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Outcomes in volume replacement and volume displacement techniques in oncoplastic breast conserving surgery: A systematic review

      Summary

      Introduction

      Volume Replacement (VR-OBCS) and Volume Displacement Oncoplastic Breast Conserving Surgery (VD-OBCS) are commonly used in the management of breast cancer. Many studies summarize the individual postoperative outcomes of these two procedures; however, there is a lack of research that compares outcomes of these approaches. This review summarizes the available VR and VD-OBCS literature in terms of oncological, cosmetic, and clinical outcomes.

      Methods

      An online literature search (MEDLINE, EMBASE, PubMed, and CINAHL) was performed. Studies were included if they were written in English, had more than 10 adult (18+) female patients who underwent VR-OBCS or VD-OBCS, and reported at least one well-described oncological, clinical, or cosmetic outcome

      Results

      Thirty-three studies (26 VR-OBCS and 7 VD-OBCS) were included in this review; VR-OBCS studies were separated based on the use of latissimus dorsi (LD) flaps. Studies utilizing VR-OBCS with LD flaps reported the highest rate of all oncological outcomes; VR-OBCS studies without LD flaps reported the lowest. Rates of hematoma, seroma, and wound dehiscence were highest in VR-OBCS with LD flaps; partial flap loss and fat necrosis were highest in VR-OBCS without LD flaps and infection was highest in VD-OBCS studies. Inconsistencies in methodology (cosmetic outcome measures, outcome definitions, and time horizons) were found in all procedural groups.

      Conclusion

      Differences in outcomes for both OBCS procedures may be due to the heterogeneity of patient populations. “Doers” and “Users” of breast oncoplastic research should consider tumor size, laterality of tumor, breast size, measurement scales, and defensible time horizons before the application of a study's conclusions.

      Keywords

      Introduction

      Advances in the identification and management of breast cancer has led to increased rates of diagnoses and survival in North American women.
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      the description of which is outside the scope of the current review.
      Because of its benefits and flexibility noted above, the use of OBCS has become widely accepted and applied in routine clinical practice. Data from a 2016 study found that from 2007 to 2014, the total percentage of breast reconstruction surgeries being performed using OBCS increased from 4% to 15%.
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      Unfortunately, there is dearth of research that focuses knowledge into one review. As such, this systematic review aims to utilize the available literature to summarize the oncological, clinical, and cosmetic outcomes between these techniques.

      Methods

       Search strategy

      A review of the literature using MEDLINE, EMBASE, PubMed, and CINAHL databases was performed on January 19, 2020. With the assistance of a medical librarian, the following search strategy was used: (((breast neoplasms OR ((cancer or neoplasm* or tumor or tumor) adj2 (breast or mammar*)))) AND (reconstructive surgical procedures OR oncoplastic OR (reconstruct* adj3 surg*) OR breast conservation)) AND (volume displacement OR volume replacement).” The initial search was insufficient as it was noted that VR-OBCS studies utilized LD flaps and did not represent other VR techniques. To address this, a secondary search of the literature was performed on PubMed for VR procedures that do not use LD flaps. The following search strategy was used: (Oncoplastic AND Volume Replacement AND Breast) (Outcomes OR Complications) AND (Latissimus Dorsi OR Fat Graft OR Perforator flap). Studies were included if they were: 1) written in English; 2) had more than 10 adult (18+) female patients; 3) had patients who underwent VR-OBCS or VD-OBCS; and 4) reported at least one, well-described, oncological, clinical, or cosmetic outcome. Studies were excluded if they were: (1) published before January 2010 (to ensure these data are recent within the last 10 years) and/or (2) were case reports, conference abstracts, or systematic reviews.

       Study selection

      All studies were entered into Covidence, a web-based screening software for systematic reviews.

      Covidence - Better systematic review management. Accessed May 27, 2020. https://www.covidence.org/home

      After the exclusion of duplicates, two independent reviewers screened the titles and abstracts of each remaining article based on the inclusion and exclusion criteria. Full-text articles were then retrieved and independently assessed by the reviewers. Disagreements between reviewers were resolved by consensus.

       Data extraction and reporting

      The following information was retrieved and recorded from each study: (1) the number of VR-OBCS or VD-OBCS techniques used in the study; (2) the number of patients with each technique; (3) follow-up periods; and (4) any measured oncological, cosmetic, or clinical outcomes.
      Oncological outcomes included mortality, distant metastasis, and cancer recurrence. Clinical outcomes included hematoma, seroma, infection, fat necrosis, partial or total flap loss, and wound dehiscence. The data extracted for clinical and oncological outcomes was tabulated and outcome probabilities for each category were calculated. Outcome probabilities were calculated by, first, totaling the number of patients in each study who were identified as having the specific outcome. This number was then divided by the overall patient population from all the studies that measured that specific outcome. For example, mortality for VR-OBCS was reported by Hernanz et al.
      • Hernanz F.
      • Sánchez S.
      • Cerdeira M.P.
      • Figuero C.R.
      Long-term results of breast conservation and immediate volume replacement with myocutaneous latissimus dorsi flap.
      , Kijima et al.
      • Kijima Y.
      • Yoshinaka H.
      • Hirata M.
      • et al.
      Oncoplastic surgery combining partial mastectomy and immediate volume replacement using a thoracodorsal adipofascial cutaneous flap with a crescent-shaped dermis.
      , and Hu et al.
      • Hu J.
      • Cuffolo G.
      • Parulekar V.
      • Chan V.
      • Tenovici A.
      • Roy P.G.
      The results of surveillance imaging after breast conservation surgery and partial breast reconstruction with chest wall perforator flaps; a qualitative analysis compared with standard breast-conserving surgery for breast cancer.
      The three studies reported 3, 1, and 0 patients, respectively, for a total of 4 patients. This number was then divided by the total patient population of all three studies (41 + 36 + 15), which is 92. The final calculated outcome probability totaled to 4.3%. Cosmetic outcomes were collected based on the specific questionnaires/scales used. Individual authors were contacted to clarify any missing data or discrepancies among the included articles if necessary. This manuscript was written in accordance with the PRISMA
      • Moher D.
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      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      checklist (Appendix A). Ethical approval was not required for this study.

      Results

      A total of 354 studies were identified from the database search; following full-text review, 28 articles (22 VR-OBCS and 6 VD-OBCS) were included in this systematic review. The included studies were published between 2011 and 2020; 17 (56%) were prospective cohort studies and 12 (41%) were retrospective cohort studies. The secondary search of the literature resulted in an additional 5 studies, bringing the new total 33 studies (26 VR-OBCS and 7 VD-OBCS) (Figure 1). Given the known complications associated with LD flaps,
      • Burgić M.
      • Bruant-Rodier C.
      • Wilk A.
      • et al.
      Complications following autologous latissimus flap breast reconstruction.
      we chose to present the outcome data separately for those VR-OBCS studies that used LD flaps and those that used alternative techniques. Appendices B1 and B2 provide details about the VR-OBCS studies included in this review; the VD-OBCS studies are summarized in Appendix C. Two studies, Farahat et al.
      • Farahat A.M.
      • Hashim T.
      • Soliman H.O.
      • Manie T.M.
      • Soliman O.M.
      Skin sparing mastectomy: technique and suggested methods of reconstruction.
      and Lee et al.,
      • Lee J.
      • Jung J.H.
      • Kim W.W.
      • et al.
      Oncologic outcomes of volume replacement technique after partial mastectomy for breast cancer: a single center analysis.
      did not specify whether clinical or oncological outcomes came from LD flaps or other VR techniques, as a result, both were omitted.
      Fig 1
      Fig. 1Flow Diagram of Included Studies.
      n; number of studies, VD-OBCS; Volume Displacement Oncoplastic Breast Conservation Surgery, and VR-OBCS; Volume Replacement Oncoplastic Breast Conservation Surgery.
      Note: The 9 combination VR-OBCS and VD-OBCS studies that were excluded were not included into the review because of the lack of specificity in outcome reporting. These studies did not specify whether the reported outcome values came from either VR-OBCS or VD-OBCS. Both clinical and oncological outcomes were not categorized under the two treatments and instead were reported for the entire patient cohort.
      Oncological Outcomes included mortality, distant metastasis, and recurrence rate. These outcomes were reported in 13 (50%)
      • Hernanz F.
      • Sánchez S.
      • Cerdeira M.P.
      • Figuero C.R.
      Long-term results of breast conservation and immediate volume replacement with myocutaneous latissimus dorsi flap.
      • Kijima Y.
      • Yoshinaka H.
      • Hirata M.
      • et al.
      Oncoplastic surgery combining partial mastectomy and immediate volume replacement using a thoracodorsal adipofascial cutaneous flap with a crescent-shaped dermis.
      • Hu J.
      • Cuffolo G.
      • Parulekar V.
      • Chan V.
      • Tenovici A.
      • Roy P.G.
      The results of surveillance imaging after breast conservation surgery and partial breast reconstruction with chest wall perforator flaps; a qualitative analysis compared with standard breast-conserving surgery for breast cancer.
      ,
      • Farahat A.M.
      • Hashim T.
      • Soliman H.O.
      • Manie T.M.
      • Soliman O.M.
      Skin sparing mastectomy: technique and suggested methods of reconstruction.
      • Lee J.
      • Jung J.H.
      • Kim W.W.
      • et al.
      Oncologic outcomes of volume replacement technique after partial mastectomy for breast cancer: a single center analysis.
      • El-Marakby H.H.
      • Kotb M.H.
      Oncoplastic volume replacement with latissimus dorsi myocutaneous flap in patients with large ptotic breasts. Is it feasible?.
      • Zhou L.
      • Wang Y.
      • Cai R.
      • et al.
      Pedicled descending branch latissimus dorsi mini-flap in repairing partial mastectomy defect: shoulder functional and esthetic outcomes.
      • De Biasio F.
      • Zingaretti N.
      • Marchesi A.
      • Vaienti L.
      • Almesberger D.
      • Parodi P.C.
      A Simple and Effective Technique of Breast Remodelling After Conserving Surgery for Lower Quadrants Breast Cancer.
      • Mele S.
      • Wright D.
      • Paramanathan N.
      • Laws S.
      • Peiris L.
      • Rainsbury R.
      Long-term effect of oncoplastic breast-conserving surgery using latissimus dorsi miniflaps on mammographic surveillance and the detection of local recurrence.
      • Yang C.E.
      • Roh T.S.
      • Yun I.S.
      • Kim Y.S.
      • Lew D.H.
      Immediate partial breast reconstruction with endoscopic Latissimus Dorsi muscle flap harvest.
      • Ho W.
      • Stallard S.
      • Doughty J.
      • Mallon E.
      • Romics L.
      Oncological outcomes and complications after volume replacement oncoplastic breast conservations—the glasgow experience.
      • Fujimoto H.
      • Shiina N.
      • Nagashima T.
      • et al.
      Oncoplastic breast-conserving surgery using chest wall perforator flaps: three-dimensional quantitative analysis of the percentage of breast volume excised and changes over time in flap volume.
      • Thekkinkattil D.K.
      • Salhab M.
      • McManus P.L.
      Feasibility of Autologous fat transfer for replacement of implant volume in complicated implant-assisted Latissimus Dorsi Flap Breast Reconstruction:.
      of the included VR-OBCS studies (five [19%]
      • Kijima Y.
      • Yoshinaka H.
      • Hirata M.
      • et al.
      Oncoplastic surgery combining partial mastectomy and immediate volume replacement using a thoracodorsal adipofascial cutaneous flap with a crescent-shaped dermis.
      ,
      • Hu J.
      • Cuffolo G.
      • Parulekar V.
      • Chan V.
      • Tenovici A.
      • Roy P.G.
      The results of surveillance imaging after breast conservation surgery and partial breast reconstruction with chest wall perforator flaps; a qualitative analysis compared with standard breast-conserving surgery for breast cancer.
      ,
      • De Biasio F.
      • Zingaretti N.
      • Marchesi A.
      • Vaienti L.
      • Almesberger D.
      • Parodi P.C.
      A Simple and Effective Technique of Breast Remodelling After Conserving Surgery for Lower Quadrants Breast Cancer.
      ,
      • Ho W.
      • Stallard S.
      • Doughty J.
      • Mallon E.
      • Romics L.
      Oncological outcomes and complications after volume replacement oncoplastic breast conservations—the glasgow experience.
      ,
      • Fujimoto H.
      • Shiina N.
      • Nagashima T.
      • et al.
      Oncoplastic breast-conserving surgery using chest wall perforator flaps: three-dimensional quantitative analysis of the percentage of breast volume excised and changes over time in flap volume.
      of which did not use LD flaps) and six (85.7%)
      • Kelemen P.
      • Pukancsik D.
      • Újhelyi M.
      • et al.
      Evaluation of the central pedicled, modified Wise-pattern technique as a standard level II oncoplastic breast-conserving surgery: a retrospective clinicopathological study of 190 breast cancer patients.
      • Kelemen P.
      • Pukancsik D.
      • Újhelyi M.
      • et al.
      Comparison of clinicopathologic, cosmetic and quality of life outcomes in 700 oncoplastic and conventional breast-conserving surgery cases: a single-centre retrospective study.
      • Lee J.
      • Jung J.H.
      • Kim W.W.
      • et al.
      Five-year oncologic outcomes of volume displacement procedures after partial mastectomy for breast cancer.
      • Gurleyik G.
      • Karagulle H.
      • Eris E.
      • Aker F.
      • Ustaalioglu B.O.
      Oncoplastic surgery; volume displacement techniques for breast conserving surgery in patients with breast cancer.
      • Yang J.D.
      • Bae S.G.
      • Chung H.Y.
      • Cho B.C.
      • Park H.Y.
      • Jung J.H.
      The Usefulness of Oncoplastic Volume displacement techniques in the superiorly located breast cancers for korean patients with small to moderate-sized breasts:.
      • Clough K.B.
      • van la Parra R.F.D.
      • Thygesen H.H.
      • et al.
      Long-term results after oncoplastic surgery for breast cancer: a 10-year follow-up.
      VD-OBCS studies. Recurrence rate, reported in 11
      • Hernanz F.
      • Sánchez S.
      • Cerdeira M.P.
      • Figuero C.R.
      Long-term results of breast conservation and immediate volume replacement with myocutaneous latissimus dorsi flap.
      ,
      • Kijima Y.
      • Yoshinaka H.
      • Hirata M.
      • et al.
      Oncoplastic surgery combining partial mastectomy and immediate volume replacement using a thoracodorsal adipofascial cutaneous flap with a crescent-shaped dermis.
      ,
      • Farahat A.M.
      • Hashim T.
      • Soliman H.O.
      • Manie T.M.
      • Soliman O.M.
      Skin sparing mastectomy: technique and suggested methods of reconstruction.
      • Lee J.
      • Jung J.H.
      • Kim W.W.
      • et al.
      Oncologic outcomes of volume replacement technique after partial mastectomy for breast cancer: a single center analysis.
      • El-Marakby H.H.
      • Kotb M.H.
      Oncoplastic volume replacement with latissimus dorsi myocutaneous flap in patients with large ptotic breasts. Is it feasible?.
      • Zhou L.
      • Wang Y.
      • Cai R.
      • et al.
      Pedicled descending branch latissimus dorsi mini-flap in repairing partial mastectomy defect: shoulder functional and esthetic outcomes.
      • De Biasio F.
      • Zingaretti N.
      • Marchesi A.
      • Vaienti L.
      • Almesberger D.
      • Parodi P.C.
      A Simple and Effective Technique of Breast Remodelling After Conserving Surgery for Lower Quadrants Breast Cancer.
      • Mele S.
      • Wright D.
      • Paramanathan N.
      • Laws S.
      • Peiris L.
      • Rainsbury R.
      Long-term effect of oncoplastic breast-conserving surgery using latissimus dorsi miniflaps on mammographic surveillance and the detection of local recurrence.
      • Yang C.E.
      • Roh T.S.
      • Yun I.S.
      • Kim Y.S.
      • Lew D.H.
      Immediate partial breast reconstruction with endoscopic Latissimus Dorsi muscle flap harvest.
      • Ho W.
      • Stallard S.
      • Doughty J.
      • Mallon E.
      • Romics L.
      Oncological outcomes and complications after volume replacement oncoplastic breast conservations—the glasgow experience.
      • Fujimoto H.
      • Shiina N.
      • Nagashima T.
      • et al.
      Oncoplastic breast-conserving surgery using chest wall perforator flaps: three-dimensional quantitative analysis of the percentage of breast volume excised and changes over time in flap volume.
      of the VR-OBCS and 6
      • Kelemen P.
      • Pukancsik D.
      • Újhelyi M.
      • et al.
      Evaluation of the central pedicled, modified Wise-pattern technique as a standard level II oncoplastic breast-conserving surgery: a retrospective clinicopathological study of 190 breast cancer patients.
      • Kelemen P.
      • Pukancsik D.
      • Újhelyi M.
      • et al.
      Comparison of clinicopathologic, cosmetic and quality of life outcomes in 700 oncoplastic and conventional breast-conserving surgery cases: a single-centre retrospective study.
      • Lee J.
      • Jung J.H.
      • Kim W.W.
      • et al.
      Five-year oncologic outcomes of volume displacement procedures after partial mastectomy for breast cancer.
      • Gurleyik G.
      • Karagulle H.
      • Eris E.
      • Aker F.
      • Ustaalioglu B.O.
      Oncoplastic surgery; volume displacement techniques for breast conserving surgery in patients with breast cancer.
      • Yang J.D.
      • Bae S.G.
      • Chung H.Y.
      • Cho B.C.
      • Park H.Y.
      • Jung J.H.
      The Usefulness of Oncoplastic Volume displacement techniques in the superiorly located breast cancers for korean patients with small to moderate-sized breasts:.
      • Clough K.B.
      • van la Parra R.F.D.
      • Thygesen H.H.
      • et al.
      Long-term results after oncoplastic surgery for breast cancer: a 10-year follow-up.
      of VD-OBCS studies, was the most reported outcome within the oncological domain. Local recurrence rate was measured in both VR- and VD-OBCS, however, locoregional recurrence rate was not reported in VR-OBCS studies; therefore, this outcome could not be compared between procedures. Studies reporting on VR-OBCS studies with LD flaps had the highest rates of mortality (0.098), distant metastasis (0.068), and local recurrence (0.029). Studies utilizing VR-OBCS without LD flaps reported slightly lower rates for each oncological outcome as compared to VD-OBCS, however, rates were similar overall. Table 1 summarizes the probability rates for each oncological outcome by procedure type.
      Table 1Summary of Oncological Outcomes and Total Probability by Procedure.
      PROCEDURE TYPESTUDY# OF MORTALITIES REPORTED# OF DISTANT METASTASIS REPORTEDRECURRENCE RATE
      LRLRR
      VDKeleman et al.,
      • Kelemen P.
      • Pukancsik D.
      • Újhelyi M.
      • et al.
      Evaluation of the central pedicled, modified Wise-pattern technique as a standard level II oncoplastic breast-conserving surgery: a retrospective clinicopathological study of 190 breast cancer patients.
      22*3.20%1.60%
      Kelemen et al.,
      • Kelemen P.
      • Pukancsik D.
      • Újhelyi M.
      • et al.
      Comparison of clinicopathologic, cosmetic and quality of life outcomes in 700 oncoplastic and conventional breast-conserving surgery cases: a single-centre retrospective study.
      01.10%0.90%
      Lee et al.,
      • Lee J.
      • Jung J.H.
      • Kim W.W.
      • et al.
      Five-year oncologic outcomes of volume displacement procedures after partial mastectomy for breast cancer.
      14**1.90%
      Gurleyik et al.,
      • Gurleyik G.
      • Karagulle H.
      • Eris E.
      • Aker F.
      • Ustaalioglu B.O.
      Oncoplastic surgery; volume displacement techniques for breast conserving surgery in patients with breast cancer.
      00.00%
      Yang et al.,
      • Yang J.D.
      • Bae S.G.
      • Chung H.Y.
      • Cho B.C.
      • Park H.Y.
      • Jung J.H.
      The Usefulness of Oncoplastic Volume displacement techniques in the superiorly located breast cancers for korean patients with small to moderate-sized breasts:.
      0.00%
      Clough t al.,
      • Clough K.B.
      • van la Parra R.F.D.
      • Thygesen H.H.
      • et al.
      Long-term results after oncoplastic surgery for breast cancer: a 10-year follow-up.
      15352.20%1.10%
      Total Outcome Probability0.0260.0370.0160.011
      VR w/o LDKijima et al.,
      • Kijima Y.
      • Yoshinaka H.
      • Hirata M.
      • et al.
      Oncoplastic surgery combining partial mastectomy and immediate volume replacement using a thoracodorsal adipofascial cutaneous flap with a crescent-shaped dermis.
      000.00%
      Hu et al.,
      • Hu J.
      • Cuffolo G.
      • Parulekar V.
      • Chan V.
      • Tenovici A.
      • Roy P.G.
      The results of surveillance imaging after breast conservation surgery and partial breast reconstruction with chest wall perforator flaps; a qualitative analysis compared with standard breast-conserving surgery for breast cancer.
      11
      De Biasio et al.,
      • De Biasio F.
      • Zingaretti N.
      • Marchesi A.
      • Vaienti L.
      • Almesberger D.
      • Parodi P.C.
      A Simple and Effective Technique of Breast Remodelling After Conserving Surgery for Lower Quadrants Breast Cancer.
      0.00%
      Ho et al.,
      • Ho W.
      • Stallard S.
      • Doughty J.
      • Mallon E.
      • Romics L.
      Oncological outcomes and complications after volume replacement oncoplastic breast conservations—the glasgow experience.
      03.30%
      Fujimoto et al.,
      • Fujimoto H.
      • Shiina N.
      • Nagashima T.
      • et al.
      Oncoplastic breast-conserving surgery using chest wall perforator flaps: three-dimensional quantitative analysis of the percentage of breast volume excised and changes over time in flap volume.
      20%
      Total Outcome Probability0.0200.0260.0110.000
      VR w/ LDZhou et al.,
      • Zhou L.
      • Wang Y.
      • Cai R.
      • et al.
      Pedicled descending branch latissimus dorsi mini-flap in repairing partial mastectomy defect: shoulder functional and esthetic outcomes.
      00%
      Hernanz et al.,
      • Hernanz F.
      • Sánchez S.
      • Cerdeira M.P.
      • Figuero C.R.
      Long-term results of breast conservation and immediate volume replacement with myocutaneous latissimus dorsi flap.
      362.44%
      El-Marakby et al.,
      • El-Marakby H.H.
      • Kotb M.H.
      Oncoplastic volume replacement with latissimus dorsi myocutaneous flap in patients with large ptotic breasts. Is it feasible?.
      1***4.00%
      Mele et al.,
      • Mele S.
      • Wright D.
      • Paramanathan N.
      • Laws S.
      • Peiris L.
      • Rainsbury R.
      Long-term effect of oncoplastic breast-conserving surgery using latissimus dorsi miniflaps on mammographic surveillance and the detection of local recurrence.
      8.00%
      Yang et al.,
      • Yang C.E.
      • Roh T.S.
      • Yun I.S.
      • Kim Y.S.
      • Lew D.H.
      Immediate partial breast reconstruction with endoscopic Latissimus Dorsi muscle flap harvest.
      0.00%
      Thekkinkattil et al.
      • Thekkinkattil D.K.
      • Salhab M.
      • McManus P.L.
      Feasibility of Autologous fat transfer for replacement of implant volume in complicated implant-assisted Latissimus Dorsi Flap Breast Reconstruction:.
      22
      Total Outcome Probability0.0980.0680.0290.000
      VD, Volume Displacement; VR w/o LD, Volume Replacement without Latissimus Dorsi Flaps; VR w/ LD, Volume Replacement with Latissimus Dorsi Flaps; LR, Local Recurrence; LRR, Locoregional Recurrence; *, Distant multiplex – Bone; **, Bone: 1; Lungs: 3; ***, Bone; and -, was not measured in study.
      Clinical outcomes included hematoma, infection, fat necrosis, seroma, partial flap loss, and wound dehiscence. These outcomes were reported in 23 (89%)
      • Kim J.
      • Yoo J.
      • Lee J.
      • Chang E.
      • Suh K.
      Oncoplastic Reconstruction with Superior Based Lateral Breast Rotation Flap after Lower Quadrant Tumor Resection.
      ,
      • Hu J.
      • Cuffolo G.
      • Parulekar V.
      • Chan V.
      • Tenovici A.
      • Roy P.G.
      The results of surveillance imaging after breast conservation surgery and partial breast reconstruction with chest wall perforator flaps; a qualitative analysis compared with standard breast-conserving surgery for breast cancer.
      ,
      • Farahat A.M.
      • Hashim T.
      • Soliman H.O.
      • Manie T.M.
      • Soliman O.M.
      Skin sparing mastectomy: technique and suggested methods of reconstruction.
      • Lee J.
      • Jung J.H.
      • Kim W.W.
      • et al.
      Oncologic outcomes of volume replacement technique after partial mastectomy for breast cancer: a single center analysis.
      • El-Marakby H.H.
      • Kotb M.H.
      Oncoplastic volume replacement with latissimus dorsi myocutaneous flap in patients with large ptotic breasts. Is it feasible?.
      • Zhou L.
      • Wang Y.
      • Cai R.
      • et al.
      Pedicled descending branch latissimus dorsi mini-flap in repairing partial mastectomy defect: shoulder functional and esthetic outcomes.
      • De Biasio F.
      • Zingaretti N.
      • Marchesi A.
      • Vaienti L.
      • Almesberger D.
      • Parodi P.C.
      A Simple and Effective Technique of Breast Remodelling After Conserving Surgery for Lower Quadrants Breast Cancer.
      ,
      • Yang C.E.
      • Roh T.S.
      • Yun I.S.
      • Kim Y.S.
      • Lew D.H.
      Immediate partial breast reconstruction with endoscopic Latissimus Dorsi muscle flap harvest.
      • Ho W.
      • Stallard S.
      • Doughty J.
      • Mallon E.
      • Romics L.
      Oncological outcomes and complications after volume replacement oncoplastic breast conservations—the glasgow experience.
      • Fujimoto H.
      • Shiina N.
      • Nagashima T.
      • et al.
      Oncoplastic breast-conserving surgery using chest wall perforator flaps: three-dimensional quantitative analysis of the percentage of breast volume excised and changes over time in flap volume.
      • Thekkinkattil D.K.
      • Salhab M.
      • McManus P.L.
      Feasibility of Autologous fat transfer for replacement of implant volume in complicated implant-assisted Latissimus Dorsi Flap Breast Reconstruction:.
      ,
      • Yang J.D.
      • Kim M.C.
      • Lee J.W.
      • et al.
      Usefulness of Oncoplastic volume replacement techniques after breast conserving surgery in small to moderate-sized breasts.
      • Abdelrahman E.M.
      • Nawar A.M.
      • Balbaa M.A.
      • Shoulah A.A.
      • Shora A.A.
      • Kharoub M.S.
      Oncoplastic Volume Replacement for Breast Cancer: latissimus Dorsi Flap versus Thoracodorsal Artery Perforator Flap.
      • Amin A.A.
      • Rifaat M.
      • Farahat A.
      • Hashem T.
      The role of thoracodorsal artery perforator flap in oncoplastic breast surgery.
      • Dogan L.
      • Gulcelik M.A.
      • Karaman N.
      • Camlibel M.
      • Serdar G.K.
      • Ozaslan C.
      Intraglandular flap technique for tumors located in the upper outer quadrant of the breast.
      • Kijima Y.
      • Koriyama C.
      • Fujii T.
      • et al.
      Immediate breast volume replacement using a free dermal fat graft after breast cancer surgery: multi-institutional joint research of short-term outcomes in 262 Japanese patients.
      • Lee J.W.
      • Kim M.C.
      • Park H.Y.
      • Yang J.D.
      Oncoplastic volume replacement techniques according to the excised volume and tumor location in small- to moderate-sized breasts.
      • Sarkar D.K.
      • Maji A.
      • Saha S.
      • Biswas J.K.
      Oncoplastic Breast Surgery - Our Experiences in the Breast Clinic, IPGME&R, Kolkata.
      • Tanaka S.
      • Sato N.
      • Fujioka H.
      • et al.
      Breast conserving surgery using volume replacement with oxidized regenerated cellulose: a cosmetic outcome analysis.
      • Klinger M.
      • Giannasi S.
      • Klinger F.
      • et al.
      Periareolar approach in oncoplastic breast conservative surgery.
      • van Huizum M.A.
      • Hage J.J.
      • Oldenburg H.A.
      • Hoornweg M.J.
      Internal mammary artery perforator flap for immediate volume replacement following wide local excision of breast cancer.
      • Hakakian C.S.
      • Lockhart R.A.
      • Kulber D.A.
      • Aronowitz J.A.
      Lateral intercostal artery perforator flap in breast reconstruction: a simplified pedicle permits an expanded role.
      • McCulley S.J.
      • Schaverien M.V.
      • Tan V.K.M.
      • Macmillan R.D.
      Lateral Thoracic Artery Perforator (LTAP) flap in partial breast reconstruction.
      of the VR-OBCS and 7 (100%)
      • Kelemen P.
      • Pukancsik D.
      • Újhelyi M.
      • et al.
      Evaluation of the central pedicled, modified Wise-pattern technique as a standard level II oncoplastic breast-conserving surgery: a retrospective clinicopathological study of 190 breast cancer patients.
      • Kelemen P.
      • Pukancsik D.
      • Újhelyi M.
      • et al.
      Comparison of clinicopathologic, cosmetic and quality of life outcomes in 700 oncoplastic and conventional breast-conserving surgery cases: a single-centre retrospective study.
      • Lee J.
      • Jung J.H.
      • Kim W.W.
      • et al.
      Five-year oncologic outcomes of volume displacement procedures after partial mastectomy for breast cancer.
      • Gurleyik G.
      • Karagulle H.
      • Eris E.
      • Aker F.
      • Ustaalioglu B.O.
      Oncoplastic surgery; volume displacement techniques for breast conserving surgery in patients with breast cancer.
      • Yang J.D.
      • Bae S.G.
      • Chung H.Y.
      • Cho B.C.
      • Park H.Y.
      • Jung J.H.
      The Usefulness of Oncoplastic Volume displacement techniques in the superiorly located breast cancers for korean patients with small to moderate-sized breasts:.
      • Clough K.B.
      • van la Parra R.F.D.
      • Thygesen H.H.
      • et al.
      Long-term results after oncoplastic surgery for breast cancer: a 10-year follow-up.
      ,
      • Gardfjell A.
      • Dahlbäck C.
      • Åhsberg K.
      Patient satisfaction after unilateral oncoplastic volume displacement surgery for breast cancer, evaluated with the BREAST-Q™.
      of the VD-OBCS studies. The most reported clinical outcome in the included VR-OBCS studies was fat necrosis and seroma. In the VD-OBCS studies, hematoma rate, infection rate, and fat necrosis were the most reported clinical outcomes. Because of the nature of VD-OBCS, partial flap loss was not reported in studies that utilize this oncoplastic procedure. Studies that report on VD-OBCS had the lowest probability of hematoma, fat necrosis, and seroma. Studies reporting on VR-OBCS with LD flaps reported the lowest probability for infection rates. Wound dehiscence rates were lowest in the studies that report on VR-OBCS without LD flaps. Between the two VR-OBCS techniques, partial flap loss rates were lowest in those studies reporting on VR-OBCS with LD flaps. A summary of the probabilities for each clinical outcome by the procedural group can be found in Table 2. The oncological and clinical outcome probabilities are graphically summarized in Figure 2.
      Table 2Summary of Clinical Outcomes and Total Probability by Procedure.
      PROCEDURE TYPESTUDYHEMA.INF.FAT NEC.SEROM.PFLWD
      VDKelemen et al.,
      • Kelemen P.
      • Pukancsik D.
      • Újhelyi M.
      • et al.
      Evaluation of the central pedicled, modified Wise-pattern technique as a standard level II oncoplastic breast-conserving surgery: a retrospective clinicopathological study of 190 breast cancer patients.
      44227
      Kelemen et al.,
      • Kelemen P.
      • Pukancsik D.
      • Újhelyi M.
      • et al.
      Comparison of clinicopathologic, cosmetic and quality of life outcomes in 700 oncoplastic and conventional breast-conserving surgery cases: a single-centre retrospective study.
      2825
      Lee et al.,
      • Lee J.
      • Jung J.H.
      • Kim W.W.
      • et al.
      Five-year oncologic outcomes of volume displacement procedures after partial mastectomy for breast cancer.
      373
      Gurleyik et al.,
      • Gurleyik G.
      • Karagulle H.
      • Eris E.
      • Aker F.
      • Ustaalioglu B.O.
      Oncoplastic surgery; volume displacement techniques for breast conserving surgery in patients with breast cancer.
      37
      Yang et al.,
      • Yang J.D.
      • Bae S.G.
      • Chung H.Y.
      • Cho B.C.
      • Park H.Y.
      • Jung J.H.
      The Usefulness of Oncoplastic Volume displacement techniques in the superiorly located breast cancers for korean patients with small to moderate-sized breasts:.
      2
      Gardfjell et al.,
      • Gardfjell A.
      • Dahlbäck C.
      • Åhsberg K.
      Patient satisfaction after unilateral oncoplastic volume displacement surgery for breast cancer, evaluated with the BREAST-Q™.
      11
      Clough et al.,
      • Clough K.B.
      • van la Parra R.F.D.
      • Thygesen H.H.
      • et al.
      Long-term results after oncoplastic surgery for breast cancer: a 10-year follow-up.
      521*243
      Total Outcome Probability0.0160.0320.0370.0110.030
      VR w/o LDHu et al.,
      • Hu J.
      • Cuffolo G.
      • Parulekar V.
      • Chan V.
      • Tenovici A.
      • Roy P.G.
      The results of surveillance imaging after breast conservation surgery and partial breast reconstruction with chest wall perforator flaps; a qualitative analysis compared with standard breast-conserving surgery for breast cancer.
      4
      De Biasio et al.,
      • De Biasio F.
      • Zingaretti N.
      • Marchesi A.
      • Vaienti L.
      • Almesberger D.
      • Parodi P.C.
      A Simple and Effective Technique of Breast Remodelling After Conserving Surgery for Lower Quadrants Breast Cancer.
      1100
      Amin et al.,
      • Amin A.A.
      • Rifaat M.
      • Farahat A.
      • Hashem T.
      The role of thoracodorsal artery perforator flap in oncoplastic breast surgery.
      1210
      Kijima et al.,
      • Kijima Y.
      • Koriyama C.
      • Fujii T.
      • et al.
      Immediate breast volume replacement using a free dermal fat graft after breast cancer surgery: multi-institutional joint research of short-term outcomes in 262 Japanese patients.
      7
      Klinger et al.,
      • Lee S.
      • Lee J.
      • Lee S.
      • Bae Y.
      Oncoplastic breast surgery with Latissimus Dorsi myocutaneous flap for large defect in patients with Ptotic breasts: is it feasible when combined with local flaps?.
      23
      Tanaka et al.,
      • Tanaka S.
      • Sato N.
      • Fujioka H.
      • et al.
      Breast conserving surgery using volume replacement with oxidized regenerated cellulose: a cosmetic outcome analysis.
      1
      Huizum et al.,
      • van Huizum M.A.
      • Hage J.J.
      • Oldenburg H.A.
      • Hoornweg M.J.
      Internal mammary artery perforator flap for immediate volume replacement following wide local excision of breast cancer.
      0000
      Dogan et al.,
      • Dogan L.
      • Gulcelik M.A.
      • Karaman N.
      • Camlibel M.
      • Serdar G.K.
      • Ozaslan C.
      Intraglandular flap technique for tumors located in the upper outer quadrant of the breast.
      28
      Ho et al.,
      • Ho W.
      • Stallard S.
      • Doughty J.
      • Mallon E.
      • Romics L.
      Oncological outcomes and complications after volume replacement oncoplastic breast conservations—the glasgow experience.
      1222
      Hakakian et al.,
      • Hakakian C.S.
      • Lockhart R.A.
      • Kulber D.A.
      • Aronowitz J.A.
      Lateral intercostal artery perforator flap in breast reconstruction: a simplified pedicle permits an expanded role.
      2030
      McCulley et al.,
      • McCulley S.J.
      • Schaverien M.V.
      • Tan V.K.M.
      • Macmillan R.D.
      Lateral Thoracic Artery Perforator (LTAP) flap in partial breast reconstruction.
      0
      Fujimoto et al.,
      • Fujimoto H.
      • Shiina N.
      • Nagashima T.
      • et al.
      Oncoplastic breast-conserving surgery using chest wall perforator flaps: three-dimensional quantitative analysis of the percentage of breast volume excised and changes over time in flap volume.
      1
      Total Outcome Probability0.0350.0300.0520.0240.0730.008
      VR w/ LDZhou et al.,
      • Zhou L.
      • Wang Y.
      • Cai R.
      • et al.
      Pedicled descending branch latissimus dorsi mini-flap in repairing partial mastectomy defect: shoulder functional and esthetic outcomes.
      1030
      El-Marakby et al.,
      • El-Marakby H.H.
      • Kotb M.H.
      Oncoplastic volume replacement with latissimus dorsi myocutaneous flap in patients with large ptotic breasts. Is it feasible?.
      456162
      Yang et al.,
      • Yang C.E.
      • Roh T.S.
      • Yun I.S.
      • Kim Y.S.
      • Lew D.H.
      Immediate partial breast reconstruction with endoscopic Latissimus Dorsi muscle flap harvest.
      004
      Yang et al.,
      • Yang J.D.
      • Kim M.C.
      • Lee J.W.
      • et al.
      Usefulness of Oncoplastic volume replacement techniques after breast conserving surgery in small to moderate-sized breasts.
      0011
      Abdelrahman et al.,42311
      Sarkar et al.,
      • Sarkar D.K.
      • Maji A.
      • Saha S.
      • Biswas J.K.
      Oncoplastic Breast Surgery - Our Experiences in the Breast Clinic, IPGME&R, Kolkata.
      0
      Lee et al.,
      • Lee J.W.
      • Kim M.C.
      • Park H.Y.
      • Yang J.D.
      Oncoplastic volume replacement techniques according to the excised volume and tumor location in small- to moderate-sized breasts.
      0026
      Thekkinkattil et al.,
      • Thekkinkattil D.K.
      • Salhab M.
      • McManus P.L.
      Feasibility of Autologous fat transfer for replacement of implant volume in complicated implant-assisted Latissimus Dorsi Flap Breast Reconstruction:.
      02
      Total Outcome Probability0.0800.0160.0200.2070.0250.048
      VD, Volume Displacement; VR w/o LD, Volume Replacement without Latissimus Dorsi Flaps; VR w/ LD, Volume Replacement with Latissimus Dorsi Flaps; Hema, Hematoma; Inf, Infection; Fat Nec., Fat Necrosis; Serom, Seroma; PFL, Partial Flap Loss; WD, Wound Dehiscence; and *, Secondary Infection after fat necrosis.
      Fig 2
      Fig. 2Graphical Summary of Oncological and Clinical Outcomes by the Procedural Group.
      DM, Distant Metastasis; LR, Local Recurrence; LRR, Locoregional Recurrence; VD, Volume Displacement; w/o LD, Volume Replacement without LD; and w/LD, Volume Replacement w. LD.
      Cosmetic outcomes were reported in 19 (73%)
      • Kim J.
      • Yoo J.
      • Lee J.
      • Chang E.
      • Suh K.
      Oncoplastic Reconstruction with Superior Based Lateral Breast Rotation Flap after Lower Quadrant Tumor Resection.
      ,
      • Hernanz F.
      • Sánchez S.
      • Cerdeira M.P.
      • Figuero C.R.
      Long-term results of breast conservation and immediate volume replacement with myocutaneous latissimus dorsi flap.
      ,
      • Kijima Y.
      • Yoshinaka H.
      • Hirata M.
      • et al.
      Oncoplastic surgery combining partial mastectomy and immediate volume replacement using a thoracodorsal adipofascial cutaneous flap with a crescent-shaped dermis.
      ,
      • Farahat A.M.
      • Hashim T.
      • Soliman H.O.
      • Manie T.M.
      • Soliman O.M.
      Skin sparing mastectomy: technique and suggested methods of reconstruction.
      ,
      • El-Marakby H.H.
      • Kotb M.H.
      Oncoplastic volume replacement with latissimus dorsi myocutaneous flap in patients with large ptotic breasts. Is it feasible?.
      • Zhou L.
      • Wang Y.
      • Cai R.
      • et al.
      Pedicled descending branch latissimus dorsi mini-flap in repairing partial mastectomy defect: shoulder functional and esthetic outcomes.
      • De Biasio F.
      • Zingaretti N.
      • Marchesi A.
      • Vaienti L.
      • Almesberger D.
      • Parodi P.C.
      A Simple and Effective Technique of Breast Remodelling After Conserving Surgery for Lower Quadrants Breast Cancer.
      ,
      • Yang C.E.
      • Roh T.S.
      • Yun I.S.
      • Kim Y.S.
      • Lew D.H.
      Immediate partial breast reconstruction with endoscopic Latissimus Dorsi muscle flap harvest.
      ,
      • Fujimoto H.
      • Shiina N.
      • Nagashima T.
      • et al.
      Oncoplastic breast-conserving surgery using chest wall perforator flaps: three-dimensional quantitative analysis of the percentage of breast volume excised and changes over time in flap volume.
      ,
      • Thekkinkattil D.K.
      • Salhab M.
      • McManus P.L.
      Feasibility of Autologous fat transfer for replacement of implant volume in complicated implant-assisted Latissimus Dorsi Flap Breast Reconstruction:.
      ,
      • Yang J.D.
      • Kim M.C.
      • Lee J.W.
      • et al.
      Usefulness of Oncoplastic volume replacement techniques after breast conserving surgery in small to moderate-sized breasts.
      • Abdelrahman E.M.
      • Nawar A.M.
      • Balbaa M.A.
      • Shoulah A.A.
      • Shora A.A.
      • Kharoub M.S.
      Oncoplastic Volume Replacement for Breast Cancer: latissimus Dorsi Flap versus Thoracodorsal Artery Perforator Flap.
      • Amin A.A.
      • Rifaat M.
      • Farahat A.
      • Hashem T.
      The role of thoracodorsal artery perforator flap in oncoplastic breast surgery.
      ,
      • Kijima Y.
      • Koriyama C.
      • Fujii T.
      • et al.
      Immediate breast volume replacement using a free dermal fat graft after breast cancer surgery: multi-institutional joint research of short-term outcomes in 262 Japanese patients.
      • Lee J.W.
      • Kim M.C.
      • Park H.Y.
      • Yang J.D.
      Oncoplastic volume replacement techniques according to the excised volume and tumor location in small- to moderate-sized breasts.
      • Sarkar D.K.
      • Maji A.
      • Saha S.
      • Biswas J.K.
      Oncoplastic Breast Surgery - Our Experiences in the Breast Clinic, IPGME&R, Kolkata.
      • Tanaka S.
      • Sato N.
      • Fujioka H.
      • et al.
      Breast conserving surgery using volume replacement with oxidized regenerated cellulose: a cosmetic outcome analysis.
      • Klinger M.
      • Giannasi S.
      • Klinger F.
      • et al.
      Periareolar approach in oncoplastic breast conservative surgery.
      • van Huizum M.A.
      • Hage J.J.
      • Oldenburg H.A.
      • Hoornweg M.J.
      Internal mammary artery perforator flap for immediate volume replacement following wide local excision of breast cancer.
      VR-OBCS studies and five (71%)
      • Kelemen P.
      • Pukancsik D.
      • Újhelyi M.
      • et al.
      Evaluation of the central pedicled, modified Wise-pattern technique as a standard level II oncoplastic breast-conserving surgery: a retrospective clinicopathological study of 190 breast cancer patients.
      ,
      • Kelemen P.
      • Pukancsik D.
      • Újhelyi M.
      • et al.
      Comparison of clinicopathologic, cosmetic and quality of life outcomes in 700 oncoplastic and conventional breast-conserving surgery cases: a single-centre retrospective study.
      ,
      • Gurleyik G.
      • Karagulle H.
      • Eris E.
      • Aker F.
      • Ustaalioglu B.O.
      Oncoplastic surgery; volume displacement techniques for breast conserving surgery in patients with breast cancer.
      ,
      • Yang J.D.
      • Kim M.C.
      • Lee J.W.
      • et al.
      Usefulness of Oncoplastic volume replacement techniques after breast conserving surgery in small to moderate-sized breasts.
      ,
      • Gardfjell A.
      • Dahlbäck C.
      • Åhsberg K.
      Patient satisfaction after unilateral oncoplastic volume displacement surgery for breast cancer, evaluated with the BREAST-Q™.
      VD-OBCS studies. Author-generated questionnaires were the most common method of data collection in both VR-OBCS (35%)
      • Farahat A.M.
      • Hashim T.
      • Soliman H.O.
      • Manie T.M.
      • Soliman O.M.
      Skin sparing mastectomy: technique and suggested methods of reconstruction.
      ,
      • El-Marakby H.H.
      • Kotb M.H.
      Oncoplastic volume replacement with latissimus dorsi myocutaneous flap in patients with large ptotic breasts. Is it feasible?.
      ,
      • Zhou L.
      • Wang Y.
      • Cai R.
      • et al.
      Pedicled descending branch latissimus dorsi mini-flap in repairing partial mastectomy defect: shoulder functional and esthetic outcomes.
      ,
      • Thekkinkattil D.K.
      • Salhab M.
      • McManus P.L.
      Feasibility of Autologous fat transfer for replacement of implant volume in complicated implant-assisted Latissimus Dorsi Flap Breast Reconstruction:.
      ,
      • Abdelrahman E.M.
      • Nawar A.M.
      • Balbaa M.A.
      • Shoulah A.A.
      • Shora A.A.
      • Kharoub M.S.
      Oncoplastic Volume Replacement for Breast Cancer: latissimus Dorsi Flap versus Thoracodorsal Artery Perforator Flap.
      ,
      • Amin A.A.
      • Rifaat M.
      • Farahat A.
      • Hashem T.
      The role of thoracodorsal artery perforator flap in oncoplastic breast surgery.
      ,
      • Kijima Y.
      • Koriyama C.
      • Fujii T.
      • et al.
      Immediate breast volume replacement using a free dermal fat graft after breast cancer surgery: multi-institutional joint research of short-term outcomes in 262 Japanese patients.
      ,
      • Sarkar D.K.
      • Maji A.
      • Saha S.
      • Biswas J.K.
      Oncoplastic Breast Surgery - Our Experiences in the Breast Clinic, IPGME&R, Kolkata.
      ,
      • van Huizum M.A.
      • Hage J.J.
      • Oldenburg H.A.
      • Hoornweg M.J.
      Internal mammary artery perforator flap for immediate volume replacement following wide local excision of breast cancer.
      and VD-OBCS (43%)
      • Kelemen P.
      • Pukancsik D.
      • Újhelyi M.
      • et al.
      Comparison of clinicopathologic, cosmetic and quality of life outcomes in 700 oncoplastic and conventional breast-conserving surgery cases: a single-centre retrospective study.
      ,
      • Gurleyik G.
      • Karagulle H.
      • Eris E.
      • Aker F.
      • Ustaalioglu B.O.
      Oncoplastic surgery; volume displacement techniques for breast conserving surgery in patients with breast cancer.
      ,
      • Yang J.D.
      • Bae S.G.
      • Chung H.Y.
      • Cho B.C.
      • Park H.Y.
      • Jung J.H.
      The Usefulness of Oncoplastic Volume displacement techniques in the superiorly located breast cancers for korean patients with small to moderate-sized breasts:.
      studies. The BREAST-Q was used in one study for each VR- and VD-OBCS; the BCCT.core was used twice in the VR- and once in the VD-OBCS literature. All five
      • Hernanz F.
      • Sánchez S.
      • Cerdeira M.P.
      • Figuero C.R.
      Long-term results of breast conservation and immediate volume replacement with myocutaneous latissimus dorsi flap.
      ,
      • Fujimoto H.
      • Shiina N.
      • Nagashima T.
      • et al.
      Oncoplastic breast-conserving surgery using chest wall perforator flaps: three-dimensional quantitative analysis of the percentage of breast volume excised and changes over time in flap volume.
      ,
      • Kelemen P.
      • Pukancsik D.
      • Újhelyi M.
      • et al.
      Evaluation of the central pedicled, modified Wise-pattern technique as a standard level II oncoplastic breast-conserving surgery: a retrospective clinicopathological study of 190 breast cancer patients.
      ,
      • Klinger M.
      • Giannasi S.
      • Klinger F.
      • et al.
      Periareolar approach in oncoplastic breast conservative surgery.
      ,
      • Gardfjell A.
      • Dahlbäck C.
      • Åhsberg K.
      Patient satisfaction after unilateral oncoplastic volume displacement surgery for breast cancer, evaluated with the BREAST-Q™.
      of these studies, however, used the questionnaires differently, making the comparison of scores between studies near impossible. For example, the BREAST-Q was used in one study in each the VR- and the VD-OBCS literature.
      • Klinger M.
      • Giannasi S.
      • Klinger F.
      • et al.
      Periareolar approach in oncoplastic breast conservative surgery.
      ,
      • Gardfjell A.
      • Dahlbäck C.
      • Åhsberg K.
      Patient satisfaction after unilateral oncoplastic volume displacement surgery for breast cancer, evaluated with the BREAST-Q™.
      However, scores could not be compared as Klinger et al.,
      • Klinger M.
      • Giannasi S.
      • Klinger F.
      • et al.
      Periareolar approach in oncoplastic breast conservative surgery.
      used only the “satisfaction with outcome” domain while Gardfjell et al.
      • Gardfjell A.
      • Dahlbäck C.
      • Åhsberg K.
      Patient satisfaction after unilateral oncoplastic volume displacement surgery for breast cancer, evaluated with the BREAST-Q™.
      reported scores for multiple domains. Although the same questionnaire was used, the lack of uniformity in measurement and reporting impeded the ability to pool and summarize outcome scores. Table 3 summarizes the questionnaires used in each study.
      Table 3Cosmetic Outcome Measures by Procedure.
      PROCEDURE GROUPSTUDYQUESTIONNAIRE
      VDKelemen et al.,
      • Kelemen P.
      • Pukancsik D.
      • Újhelyi M.
      • et al.
      Evaluation of the central pedicled, modified Wise-pattern technique as a standard level II oncoplastic breast-conserving surgery: a retrospective clinicopathological study of 190 breast cancer patients.
      BCCT.core
      Kelemen et al.,
      • Kelemen P.
      • Pukancsik D.
      • Újhelyi M.
      • et al.
      Comparison of clinicopathologic, cosmetic and quality of life outcomes in 700 oncoplastic and conventional breast-conserving surgery cases: a single-centre retrospective study.
      Author-Generated
      Gurleyik et al.,
      • Gurleyik G.
      • Karagulle H.
      • Eris E.
      • Aker F.
      • Ustaalioglu B.O.
      Oncoplastic surgery; volume displacement techniques for breast conserving surgery in patients with breast cancer.
      Author-Generated
      Yang et al.,
      • Yang J.D.
      • Bae S.G.
      • Chung H.Y.
      • Cho B.C.
      • Park H.Y.
      • Jung J.H.
      The Usefulness of Oncoplastic Volume displacement techniques in the superiorly located breast cancers for korean patients with small to moderate-sized breasts:.
      Author-Generated
      Gardfjell et al.,
      • Gardfjell A.
      • Dahlbäck C.
      • Åhsberg K.
      Patient satisfaction after unilateral oncoplastic volume displacement surgery for breast cancer, evaluated with the BREAST-Q™.
      BREAST-Q
      VR w/o LDKijima et al.,
      • Kijima Y.
      • Yoshinaka H.
      • Hirata M.
      • et al.
      Oncoplastic surgery combining partial mastectomy and immediate volume replacement using a thoracodorsal adipofascial cutaneous flap with a crescent-shaped dermis.
      Japan Breast Cancer Society Questionnaire
      De Biasio et al.,
      • De Biasio F.
      • Zingaretti N.
      • Marchesi A.
      • Vaienti L.
      • Almesberger D.
      • Parodi P.C.
      A Simple and Effective Technique of Breast Remodelling After Conserving Surgery for Lower Quadrants Breast Cancer.
      Japan Breast Cancer Society Questionnaire
      Amin et al.,
      • Amin A.A.
      • Rifaat M.
      • Farahat A.
      • Hashem T.
      The role of thoracodorsal artery perforator flap in oncoplastic breast surgery.
      Author-Generated
      Kijima et al.,
      • Kijima Y.
      • Koriyama C.
      • Fujii T.
      • et al.
      Immediate breast volume replacement using a free dermal fat graft after breast cancer surgery: multi-institutional joint research of short-term outcomes in 262 Japanese patients.
      Author-Generated
      Klinger et al.,
      • Lee S.
      • Lee J.
      • Lee S.
      • Bae Y.
      Oncoplastic breast surgery with Latissimus Dorsi myocutaneous flap for large defect in patients with Ptotic breasts: is it feasible when combined with local flaps?.
      BREAST-Q
      Tanaka et al.,
      • Tanaka S.
      • Sato N.
      • Fujioka H.
      • et al.
      Breast conserving surgery using volume replacement with oxidized regenerated cellulose: a cosmetic outcome analysis.
      Japan Breast Cancer Society Questionnaire
      Huizum et al.,
      • van Huizum M.A.
      • Hage J.J.
      • Oldenburg H.A.
      • Hoornweg M.J.
      Internal mammary artery perforator flap for immediate volume replacement following wide local excision of breast cancer.
      Author-Generated
      Fujimoto et al.,
      • Fujimoto H.
      • Shiina N.
      • Nagashima T.
      • et al.
      Oncoplastic breast-conserving surgery using chest wall perforator flaps: three-dimensional quantitative analysis of the percentage of breast volume excised and changes over time in flap volume.
      BCCT.core Four-Category Harvard Scale
      Kim et al.,
      • Kim J.
      • Yoo J.
      • Lee J.
      • Chang E.
      • Suh K.
      Oncoplastic Reconstruction with Superior Based Lateral Breast Rotation Flap after Lower Quadrant Tumor Resection.
      KNUH Breast Satisfaction Survey
      VR w/ LDZhou et al.,
      • Zhou L.
      • Wang Y.
      • Cai R.
      • et al.
      Pedicled descending branch latissimus dorsi mini-flap in repairing partial mastectomy defect: shoulder functional and esthetic outcomes.
      Author-Generated
      El-Marakby et al.,
      • El-Marakby H.H.
      • Kotb M.H.
      Oncoplastic volume replacement with latissimus dorsi myocutaneous flap in patients with large ptotic breasts. Is it feasible?.
      Author-Generated
      Yang et al.,
      • Yang C.E.
      • Roh T.S.
      • Yun I.S.
      • Kim Y.S.
      • Lew D.H.
      Immediate partial breast reconstruction with endoscopic Latissimus Dorsi muscle flap harvest.
      POSAS
      Yang et al.,
      • Yang J.D.
      • Kim M.C.
      • Lee J.W.
      • et al.
      Usefulness of Oncoplastic volume replacement techniques after breast conserving surgery in small to moderate-sized breasts.
      Adapted Michigan Breast Reconstruction Outcomes Survey
      Abdelrahman et al.,
      • Abdelrahman E.M.
      • Nawar A.M.
      • Balbaa M.A.
      • Shoulah A.A.
      • Shora A.A.
      • Kharoub M.S.
      Oncoplastic Volume Replacement for Breast Cancer: latissimus Dorsi Flap versus Thoracodorsal Artery Perforator Flap.
      Author-Generated
      Sarkar et al.,
      • Sarkar D.K.
      • Maji A.
      • Saha S.
      • Biswas J.K.
      Oncoplastic Breast Surgery - Our Experiences in the Breast Clinic, IPGME&R, Kolkata.
      Author-Generated
      Lee et al.,
      • Lee J.W.
      • Kim M.C.
      • Park H.Y.
      • Yang J.D.
      Oncoplastic volume replacement techniques according to the excised volume and tumor location in small- to moderate-sized breasts.
      KNUH Breast Satisfaction Survey
      Hernanz et al.,
      • Hernanz F.
      • Sánchez S.
      • Cerdeira M.P.
      • Figuero C.R.
      Long-term results of breast conservation and immediate volume replacement with myocutaneous latissimus dorsi flap.
      BCCT.core
      Thekkinattil et al.,
      • Thekkinkattil D.K.
      • Salhab M.
      • McManus P.L.
      Feasibility of Autologous fat transfer for replacement of implant volume in complicated implant-assisted Latissimus Dorsi Flap Breast Reconstruction:.
      Author-Generated
      VD, Volume Displacement; VR w/o LD, Volume Replacement without Latissimus Dorsi Flaps; VR w/ LD, Volume Replacement with Latissimus Dorsi Flaps; BCCT.core, Breast Cancer Conservation Treatment cosmetic results; POSAS, The Patient and Observer Scar Assessment Scale; and KNUH, Kyungpook National University Hospital.

      Discussion

      Oncoplastic breast conservation surgery (OBCS) is an effective and safe treatment option for patients with breast cancer.
      • Gurleyik G.
      • Karagulle H.
      • Eris E.
      • Aker F.
      • Ustaalioglu B.O.
      Oncoplastic surgery; volume displacement techniques for breast conserving surgery in patients with breast cancer.
      ,
      • Klinger M.
      • Giannasi S.
      • Klinger F.
      • et al.
      Periareolar approach in oncoplastic breast conservative surgery.
      ,
      • Lee S.
      • Lee J.
      • Lee S.
      • Bae Y.
      Oncoplastic breast surgery with Latissimus Dorsi myocutaneous flap for large defect in patients with Ptotic breasts: is it feasible when combined with local flaps?.
      Despite the growing support for OBCS procedures, there are very few studies that summarize patient outcomes following these procedures. Earlier studies have inappropriately attempted to show superiority of one procedure (VR or VD-OBCS) over the other.
      • El-Marakby H.H.
      • Kotb M.H.
      Oncoplastic volume replacement with latissimus dorsi myocutaneous flap in patients with large ptotic breasts. Is it feasible?.
      ,
      • Schaverien M.V.
      • Kuerer H.M.
      • Caudle A.S.
      • Smith B.D.
      • Hwang R.F.
      • Robb G.L.
      Outcomes of Volume Replacement Oncoplastic Breast-Conserving Surgery Using Chest Wall Perforator Flaps: comparison with Volume Displacement Oncoplastic Surgery and Total Breast Reconstruction.
      The objective of this review was to provide a synopsis of the available literature reporting oncological, clinical, and cosmetic outcomes following VR- and VD-OBCS. To properly examine outcomes following VR-OBCS, the VR data were reported separately, based on the use of LD flaps (Table 1, Table 2, Table 3 and Figure 2).
      Although direct comparisons between VR- and VD-OBCS patients are inappropriate, it is interesting to explore the differences extrapolated from the literature. Rates of all oncological outcomes summarized in this review were highest in VR-OBCS studies with LD flaps and lowest in VR-OBCS studies without LD flaps; rates following VD-OBCS procedures fell between the two VR techniques. The oncological outcomes were worse in those patients who received VR-OBCS with LD flaps. This could be due to larger tumor size, and therefore a larger defect, that required larger flap reconstruction such as that provided by the LD. Results were less consistent within the clinical outcome category. Fat necrosis mirrored the pattern seen in oncological outcomes while partial flap loss rates were lower in studies reporting on VR-OBCS with LD flaps versus without LD flaps. Infection rates were lowest in VR-OBCS studies with LD flaps, however, these studies reported considerably higher rates of hematoma, seroma, and wound dehiscence as compared to VR-OBCS studies without LD flaps. The donor site for LD is much larger than local perforator flaps, even when compared with those perforator flaps, which arise from the thoracodorsal vessels. Therefore, the LD is expected to have a higher incidence of hematoma than any of the other local perforator flaps or indeed the VD techniques.
      In addition to reporting the oncological and clinical outcome rates between procedures, this study also summarized the measures used to document cosmetic outcomes. Author-generated questionnaires were incredibly common in the reviewed literature. Utilizing author-generated, and potentially questionnaires that are not validated to measure outcomes, makes it difficult to compare and pool data. It is not feasible to compare cosmetic outcome scores from author-generated questionnaires as they are unlike scores from a common and validated scale such as the BREAST-Q. This, therefore, makes it near impossible to compare cosmetic outcomes between studies. A similar issue was found when trying to compare recurrence rates between studies. Studies were inconsistent in measuring and reporting of local and locoregional recurrence. It was common to see different terminology used in describing tumor recurrences (i.e., local, regional, locoregional, and tumor). Lastly, there was an inconsistency in the mean follow-up period, both between and within procedural groups. In VD-OBCS studies, follow-up periods of 21–60.8 months were documented. Similarly, follow-up periods of less than 1 month to 127 months were noted in VR-OBCS studies. Similar to inconsistent outcome measurement and reporting, having such a vast range of time horizons within one area of research makes it difficult to properly compare the results of individual studies.
      Although the authors understand that direct comparisons between OBCS procedures cannot be made, the heterogeneity in outcome measurement and reporting makes it difficult to compare outcomes even within the same procedural group. Oncoplastic breast surgery research groups would benefit from: 1) standardizing the breast defects by size and breast quadrants; 2) developing core outcome sets (COS); 3) consistently using validated measures; and 4) the consistent (standardized) use of evidence-based time horizons.
      • Thoma A.
      • Murphy J.
      • Voineskos S.
      • Coroneos C.
      • Goldsmith C.
      Improving science in surgery.
      A COS is an agreed upon list of critical outcomes to be measured, and reported, at minimum in all clinical trials.
      • Williamson P.R.
      • Altman D.G.
      • Bagley H.
      • et al.
      The COMET Handbook: version 1.0.
      The use of COS has become increasingly common and is now recommended by initiatives such as COMET to increase consistency and decrease waste in biomedical research. Appropriate scales and questionnaires should also be identified through a literature search or through the COSMIN Initiative.

      The COSMIN Initiative. About the COSMIN Initiative. COSMIN. Published NA. Accessed June 30, 2020. https://www.cosmin.nl/.

      This initiative aims to improve the selection of outcome measurement tools in healthcare. Through the consistent use of appropriate scales, this too, will allow for data from multiple studies to be pooled and compared. Once an agreed set of outcomes is selected, the COSMIN database could be used to decide how to consistently measure these outcomes across research studies. Lastly, the selection of a time horizon should be appropriate for the outcome of interest and should be justified with a review of the literature.
      • Mowakket S.
      • Karpinski M.
      • Gallo L.
      • et al.
      Reporting Time Horizons in RCTs in plastic surgery: a systematic review.
      The results of the current review should be interpreted while considering the following points and limitations. First, data regarding the breast or tumor size were not available to report in this review. Patient- and cancer-related characteristics could have impacted both oncological and clinical outcomes. As mentioned earlier, the literature indicates that volume excision is the greater predictor of unfavorable outcomes and deformities.
      • Clough K.B.
      • van la Parra R.F.D.
      • Thygesen H.H.
      • et al.
      Long-term results after oncoplastic surgery for breast cancer: a 10-year follow-up.
      As volume-related data were not always available to include in our review, it is unknown how this factor influenced patient outcomes. In addition, data on delays in adjuvant therapy were not considered in this study and may have impacted conclusions with regard to patient-reported outcomes. Despite the limitations of the current study, this review has helped to identify major gaps in methodology and reporting among the OBCS literature. Future studies should consider the suggestions above and integrate standardized measurement and reporting into their studies. In addition, the authors encourage both consumers and producers of OBCS research to consider the following variables: breast size, tumor size, excised volume, and adjuvant therapy, both when interpreting and designing oncoplastic research studies.

      Declaration of Competing Interest

      The authors have no conflicts of interest to report.

      Financial Disclosure

      The authors have no financial disclosures to report.

      Appendix. Supplementary materials

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