INTRODUCTION
Breast conserving surgery (BCS) is the standard treatment of breast cancer. The proportion of BCS has gradually grown, now accounting for up to 70% of all breast cancer surgery [1-4]. In comparison with mastectomy, BCS has the benefits of relatively satisfactory cosmetic outcome while showing no difference in the oncologic radicality [1,2]. However, sometimes BCS shows cosmetic limitation according to oncologic (tumor volume, multifocality) and anatomic (breast size, tumor-breast ratio, tumor location) characteristics [5]. Because of this limitation, oncoplastic surgery has emerged in the purpose of achieving oncologic safety whilst satisfying aesthetic outcomes [6-8]. The term oncoplastic surgery was first used by Audretsch [9] in 1998, meaning immediate defect-filling reconstruction to prevent deformity after BCS. Nowadays the term covers a broader aspect, which includes both immediate and delayed reconstruction not only in BCS but also in total mastectomy [10,11]. Breast oncoplastic surgery is divided into two large categories, which are volume displacement and volume replacement. The former is resection of cancer along with reshaping breast tissue; the latter is using autologous flap or prothesis to reconstruct breast contour [12].
Breast oncoplastic surgery is an worldwide used method, and various surgical techniques are performed [13,14]. Korean women’s average breast size is relatively small compared to that of western women, so the role of oncoplastic surgery could be more important. This study was performed to survey the satisfaction rates of breast cancer patients who underwent BCS with volume displacement oncoplastic surgery.
METHODS
Between January 2008 and December 2013, a total of 600 patients underwent oncoplastic surgery with breast cancer by one surgeon at the Department of Surgery, Busan Paik Hospital. Among these patients, 173 patients who had agreed with this study were enrolled in this study and the patients who underwent reduction mammoplasty in large breast were excluded from this study.
Patients’ satisfaction was surveyed with a questionnaire. In addition, cosmetic outcome was evaluated by a doctor. The doctor’s judgement on aesthetic point of view was recorded by another doctor who did not participate in the surgery. In addition, the study looks into the patients’ acceptability of long scars, which are possible results of oncoplastic surgery. This study was approved by the Institutional Review Board of Hospital (IRB approval number, 14-0127).
Volume displacement oncoplastic surgery
Oncoplastic surgery was named as three different groups depending on the amount of excised tissue, skin excision and the range of displacement of breast parenchymal tissue. Simple glandular advancement (SGA) indicates surgical technique that does not require further skin excision, which is performed only in small size mass with small defects. The defect is filled with minimal breast parenchymal displacement (Fig. 1). Dermo-glandular advancement (DGA) is performed when defect is relatively big; a further skin excision is made, followed by excision of breast mass and parenchyme and then displacement of skin and breast parenchyme to fill in the defect (Fig. 2). Dermo-glandular rotation (DGR) is a surgical technique that requires a long skin incision with wide excision of breast parenchyme and skin, thereby resulting in a relatively large defect; this is replaced by the rotation of another quadrant of breast parenchyme and skin (Fig. 3). Surgical method was selected according to tumor and breast size (excision volume) and tumor location, which was judged subjectively by an operator.
Questionnaire on patients’ satisfaction
The questionnaire on patients’ satisfaction was carried out at the follow-up visit at least one year after surgery. The questionnaire was adapted from Pusic’s BREAST-Q [15], which was revised and adjusted to fit this study. The questionnaire was divided into five categories; cosmetic satisfaction, satisfaction on operative method, femininity, postoperative side effects, and preference of operative method. Last category was added to investigate the patients’ acceptability of long surgical scar has the benefits of maintaining breast contour, but leaves a relatively long scar. Patients answered questions of the five-point scale (Table 1).
Doctor’s cosmetic assessment
Cosmetic outcome was evaluated by a doctor who did not participate in the surgery. He inspected the operation site in the point of breast shape and symmetry, dimpling, nipple deviation, deformity, scar contracture either at the clinic during the patient following or via photographs without knowledge of questionnaire results.
The result was classified according to specific criteria using four-point Likert scale [16] and scored as follows: (1) excellent (implies absolutely satisfactory outcomes)=4; treated breast was nearly identical to untreated breast, (2) good (implies satisfactory outcomes)=3; treated breast was slightly different to untreated breast, (3) fair (implies somewhat satisfactory outcomes) =2; treated breast was clearly different to untreated breast, (4) poor (implies needing corrections)=1; treated breast was seriously distorted.
Percentage of removed breast volume
We evaluated the patients’ cosmetic satisfaction according to percentage of removed breast volume. Removed breast volume was estimated by dividing the pathologic specimen weight by the calculated preoperative breast volume. The cone breast volume was estimated with using formula V=1/3πr2h. The breast height and radius was measured in preoperative mediolateral oblique mammogram by two independent observers. This method was adapted from previous study [17].
Statistical analysis
The survey on patients’ satisfaction and doctor’s assessment were technically analyzed on each question. Analysis of varianc test was used for the comparison of mean score. All statistical tests were performed by PASW ver. 18 (SPSS Inc., Chicago, IL, USA) and P-value <0.05 was considered as statistically significant in all results.
RESULTS
Patients’ characteristics
A total of 173 females were enrolled in this study and their mean age of the patients was 53.9±9.0 years. The mean tumor size was 2.3±1.4 cm. In terms of tumor location, 107 tumors (61.8%) located in upper outer quadrant, 25 tumors (14.5%) in lower outer quadrant, 31 tumors (17.9%) in upper inner quadrant, and 10 tumors (5.8%) in lower inner quadrant. In operative methods, 56 patients (32.4%) underwent SGA, 102 patients (60.0%) underwent DGA and the rest 15 patients (7.6%) underwent DGR. The average weight of removed specimens was 74.0±67.2 g and the average breast volume was 497.5±247.6 mL. The mean specimen weight to breast volume ratio was 15.4%±9.3%. Table 2 presents the clinicopathologic characteristics of all patients.
Survey on patients’ satisfaction and doctor’s cosmetic assessment
Table 3 showed the patients’ satisfaction on cosmetic appearance, operative method, femininity, and side effect. For the cosmetic appearance, over the 50.0% of the patients were above satisfied in all questions except for the undressed appearance (44.6%). However, 82.2% of patients answered above the fair in their undressed appearance. In respect to operative method, 72.3% of all patients were above satisfied in their operative results and about 60.0% of the patients showed their satisfaction on the results coincide with expectation before surgery and surgery procedure. Regarding to the femininity criteria, patients showed relatively low confidence compared to other criteria. Especially, only 17.9% of patients agreed that they were attractive. In the case of side effect, less than 5% of all patients experienced very poor side effect in all items.
Doctor’s cosmetic perception on volume displacement breast oncoplastic surgery showed relatively good results. Among the 173 cases, 43 (24.9%) cases, and 81 (46.8%) cases were scored as excellent and good, respectively. Only, seven cases (4.0%) were scored as poor (Table 4).
Cosmetic assessment according to removed specimen volume
The patients’ satisfaction and doctor’s assessment score were analyzed according to removed specimen volume. In respective to patients’ satisfaction, when the removed volume was less than 10%, patients’ cosmetic satisfaction score was the highest and score dropped significantly as removed specimen volume increased (P<0.05). However, no significant differences were observed in the other question items according to removed volume. Regarding to doctor’s cosmetic assessment, the score also decreased significantly when the removed volume became larger (P<0.001) (Tables 5, 6).
Acceptance of long scar (preference of good contour vs. minimal scar)
We evaluated the patients’ preference of good breast contour vs. minimal scar after surgery. Of the patients, 94 (54.3%) of them preferred good contour over long scar regardless of age and marital status. Only, 37 (21.4%) patients preferred short scar despite bad contour (Table 7).
DISCUSSION
Oncoplastic surgery is divided into two large categories, which are volume displacement and volume replacement surgery [12]. Among these, volume displacement oncoplastic surgery is resection of cancer along with reshaping breast tissue and this usually needs large breast volume [17]. Considering this, application of displacement of oncoplastic surgery to small to medium breast like in Korean women could be limited. Moreover, the acceptability of long scar for fine breast contour did not have been evaluated for Korean women who received oncoplastic surgery.
This study has surveyed the satisfaction of patients with breast cancer who underwent volume displacement oncoplastic surgery after BCS. Cosmetic outcome was considered satisfactory over 50% of all patients in all questions but for the undressed appearance (44.6%); however, if “fair” is included, 82.2% of patients answered above the fair in their undressed appearance and the rate peaks up to around 90% in the other cosmetic satisfaction items. In complication items, only less than 5% of all patients reported of severe complications such as cramps or limitations of exercise.
Chan et al. [17] studied the cosmetic outcome according to percentage of volume after oncoplastic BCS in Asian women, who have relatively small breast. They also performed oncoplastic surgery applying displacement surgery and reported very high satisfaction rate for cosmetic appearance; over the 90% of the patients were very satisfied or satisfied in their postoperative appearance. In the other previous meta-analysis study which compared patients’ cosmetic satisfaction on those who had oncoplastic BCS with those who only had BCS, the satisfaction rate of oncoplastic BCS group was reported as 89.5% while that of BCS only group was 83.0% [18]. These results are relatively high satisfaction results compared to ours, and we think that this might be attributed to mean removed specimen weight to breast volume ratio. Actually, in Chan’s study, their median percentage of volume excision was smaller compared to ours (7.4% vs. 12.8%) and the meta-analysis study also discussed patients with larger breasts were most satisfied for their cosmetic results [17,18]. Although this study did not compare satisfaction between oncoplastic surgery and BCS, the cosmetic satisfaction rated up to about 90% (including fair) with postoperative severe complications being less than 5%, suggesting that oncoplatic surgery is a good surgical technique.
We evaluated patients’ satisfaction depending on specimen volume. According to the previous study, oncoplastic surgery enables to resect up to 50% of the breast [19] and our maximum percentage of removed volume specimen was around 40%. In this result, patients’ cosmetic satisfaction score were significantly inversely related with removed specimen volume and doctor’s cosmetic assessment was also accordance with this result (P<0.05). On the basis of this result, we could recognize the pattern of satisfaction score change according to specimen volume. In the case of cosmetic score, mean cosmetic satisfaction score dropped until removed volume reached 30% and score was plateau when the removed volume was over 30% in both patient’s and doctor’s results. In the patients’ satisfaction operative method, mean score was similar until removed volume became 30%, but the score dropped dramatically when the removed volume was over 30%. The previous study on volume displacement oncoplastic surgery showed patients’ satisfaction score was almost similar until removed volume was around 20% and after that satisfaction score dropped dramatically [17]. Considering these results, we suggest carefully that marginal value of percentage of volume excision for better cosmetic result could be between 20% and 30% in volume displacement oncoplastic surgery and volume replacement oncoplastic surgery might be necessary when the excised volume is more than 40% of the breast. However, we think that more studies will be needed to clarify this suggestion.
This study has evaluated the acceptability of long scar for fine breast contour. Generally speaking, good breast contour was preferred over short scar (54.5% vs. 21.4%), regardless of age and marital status. Interestingly, the preference for good contour increased as patients get older. This shows that Korean women put importance on general appearance with their clothing on and older women less concerns on scar compared to young women.
Volume displacement breast oncoplastic surgery ensures both the best possible cosmetic outcome of breast cancer resection and high patient satisfaction for Korean women with small sized breasts. For this reason, it is a recommendable surgical technique. Korean women tend to consider general contour of breast more than the size of scar in terms of cosmetic satisfaction.
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