Turkish Journal of Plastic Surgery

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 29  |  Issue : 1  |  Page : 20--27

Utility of short-scar incisions mimicking breast augmentation incisions through periareolar or submammary approach for a better aesthetic outcome and patient satisfaction


Ayhan Okumus 
 Private Aesthetic Plastic and Reconstructive Surgeon, Bursa, Turkey

Correspondence Address:
Dr. Ayhan Okumus
Ihsaniye Mah, Ilknur Sok, Bulvar 224 Sitesi B/10 Nilufer, Bursa
Turkey

Abstract

Purpose: The purpose of the study is to evaluate the long-term aesthetic outcome of single-session nipple-sparing mastectomy (NSM) and immediate breast reconstruction operations performed using short-scar incisions mimicking breast augmentation incisions through periareolar or submammary approach. Materials and Methods: A total of 23 breast cancer patients (mean age: 32 years, range 21–44 years) who underwent single-session NSM and immediate breast reconstruction operations (bilateral in 9) performed through periareolar or submammary approach were included. Data on patient age, breast cancer characteristics, side of mastectomy and reconstruction, postoperative complications were retrieved from hospital records. Aesthetic outcome (by both patients and plastic surgeon), patient satisfaction (visual analog scale [VAS] scores), and psychological outcome (via body image scale) were evaluated after a median 4-year (range, 9 months–11 years) follow-up. Results: Majority of the patients identified that size of the breast (95.7%), shape of breast (95.7%), breast symmetry (95.7%), scars on the breast (100.0%), nipple-areola complex (100%), and overall aesthetic results (95.7%) fulfilled expectations very much. Physician evaluation also revealed that aesthetic outcome was excellent for majority of patients in terms of breast symmetry (80.7%), breast volume (95.7%), position of submammary fold (95.7%), and overall aesthetic result (95.7%) and all patients in terms of scar appearance on the breast (100.0%). Mean (standard deviation) VAS scores for patient satisfaction were 9.4 (0.8). Total body image scale indicated very good body image in terms of affective (e.g. feeling self-conscious), behavioral (e.g. difficulty in looking at the naked body), and cognitive (e.g. satisfaction with appearance) aspects in all patients. Conclusion: Our findings indicate the utility of short-scar (~4 cm) incisions mimicking breast augmentation incisions in a single-session NSM and immediate breast reconstruction as associated with a low-postoperative complication rate, an excellent aesthetic outcome and a very high patient satisfaction.



How to cite this article:
Okumus A. Utility of short-scar incisions mimicking breast augmentation incisions through periareolar or submammary approach for a better aesthetic outcome and patient satisfaction.Turk J Plast Surg 2021;29:20-27


How to cite this URL:
Okumus A. Utility of short-scar incisions mimicking breast augmentation incisions through periareolar or submammary approach for a better aesthetic outcome and patient satisfaction. Turk J Plast Surg [serial online] 2021 [cited 2021 Jan 21 ];29:20-27
Available from: http://www.turkjplastsurg.org/text.asp?2021/29/1/20/305910


Full Text



 Introduction



A growing increase in the number of patients undergoing mastectomy for breast cancer or prophylactic risk-reducing surgery along with the improved survival of breast cancer patients resulted in consideration of the achievement of acceptable aesthetic outcomes besides the oncological safety to be a significant factor for the preservation of quality of life among survivors.[1],[2],[3],[4] This new focus led to consequent advances in surgical techniques to optimize the aesthetic results for improved self-image and self-confidence among patients undergoing mastectomy and breast reconstruction.[1]

The nipple-sparing mastectomy (NSM), an extension of skin-sparing mastectomy to include the nipple-areola complex (NAC), is a novel surgical approach aimed at avoiding the removal of the NAC and facilitating immediate reconstruction to optimize cosmetic outcomes, while still providing an oncologically safe approach in the cancer setting and for risk reduction surgery.[5],[6],[7],[8],[9],[10],[11],[12],[13] Immediate postmastectomy breast reconstruction has been considered to be a potentially less surgically challenging and traumatic approach than delayed reconstruction yielding improved psychosocial and emotional outcomes.[14],[15]

Accordingly, a combination of NSM with immediate breast reconstruction approach has gained popularity for both therapeutic and prophylactic indications in terms of its potential to achieve the best aesthetic outcome while maintaining oncological safety.[4],[16],[17]

Type of skin incision is considered relevant for the optimal surgical, oncological, and cosmetic results related to NSM.[11],[18] Several approaches (i.e., a periareolar incision, a transareolar incision or trans-nipple incision, an inferior or lateral mammary incision, and a superior or inferior hemiperiareolar incision) have been described as alternatives to the classic radial or italic S-skin incision in the upper breast quadrants.[4],[11],[13],[19],[20] However, there is no consensus in the literature regarding the optimal incision to provide oncological safety alongside a high level of patient satisfaction and an excellent aesthetic outcome.[4],[6],[13],[21],[22]

Notably, despite significant advances in postmastectomy reconstructive surgery, aesthetic outcomes perceived by patients after reconstructive breast surgery for correction of postmastectomy deformities have been suggested to be inferior to outcomes after purely aesthetic breast augmentation surgery for the improved cosmetic appearance of healthy breasts.[15],[23],[24],[25],[26]

In this regard, we have hypothesized that using short-scar incisions mimicking breast augmentation incisions for mastectomy and reconstruction operation might improve the aesthetic outcome and enable greater patient satisfaction compared with the purely aesthetic cosmetic breast surgery.

This study was therefore designed to evaluate the utility of short-scar incisions mimicking breast augmentation incisions through a periareolar or submammary approach for a better long-term aesthetic outcome and patient satisfaction after single-session NSM and immediate breast reconstruction operation in breast cancer patients.

 Materials and Methods



Study population

A total of 23 breast cancer patients (mean age: 32 years, range 21–44 years) who underwent single-session NSM and immediate breast reconstruction operation (bilateral in 9) performed through a periareolar or submammary approach were included in this single-center study conducted between February 2006 and August 2016. Inclusion criteria comprised adult female patients scheduled to undergo NSM with immediate implant-based reconstruction performed through a periareolar or submammary incision. Patients with extensive skin involvement, areolar or nipple retraction, malignant nipple discharge, or positive intraoperative retroareolar frozen sections were excluded from the study.

We obtained written informed consent from each subject for the operative procedures and the use of patient data for publication purposes.

Assessments

Data on patient age, histopathological type of breast cancer, family history, BRCA mutation, side of mastectomy and reconstruction, and postoperative complications (implant removal, skin-nipple necrosis, seroma, wound dehiscence, surgical site infection, and hematoma) were retrieved from hospital records. Aesthetic outcome (by both patients and the plastic surgeon), patient satisfaction (visual analog scale [VAS] scores), and psychological outcome (via body image scale) were evaluated after a median 4-year (range, 9 months–11 years) follow-up.

Operative technique

Preoperative markings were made with the patient in both standing and supine positions. The incision site was marked as periareolar or submammary according to the location of the tumor, size of the breast, and ease of mastectomy considered by the general surgeon [Figure 1]. The operations were performed under general anesthesia. Local anaesthetic solution (1000 ml saline, 50 ml 1% lignocaine, and 1 ml 1:1000 epinephrine) was injected subcutaneously and between muscle and breast tissue to enable hemostasis. The general surgeon performed a 4–5 cm (average 4.6 cm) periareolar (in 13 patients) or submammary (in 10 patients) incision for excision of mammary tissue leaving the pectoral fascia intact. An additional axillary incision was made in 7 patients for sentinel node dissection. Frozen sections of the retroareolar tissue were routinely acquired for intraoperative histological diagnosis to confirm that there was no tumor invasion to the NAC borders. In patients with a small tumor-to-skin distance necessitating skin excision, incision, and excision were extended according to oncological safety <2 cm; these patients were not included in the study. After the achievement of hemostasis, a subcutaneous (n = 8) or submuscular (n = 24) implant-based immediate breast reconstruction was performed depending on the thickness of skin flaps. Submusculer prostheses were preferred for flaps thinner than 1 cm, and supramuscles for flaps 1 cm or thicker. Anatomical texture prosthesis was used in 7 patients and round texture prostheses were used in 16 patients. No acellular dermal matrix or a similar product was used during reconstruction. Following placement of a suction drain, subcutaneous, and skin closure was performed in all patients.{Figure 1}

Aesthetic outcome (patient self-assessment and physician assessment)

The subjective aesthetic evaluation included the patient's opinion on the extent to the size of the breast, breast shape, breast symmetry, scars on the breast, NAC, and overall aesthetic result fulfilled expectations. Each category was graded from 0 (not at all) to 3 (very much).[27]

The aesthetic outcome was also assessed by the plastic surgeon based on 6-categories, including breast symmetry, breast volume, the position of submammary fold, scar appearance on the breast, and overall aesthetic result. A scale of six grades was used in each category (6: excellent, 5: good, 4: acceptable, 3: bad, 2: very bad, and 1: not completed reconstruction).[27]

Patient satisfaction

The patient satisfaction was evaluated using VAS scores (possible range 1–10, 10 being most satisfied).

Body image scale

The body image scale is a 10-item scale developed by Hopwood et al.[28] to briefly and comprehensively assess the effective (e.g., feeling self-conscious), behavioral (e.g., difficulty in looking at the naked body), and cognitive (e.g., satisfaction with appearance) aspects of body image in cancer patients. It was designed to be used in all types of cancer or treatment. It is a 4-point scale (0 = not at all and 3 = very much), and the final score is the sum of scores for 10 items, ranging from 0 to 30, with a lower score representing a better body image.[28] Karayurt et al. studied Turkish reliability and validity of BIS in 2015.[29]

 Results



Baseline characteristics

Overall, invasive ductal carcinoma (60.8%) was the most common histopathological diagnosis, while BRCA1 and 2 mutations or family history was positive in 47.8% of patients. Mastectomy and immediate breast reconstruction operations were bilateral in 39.1% of patients and submuscular implants were used for reconstruction in 75.0% of patients [Table 1]. Four patients underwent postoperative radiotherapy, while other patients did not require radiotherapy.{Table 1}

Postoperative complications

None of the patients had implant removal, skin-nipple necrosis, seroma, wound dehiscence, surgical site infection, or hematoma postoperatively. Overall two patients underwent reoperation for breast reconstruction due to the development of Paget disease in the same breast 5 years after the operation in 1 patient and due to capsule contracture that developed 2 years' postoperatively in 1 patient.

The aesthetic outcome, body image, and patient satisfaction

Considering subjective evaluation of aesthetic outcome, the majority of patients identified that size of the breast (95.7%), breast shape (95.7%), breast symmetry (95.7%) and overall aesthetic results fulfilled expectations extremely well, while scars on the breast (100.0%) and NAC (100.0%) were considered to fulfill expectations very much by all patients [Table 2] and [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13].{Table 2}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}{Figure 7}{Figure 8}{Figure 9}{Figure 10}{Figure 11}{Figure 12}{Figure 13}

Physician evaluation also revealed that aesthetic outcome was excellent for the majority of patients in terms of breast symmetry (80.7%), breast volume (95.7%), position of submammary fold (95.7%), and overall aesthetic result (95.7%) and for all patients in terms of scar appearance on the breast (100.0%) [Table 2].

Mean (standard deviation [SD]) VAS score for patient satisfaction was 9.4 (0.8) [Table 2].

Total body image scale score mean (SD, min-max) was 0.8 (1.8, 0–5) in the overall study population which indicated very positive body image in terms of effective (e.g., feeling self-conscious), behavioral (e.g., difficulty in looking at the naked body), and cognitive (e.g., satisfaction with appearance) aspects in all patients after single-session NSM and immediate breast reconstruction operation. None of the patients identified dissatisfaction with the appearance of the scar, body, or appearance [Table 3]. In this study, the aesthetic superiority of the incision preferences could not be determined.{Table 3}

 Discussion



Our findings revealed excellent aesthetic outcome based on both subjective- and physician-based assessments and very high patient satisfaction with scars and overall body image at a median 4-year postoperative follow-up with the use of periareolar and submammary approaches for single-session NSM and immediate breast reconstruction operations among breast cancer patients.

NSM is considered a technique that preserves the integrity of the body, reduces the feeling of mutilation, improves the cosmetic breast results, and reduces the psychological distress regarding the loss of the breast.[30] Moreover, evolving technologies and techniques to optimize autologous and implant-based breast reconstruction further augmented the aesthetic results.[31],[32],[33] Thus, NSM and immediate breast reconstruction should be considered a safe approach associated with a fast recovery and favorable outcome in terms of aesthetic, psychological, and quality of life measures.[6]

However, aesthetic results perceived by patients after reconstructive breast surgery are considered likely to be inferior to outcomes after purely aesthetic breast surgery.[23],[24],[25] Notably, in a past study comparing aesthetic outcomes of cosmetic (breast augmentation) and reconstructive surgery via postoperative images of 10 patients presented anonymously to participants who were blinded to clinical details, mean aesthetic outcomes were considered equivalent regardless of surgery type in terms of natural appearance, size, symmetry, and nipple position, whereas breast position scored better after reconstruction and scars were found more favorable after breast augmentation.[26] The authors also noted that participants were more likely to rank outcomes less favorably if they believed the surgery had been for reconstructive rather than cosmetic indications.[26]

In this regard, the use of periareolar or submammary incisions mimicking breast augmentation scars for mastectomy and immediate reconstruction in our study seems to further augment the postoperative aesthetic outcome and patient satisfaction compared with the ideal aesthetic standards of cosmetic breast surgery. This finding also appears to be supported by consideration of the visibility of scarring to be excellent by all patients in our cohort.

There is no consensus in the literature regarding the optimal incision type for NSM.[4],[13] The utility of a hemi-periareolar incision with or without medial-lateral extensions in NSM was reported in a past study indicating this to be an oncologically-safe technique with a high level of patient satisfaction and an excellent aesthetic outcome.[4] In another study on four different non-conventional types of skin incisions for NSM including hemi-periareolar, round block, vertical and wise pattern, no significant difference was reported between the four types of incisions with regard to overall postoperative surgical complications and satisfaction with breasts and psychosocial, physical (chest and abdomen), and sexual well-being.[13] Authors emphasized that these approaches, being more sophisticated than the classical radial incision, are safe in terms of overall and specific postoperative complications provided that they are performed based on rigorous patient selection criteria and by experienced surgeons.[13]

Our data indicates the safety and reliability of using short-scar (~4 cm) periareolar and submammary approaches in NSM and immediate breast reconstruction based on low complication rates in the early postoperative period as well as the satisfactory long-term results with a favorable aesthetic outcome and high patient satisfaction. This result emphasizes the achievement of a texturally accurate, symmetric, and aesthetically appropriate breast reconstruction consistent with the criteria for the “ideal” breast reconstructive technique (1), which seems significant given the positive correlations between aesthetic outcome and quality of life.[34],[35],[36]

With a long-term follow-up for a median 4 years after NSM and immediate reconstruction, our findings provide reliable data on complication rates given the continued change in the breast shape postoperatively as well as the potential long-term effects of irradiation.[9],[37],[38],[39]

In addition, given the presence of BRCA mutation carriage necessitating prophylactic contralateral mastectomy for risk-reducing purposes in nearly half of the patients, our findings also support the association of NSM in these patients with a low rate of complications and risk of breast cancer indicating long-term oncological safety of NSM in BRCA gene mutation-positive patients.[7],[8]

NSM and immediate reconstruction is an increasingly popular procedure in selected patients for either therapeutic or prophylactic reasons in according to the increased numbers of mastectomies and higher patient expectations regarding the cosmetic and psychosocial outcomes.[1],[4],[40],[41],[42],[43] Accordingly, our findings indicate that use of incisions mimicking breast augmentation incisions in the single-session mastectomy and reconstruction operation may be an alternative not only to maximize cosmetic outcomes but also with potential psychological benefits by avoiding feelings of loss arising from mutilation and enabling better coping with the traumatic experience of breast cancer.[4],[40],[41]

Certain limitations to this study should be considered. First, a relatively small patient cohort limits the generalizing our findings to the overall breast cancer population. Second, the lack of data on quality of life assessment is another limitation which otherwise would extend the knowledge achieved in the current study. Nonetheless, providing data on the long-term follow-up enabling appropriate assessment of potential long-term complications and use of patient self-evaluation in the evaluation of outcome, our findings demonstrate the safety and feasibility of our novel approach.

 Conclusion



Our findings indicate the utility of short-scar (~4 cm) incisions mimicking breast augmentation incisions in a single-session NSM and immediate breast reconstruction as associated with a low-postoperative complication rate, an excellent aesthetic outcome, and a very high patient satisfaction.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that names and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1O'Halloran N, Potter S, Kerin M, Lowery A. Recent advances and future directions in postmastectomy breast reconstruction. Clin Breast Cancer 2018;18:e571-85.
2Neuburger J, Macneill F, Jeevan R, van der Meulen JH, Cromwell DA. Trends in the use of bilateral mastectomy in England from 2002 to 2011: Retrospective analysis of hospital episode statistics. BMJ Open 2013;3. pii: E003179.
3Yao K, Sisco M, Bedrosian I. Contralateral prophylactic mastectomy: Current perspectives. Int J Womens Health 2016;8:213-23.
4El Hage Chehade H, Headon H, Wazir U, Carmaichael AR, Choy C, Kasem A, et al. Nipple-sparing mastectomy using a hemi-periareolar incision with or without minimal medial-lateral extensions; clinical outcome and patient satisfaction: A single centre prospective observational study. Am J Surg 2017;213:1116-24.
5Regolo L, Ballardini B, Gallarotti E, Scoccia E, Zanini V. Nipple sparing mastectomy: An innovative skin incision for an alternative approach. Breast 2008;17:8-11.
6Casella D, Di Taranto G, Marcasciano M, Sordi S, Kothari A, Kovacs T, et al. Nipple-sparing bilateral prophylactic mastectomy and immediate reconstruction with TiLoop® Bra mesh in BRCA1/2 mutation carriers: A prospective study of long-term and patient reported outcomes using the BREAST-Q. Breast 2018;39:8-13.
7De La Cruz L, Moody AM, Tappy EE, Blankenship SA, Hecht EM. Overall survival, disease-free survival, local recurrence, and nipple-areolar recurrence in the setting of nipple-sparing mastectomy: A meta-analysis and systematic review. Ann Surg Oncol 2015;22:3241-9.
8Yao K, Liederbach E, Tang R, Lei L, Czechura T, Sisco M, et al. Nipple-sparing mastectomy in BRCA1/2 mutation carriers: An interim analysis and review of the literature. Ann Surg Oncol 2015;22:370-6.
9Munhoz AM, Aldrighi C, Montag E, Arruda E, Aldrighi JM, Filassi JR, et al. Optimizing the nipple-areola sparing mastectomy with double concentric periareolar incision and biodimensional expander-implant reconstruction: Aesthetic and technical refinements. Breast 2009;18:356-67.
10Galimberti V, Vicini E, Corso G, Morigi C, Fontana S, Sacchini V, et al. Nipple-sparing and skin-sparing mastectomy: Review of aims, oncological safety and contraindications. Breast 2017;34 Suppl 1:S82-S84.
11Murthy V, Chamberlain RS. Defining a place for nipple sparing mastectomy in modern breast care: An evidence based review. Breast J 2013;19:571-81.
12Mallon P, Feron JG, Couturaud B, Fitoussi A, Lemasurier P, Guihard T, et al. The role of nipple-sparing mastectomy in breast cancer: A comprehensive review of the literature. Plast Reconstr Surg 2013;131:969-84.
13Corso G, De Lorenzi F, Vicini E, Pagani G, Veronesi P, Sargenti M, et al. Nipple-sparing mastectomy with different approaches: Surgical incisions, complications, and cosmetic results. Preliminary results of 100 consecutive patients at a single center. J Plast Reconstr Aesthet Surg 2018;71:1751-60.
14Heneghan HM, Prichard RS, Lyons R, Regan PJ, Kelly JL, Malone C, et al. Quality of life after immediate breast reconstruction and skin-sparing mastectomy – A comparison with patients undergoing breast conserving surgery. Eur J Surg Oncol 2011;37:937-43.
15Prasad K, Zhou R, Zhou R, Schuessler D, Ostrikov KK, Bazaka K. Cosmetic reconstruction in breast cancer patients: Opportunities for nanocomposite materials. Acta Biomater 2019;86:41-65.
16Babiera G, Simmons R. Nipple-areolar complex-sparing mastectomy: Feasibility, patient selection, and technique. Ann Surg Oncol 2010;17 Suppl 3:245-8.
17Nava MB, Catanuto G, Pennati A, Garganese G, Spano A. Conservative mastectomies. Aesthetic Plast Surg 2009;33:681-6.
18Rossi C, Mingozzi M, Curcio A, Buggi F, Folli S. Nipple areola complex sparing mastectomy. Gland Surg 2015;4:528-40.
19Dietz J, Fedele G. Skin reduction nipple-sparing mastectomy. Ann Surg Oncol 2015;22:3404.
20Sacchini V, Pinotti JA, Barros AC, Luini A, Pluchinotta A, Pinotti M, et al. Nipple-sparing mastectomy for breast cancer and risk reduction: Oncologic or technical problem? J Am Coll Surg 2006;203:704-14.
21Casella D, Calabrese C, Orzalesi L, Gaggelli I, Cecconi L, Santi C, et al. Current trends and outcomes of breast reconstruction following nipple-sparing mastectomy: Results from a national multicentric registry with 1006 cases over a 6-year period. Breast Cancer 2017;24:451-7.
22Orzalesi L, Casella D, Santi C, Cecconi L, Murgo R, Rinaldi S, et al. Nipple sparing mastectomy: Surgical and oncological outcomes from a national multicentric registry with 913 patients (1006 cases) over a six year period. Breast 2016;25:75-81.
23Crerand CE, Infield AL, Sarwer DB. Psychological considerations in cosmetic breast augmentation. Plast Surg Nurs 2007;27:146-54.
24McCarthy CM, Cano SJ, Klassen AF, Scott A, Van Laeken N, Lennox PA, et al. The magnitude of effect of cosmetic breast augmentation on patient satisfaction and health-related quality of life. Plast Reconstr Surg 2012;130:218-23.
25Waljee JF, Ubel PA, Atisha DM, Hu ES, Alderman AK. The choice for breast cancer surgery: Can women accurately predict postoperative quality of life and disease-related stigma? Ann Surg Oncol 2011;18:2477-82.
26Rochlin DH, Davis CR, Nguyen DH. Breast augmentation and breast reconstruction demonstrate equivalent aesthetic outcomes. Plast Reconstr Surg Glob Open 2016;4:e811.
27Gahm J, Jurell G, Edsander-Nord A, Wickman M. Patient satisfaction with aesthetic outcome after bilateral prophylactic mastectomy and immediate reconstruction with implants. J Plast Reconstr Aesthet Surg 2010;63:332-8.
28Hopwood P, Fletcher I, Lee A, Al Ghazal S. A body image scale for use with cancer patients. Eur J Cancer 2001;37:189-97.
29Karayurt Ö, Edeer AD, Süler G, Dorum H, Harputlu D, Vural F, et al. Psychometric properties of the body image scale in Turkish ostomy patients. Int J Nurs Knowl 2015;26:127-34.
30Sisti A, Grimaldi L, Tassinari J, Cuomo R, Fortezza L, Bocchiotti MA, et al. Nipple-areola complex reconstruction techniques: A literature review. Eur J Surg Oncol 2016;42:441-65.
31Ballard TN, Momoh AO. Advances in breast reconstruction of mastectomy and lumpectomy defects. Surg Oncol Clin N Am 2014;23:525-48.
32Spear SL, Parikh PM, Reisin E, Menon NG. Acellular dermis-assisted breast reconstruction. Aesthetic Plast Surg 2008;32:418-25.
33Kanchwala SK, Glatt BS, Conant EF, Bucky LP. Autologous fat grafting to the reconstructed breast: The management of acquired contour deformities. Plast Reconstr Surg 2009;124:409-18.
34Heil J, Czink E, Golatta M, Schott S, Hof H, Jenetzky E, et al. Change of aesthetic and functional outcome over time and their relationship to quality of life after breast conserving therapy. Eur J Surg Oncol 2011;37:116-21.
35Heil J, Holl S, Golatta M, Rauch G, Rom J, Marmé F, et al. Aesthetic and functional results after breast conserving surgery as correlates of quality of life measured by a German version of the Breast Cancer Treatment Outcome Scale (BCTOS). Breast 2010;19:470-4.
36Santos G, Urban C, Edelweiss MI, Zucca-Matthes G, de Oliveira VM, Arana GH, et al. Long-term comparison of aesthetical outcomes after oncoplastic surgery and lumpectomy in breast cancer patients. Ann Surg Oncol 2015;22:2500-8.
37Vrieling C, Collette L, Fourquet A, Hoogenraad WJ, Horiot JH, Jager JJ, et al. The influence of patient, tumor and treatment factors on the cosmetic results after breast-conserving therapy in the EORTC 'boost vs. no boost' trial. EORTC radiotherapy and breast cancer cooperative groups. Radiother Oncol 2000;55:219-32.
38Haloua MH, Krekel NM, Winters HA, Rietveld DH, Meijer S, Bloemers FW, et al. A systematic review of oncoplastic breast-conserving surgery: Current weaknesses and future prospects. Ann Surg 2013;257:609-20.
39Ojala K, Meretoja TJ, Leidenius MH. Aesthetic and functional outcome after breast conserving surgery – Comparison between conventional and oncoplastic resection. Eur J Surg Oncol 2017;43:658-64.
40Shi A, Wu D, Li X, Zhang S, Li S, Xu H, et al. Subcutaneous nipple-sparing mastectomy and immediate breast reconstruction. Breast Care (Basel) 2012;7:131-6.
41Özkurt E, Tükenmez M, Güven E, Çelet Özden B, Öner G, Müslümanoğlu M, et al. Favorable outcome with close margins in patients undergoing nipple/skin sparing mastectomy with immediate breast reconstruction: 5-year Follow-up. Balkan Med J 2018;35:84-92.
42Dayicioglu D, Tugertimur B, Zemina K, Dallarosa J, Killebrew S, Wilson A, et al. Vertical mastectomy incision in implant breast reconstruction after skin sparing mastectomy: Advantages and outcomes. Ann Plast Surg 2016;76 Suppl 4:S290-4.
43Tukenmez M, Ozden BC, Agcaoglu O, Kecer M, Ozmen V, Muslumanoglu M, et al. Videoendoscopic single-port nipple-sparing mastectomy and immediate reconstruction. J Laparoendosc Adv Surg Tech A 2014;24:77-82.