. Within the BCS subgroup, oncoplastic surgery utilization increased from 3% to 10%, leading to a declining proportion of partial mastectomies: 97% to 90.0% (both p < 0.01). The racial index of disparity for overall BCS patients decreased from 7% to 6%, remained unchanged (1%) for partial mastectomies, and significantly decreased in oncoplastics (23%-7.6%). CONCLUSION: BCS represents a mainstay option for early-staged breast cancer interventions, this study demonstrate promising progress in decreasing the index of disparity among races and persistent racial inequalities.

Comparison of the Quality of Recovery-15 score in patients undergoing oncoplastic breast-conserving surgery under monitored anesthesia care versus general anesthesia: a prospective quality improvement study.

PURPOSE: Whether changing the institutional practice from general anesthesia (GA) to monitored anesthesia care (MAC) affects postoperative quality of recovery for oncoplastic breast-conserving surgery (BCS) is currently unknown. We designed this quasi-experimental study to evaluate a quality improvement (QI) initiative instituted in Edmonton, AB, Canada. METHODS: We chose a prospective controlled cohort study design for this QI study, where patients underwent oncoplastic BCS under MAC in one hospital and BCS under GA at another hospital (control). A total of 125 patients undergoing surgery between May 2021 and February 2022 were enrolled. Exclusion criteria were male sex, total mastectomy, or age under 18. All other patients were included. The primary outcome was the change in Quality of Recovery-15 score at 24 hr compared with a preoperative baseline. Secondary outcomes included intra- and postoperative time profiles, perioperative analgesic and antiemetic use and length of hospital stay. Statistical analysis included a propensity score analysis to account for confounding variables. RESULTS: Sixty-four patients received GA and 61 MAC. No enrolled patients were lost to follow up but two were excluded secondarily. No patients receiving MAC needed conversion to GA or unplanned airway management. Monitored anesthesia care was associated with superior outcomes for the primary outcome (ß/SE[ß], 3.31; 99.5% confidence interval, 0.45 to 6.17; P = 0.001) and most secondary outcomes, when accounting for confounding factors. CONCLUSIONS: A care transformation initiative for patients undergoing oncoplastic BCS under MAC was associated with a higher quality recovery profile and shorter length of stay without any increase in perioperative or postoperative adverse events.

RéSUMé: OBJECTIF: On ignore actuellement si le fait de modifier la pratique institutionnelle de l'anesthésie générale (AG) à la sédation procédurale (monitored anesthesia care) affecte la qualité de la récupération postopératoire en cas de chirurgie mammaire conservatrice oncoplastique. Nous avons conçu cette étude quasi expérimentale pour évaluer une initiative d'amélioration de la qualité mise en place à Edmonton, Alberta, Canada. MéTHODE: Nous avons choisi une méthodologie d'étude de cohorte prospective contrôlée pour cette étude d'amélioration de la qualité, dans laquelle des patientes ont bénéficié d'une chirurgie mammaire conservatrice oncoplastique sous sédation procédurale dans un hôpital et de la même chirurgie sous anesthésie générale dans un autre hôpital (groupe témoin). Au total, 125 patientes bénéficiant d'une intervention chirurgicale entre mai 2021 et février 2022 ont été recrutées. Les critères d'exclusion étaient le sexe masculin, la mastectomie totale ou un âge de moins de 18 ans. Toutes les autres personnes ont été incluses. Le critère d'évaluation principal était la variation du score de Qualité de la récupération 15 à 24 heures par rapport aux valeurs initiales préopératoires. Les critères d'évaluation secondaires comprenaient les profils temporels per- et postopératoires, l'utilisation périopératoire d'analgésiques et d'antiémétiques et la durée du séjour à l'hôpital. L'analyse statistique comprenait une analyse par score de propension pour tenir compte des variables de confusion. RéSULTATS: Soixante-quatre patientes ont reçu une anesthésie générale et 61 une sédation procédurale. Aucune patiente recrutée n'a été perdue au suivi, mais deux ont été exclues secondairement. Aucune patiente recevant une sédation procédurale n'a eu besoin d'une conversion en anesthésie générale ou d'une prise en charge non planifiée des voies aériennes. La sédation procédurale était associée à des issues supérieures pour le critère d'évaluation principal (ß/ET[ß], 3,31; intervalle de confiance à 99,5 %, 0,45 à 6,17; P = 0,001) et la plupart des critères d'évaluation secondaires, en tenant compte des facteurs de confusion. CONCLUSION: Une initiative de transformation des soins pour les patientes bénéficiant d'une chirurgie mammaire conservatrice oncoplastique sous sédation procédurale a été associée à un profil de récupération de meilleure qualité et à une durée de séjour plus courte sans augmentation des événements indésirables périopératoires ou postopératoires.

Modified oncoplastic lift, lymphatic excision, and reconstruction: Introduction of a novel technique in oncoplastic breast surgery with simple surgical principles.

INTRODUCTION: Oncoplastic surgery is an important component of the management of breast cancer. As prognosis has improved, the need for proficient techniques to achieve disease eradication while maintaining cosmesis for naturally appearing breasts has gained importance. This study describes an easy-to-learn modified oncoplastic technique for patients undergoing breast-conserving treatment. DESCRIPTION OF THE TECHNIQUE: Tumor resection is performed through different peri-areolar, inframammary, or radial incisions. To reduce the size of the surgical defect created after tissue resection, an internal purse-string is performed parallel to the chest wall or base of the wound with subsequent staggering in three or more layers as needed, while maintaining the parallel orientation of the needle. This is followed by the creation and overlapping of internal breast tissue flaps that are rearranged to decrease the dead space with the aim of improving cosmesis. The redundant skin is removed for the skin envelope to maintain shape. The wound is closed in layers. We also describe steps in performing sentinel lymph node and tumor extraction through the same periareolar, inframammary, or radial incisions for tumors located in outer quadrants. Following closure, contour and projection of the breast were maintained without indentation or loss of projection, with a symmetrical appearance to the contralateral side. CONCLUSION: This simplified oncoplastic (MOLLER) technique can be easily learned and used by surgeons who treat cancer patients and have limited oncoplastic training. It uses basic known surgical principles to decrease the size of the defect created while minimizing the need for larger incisions/pedicles.

An Oncoplastic Approach to Primary Pediatric Pterygomaxillary Osteosarcoma.

Osteosarcomas arising within the pterygomaxillary/infratemporal fossa region are rare among the pediatric population. Survival rates are most influenced by tumor resection with negative margins, which can be dependent on surgical accessibility of the tumor site. The pterygomaxillary/infratemporal fossa location poses several challenges to safe and adequate tumor resection, including proximity of the facial nerve and great vessels and scarring associated with traditional transfacial approaches. In this article, we present the case of a 6-year-old boy with an osteosarcoma of the left pterygomaxillary/infratemporal fossa region successfully managed with an "oncoplastic" approach, incorporating the use of CAD/CAM and mixed reality technologies.

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

INTRODUCTION: Oncoplastic breast reduction mammoplasty (ORM) is an excellent treatment option for women with breast cancer and macromastia undergoing breast conservation therapy. Here, we aim to better understand the risks associated with ORM compared to standard reduction mammoplasty (SRM). METHODS: A retrospective chart review was performed of patients undergoing ORM or SRM from 2015 to 2021. Primary outcomes included the occurrence of major or minor postoperative complications in the two groups and delays to adjuvant therapy (>90 days) among the women undergoing ORM. RESULTS: Women in the ORM group (n = 198) were significantly older (p < 0.001) with a higher prevalence of smoking (p < 0.001), diabetes mellitus (p < 0.01), and a Charlson comorbidity index ≥ 3 (p < 0.001) compared to women undergoing SRM (n = 177). After controlling for potential confounders, there were no significant between-group differences in the odds of developing postoperative complications (odds ratio = 0.80, 95% confidence interval: 0.36-1.69). Only 3% (n = 4) of the 150 women undergoing adjuvant radiation or chemotherapy experienced delays related to postoperative complications. CONCLUSION: ORM has a similar safety profile as SRM, despite the older age and higher number of comorbidities often seen in patients undergoing ORM, and is a safe option for achieving contralateral symmetry at the time of partial mastectomy without delays to adjuvant therapy.

A New Level II Oncoplastic Technique for Inferior Pole Defects: The Three-Petal Glandular Reconstruction (3-PR).

INTRODUCTION: Oncoplastic surgery (OPS) allows wide excisions and accurate tumor resection and reduces breast deformities by immediate reconstruction of large defects. Superior pedicled mammaplasties allow excellent results in large breasts. Conversely, loco-regional flaps are the standard of care in small-to-medium breasts. However, both techniques show limitations in case of large resections of the lower pole, resulting in skin retraction and downward deviation of nipple and areola. We present a new technique for inferior pole reconstruction to overcome these limitations. It is called "the three-petal reconstruction" (3-PR). METHODS: Between September 2016 and May 2019, ten patients with invasive breast cancer of the lower pole underwent breast conservation and 3-PR. RESULTS: The 3-PR was uneventful in all patients. No major or minor complications were recorded. Patient and surgeon evaluations scored as good to excellent in all cases. Surveillance examinations in the follow-up did not reveal calcifications nor any findings of suspicion within the reconstructed area. CONCLUSIONS: In case of very large defect of lower pole, the 3-PR reveals to be an easy, fast, reproducible method for inferior pole reconstruction. It can represent a niche between therapeutic mammaplasty and perforator flaps, and it could be added to existing available options for tailored reconstruction. 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 .

Current perspectives of oncoplastic breast surgery in Pakistan.

Oncoplastic breast surgery is based on the concept of tumour-specific immediate reconstruction. It combines both local and distant techniques to maintain breast texture, symmetry and cosmesis without compromising oncological outcome. The current narrative review was planned to highlight the current state and future of oncoplastic breast surgery in low- and middle-income countries where its utilisation in surgical practice remains insubstantial because majority of the surgeons who are treating breast cancer are either general surgeons or breast surgeons who do not have expertise in oncoplastic breast surgery or reconstructive surgery. Moreover, scarcity of financial resources, ignorance about oncoplastic breast surgery techniques, disfigurement distress and cultural taboos coerce women to hide in the shadows with their breast disease. Oncoplastic breast surgery needs more exposure in a developing country like Pakistan. There is a need to establish dedicated oncoplastic breast surgery training centres, fellowship programmes, workshops, and webinars to incorporate such techniques in the practice of breast surgeons.

Outcomes in Hybrid Breast Reconstruction: A Systematic Review.

Background and Objectives: Lipofilling is a commonly performed procedure worldwide for breast augmentation and correction of breast contour deformities. In breast reconstruction, fat grafting has been used as a single reconstructive technique, as well as in combination with other procedures. The aim of the present study is to systematically review available studies in the literature describing the combination of implant-based breast reconstruction and fat grafting, focusing on safety, complications rate, surgical sessions needed to reach a satisfying reconstruction, and patient-reported outcomes. Materials and Methods: We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) throughout the whole review protocol. A systematic review of the literature up to April 2022 was performed using Medline, Embase, and Cochrane Library databases. Only studies dealing with implant-based breast reconstruction combined with fat grafting were included. Results: We screened 292 articles by title and abstract. Only 48 articles were assessed for full-text eligibility, and among those, 12 studies were eventually selected. We included a total of 753 breast reconstructions in 585 patients undergoing mastectomy or demolitive breast surgeries other than mastectomy (quadrantectomy, segmentectomy, or lumpectomy) due to breast cancer or genetic predisposition to breast cancer. Overall, the number of complications was 60 (7.9%). The mean volume of fat grafting per breast per session ranged from 59 to 313 mL. The mean number of lipofilling sessions per breast ranged from 1.3 to 3.2. Conclusions: Hybrid breast reconstruction shows similar short-term complications to standard implant-based reconstruction but with the potential to significantly decrease the risk of long-term complications. Moreover, patient satisfaction was achieved with a reasonably low number of lipofilling sessions (1.7 on average).

The impact of age on patient-reported outcomes after oncoplastic versus conventional breast cancer surgery.

PURPOSE: Some studies have indicated age-specific differences in quality of life (QoL) among breast cancer (BC) patients. The aim of this study was to compare patient-reported outcomes after conventional and oncoplastic breast surgery in two distinct age groups. METHODS: Patients who underwent oncoplastic and conventional breast surgery for stage I-III BC, between 6/2011-3/2019, were identified from a prospectively maintained database. QoL was prospectively evaluated using the Breast-Q questionnaire. Comparisons were made between women < 60 and ≥ 60 years. RESULTS: One hundred thirty-three patients were included. Seventy-three of them were ≥ 60 years old. 15 (20.5%) of them received a round-block technique (RB) / oncoplastic breast-conserving surgeries (OBCS), 10 (13.7%) underwent nipple-sparing mastectomies (NSM) with deep inferior epigastric perforator flap (DIEP) reconstruction, 23 (31.5%) underwent conventional breast-conserving surgeries (CBCS), and 25 (34.2%) received total mastectomy (TM). Sixty patients were younger than 60 years, 15 (25%) thereof received RB/OBCS, 22 (36.7%) NSM/DIEP, 17 (28.3%) CBCS, and 6 (10%) TM. Physical well-being chest and psychosocial well-being scores were significantly higher in older women compared to younger patients (88.05 vs 75.10; p < 0.001 and 90.46 vs 80.71; p = 0.002, respectively). In multivariate linear regression, longer time intervals had a significantly positive effect on the scales Physical Well-being Chest (p = 0.014) and Satisfaction with Breasts (p = 0.004). No significant results were found concerning different types of surgery. CONCLUSION: Our findings indicate that age does have a relevant impact on postoperative QoL. Patient counseling should include age-related considerations, however, age itself cannot be regarded as a contraindication for oncoplastic surgery.

Oncological Safety of Oncoplastic Level II Mammoplasties After Neoadjuvant Chemotherapy for Large Breast Cancers: A Matched-Cohort Analysis.

BACKGROUND: Oncoplastic surgery (OPS) has extended the indications for breast-conserving surgery (BCS). Its role in patients with large breast cancers treated with neoadjuvant chemotherapy (NAC) is unclear. This study evaluated the oncological safety of OPS for tumors with partial response after NAC. METHODS: A consecutive series of 65 patients who underwent OPS (study group) after NAC for large breast cancer from January 2004 to July 2018 was compared with 130 matched patients treated by NAC, followed by standard BCS in 65 cases and mastectomy in 65 cases (two case-controlled groups). RESULTS: The mean initial radiological tumor size was 46 mm. Residual pathological tumor size was 22 mm in the OPS cohort, 19 mm in the standard BCS cohort, and 31 mm in the mastectomy cohort (p > 0.05). The mean follow-up was 59 months in the study cohort. Five-year local recurrence rates were 0%, 0%, and 10.5% (0-22%) for the OPS, BCS, and mastectomy cohorts, respectively, while 5-year regional recurrence rates were 4.1% (0-11.1%), 0, and 19.4% (0-35.2%, p > 0.05), respectively. Five-year overall survival was 85.3% for the OPS cohort, 94.1% for the standard BCS cohort (p = 0.194), and 79.9% for the mastectomy cohort (p = 0.165). CONCLUSIONS: OPS is safe after NAC for large breast cancers, and provides excellent local control, identical to that of tumors with a better response, treated by standard BCS. After NAC, OPS can be a valuable treatment option for tumors that did not shrink optimally and would not be suitable for standard BCS.

Oncoplastic breast surgery versus conventional breast conserving surgery - a prospective follow-up study of subjective loco-regional late morbidity.

Background and aim: Few studies have focused on the symptoms of loco-regional morbidity in shoulders, arms, and breasts related to oncoplastic breast surgery (OPS). This study aimed to determine if a difference exists in the prevalence or variety of subjective symptoms of shoulder, arm, and breast morbidity in patients undergoing OPS compared with patients receiving conventional breast conserving surgery (C-BCS). Cosmetic result and body image were included as secondary endpoints.Methods: This prospective follow-up study with 18 months of questionnaire-based follow-up included women with breast cancer or ductal carcinoma in situ. They were divided into two groups - C-BCS or OPS - depending on type of surgery performed. Furthermore, patient, disease, and treatment characteristics were recorded.Results: Among 334 completers, 229 (69%) received C-BCS and 105 (31%) received OPS. Participants were comparable regarding age, comorbidity, BMI, re-excision rate (15-16%), and axillary surgery. As for tumor characteristics, a more advanced disease stage was shown in the OPS than in the C-BCS group with larger tumor and lumpectomy size, more multifocality, and the corresponding following systemic adjuvant therapy.The questionnaire revealed that the two groups were comparable with no significant differences in frequency or variety of symptoms of shoulder and arm morbidity. Overall, participants were highly satisfied with the cosmetic results in both groups and no significant inter-group differences were observed.Conclusion: In patients with larger tumors, breast conserving surgery utilizing oncoplastic techniques yields results regarding subjective shoulder, arm, and breast morbidity as well as cosmetic outcome comparable with those of C-BCS performed on smaller tumors.Trial registration: ClinicalTrials.gov, registration number: NCT02159274 (2014).HIGHLIGHTSSubjective symptoms of shoulder, arm, and breast morbidity are comparable when oncoplastic breast surgery is compared to conventional breast conserving surgery.The variety of symptoms of shoulder and arm morbidity following oncoplastic surgery does not differ from symptoms following conventional breast conserving surgery.The cosmetic outcome following oncoplastic breast surgery is comparable to breast conserving surgery without oncoplastic techniques.