Patient-reported Outcomes Utilizing the BREAST-Q Questionnaire After Breast-Conserving Surgery With and Without Oncoplastic Breast Surgery: A Systematic Review and Meta-analysis

Abstract

 

Oncoplastic breast surgery (OBS) arose to decrease the deformity following breast-conserving surgery (BCS) for breast cancer. In this meta-analysis (MA), we pool BREAST-Q questionnaire data to compare quality of life (QOL) in breast cancer patients who received BCS alone or in combination with level I or II oncoplastic breast surgery (BCS + OBS). All relevant databases were searched following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and QUOROM (Quality of Reporting of Meta-Analyses) guidelines. All prospective or retrospective studies with a BCS or BCS + OBS cohort that reported QOL as assessed with the BREAST-Q questionnaire were eligible. Fifty-five studies (75 distinct patient cohorts; 11,186 patients) were included in the MA, with 12 studies reporting both preoperative and postoperative values and eligible for a pair-wise MA. The pair-wise MA showed a significant postoperative improvement in the overall satisfaction with the breast (mean difference [MD] +8.0%, P = .003) and in the psychosocial well-being (MD +9.2%, 3.5-14.8, P = .001) of the entire cohort (BCS and BCS + OBS). A subgroup MA of proportions highlighted a superiority of BCS + OBS to BCS in overall satisfaction with the breast (72.0%, 68.0-76.1, vs 62.9%, 58.3-67.5; P = .02) and psychosocial well-being (78.9%, 71.5-86.4, vs 73.3%, 67.3-76.5, P = .0001). A leave-1-out sensitivity analysis confirmed the results of the pair-wise MA and the MA of proportions. Oncoplastic breast surgery effectively improves QOL and patient satisfaction based on the patient-reported outcomes assessed with the BREAST-Q questionnaire. The improvements were associated with acceptable complication rates, further supporting BCS followed by OBS when mastectomy would otherwise be necessary.

Level of Evidence: 3

With advances in medical and surgical care, long-term disease-free survival of patients diagnosed with primary breast cancer can be 80% to 90%.¹ The rise in long-term survival following oncological breast surgery underscores the importance of achieving satisfactory cosmetic results. Improvements in quality of life (QOL) and overall satisfaction with the postoperative cosmetic result, in addition to traditional outcome indicators such as mortality or morbidity, all carry importance when evaluating quality of care.² Oncoplastic breast surgery (OBS) therefore shares many of the aims and principles of cosmetic breast surgery.

According to the American Society of Breast Surgeons, OBS is defined as the surgery that follows the oncologic resection, partial mastectomy, or lumpectomy performed during breast-conserving surgery (BCS) and can be ipsilateral reconstruction through volume displacement or replacement techniques and possible contralateral symmetry surgery (Figure 1). Volume displacement can be further subdivided into level I or II according to the type of resection. Level I OBS is defined as less than 20% breast tissue excision in small- to moderate-size breasts with minimal ptosis. Level II OBS indicates that 20% to 50% of breast tissue is excised in moderate- to large-size breasts with moderate to severe ptosis.³

OBS following BCS offers multiple advantages. First, it is an effective treatment for different forms of breast cancer, including multifocal tumors or those located in unfavorable quadrants. Second, breast reduction options can optimize radiotherapy and decrease negative outcomes.⁴ Evidence has revealed that when radiotherapy is applied to larger breasts, that is to patients with macromastia, complications such as discolorations, fibrosis, and asymmetry are more frequent.⁵ At the same time, oncoplastic breast reduction, just as nononcologic breast reduction, can alleviate macromastia symptoms, including back, neck, and shoulder pain and intertriginous infections.⁶ Given the extensive effect these advantages can have on patient QOL, accurate evaluation of the patient perspective and satisfaction becomes imperative.

Since its introduction in 2009, the BREAST-Q questionnaire (Q-Portfolio, Memorial Sloan Kettering Cancer Center and the University of British Columbia) has become a well-established tool for assessing QOL outcomes and improvement of symptoms after mammaplasty.⁷ BREAST-Q provides quantitative measures of patient-reported outcomes, allowing for score comparison over time and accounting for study-specific factors, such as patient demographics, comorbidities, and surgical characteristics, including incision pattern and resection volume, as well as complication rates.⁸

In a previous meta-analysis (MA), we synthesized all available data to establish the efficacy of the BREAST-Q reduction module and predict satisfaction in patients undergoing nononcological breast reduction, identifying that postoperative satisfaction was independent of resection volume.⁹ In this MA, we sought to pool all available evidence to assess the changes in the BREAST-Q scores in patients who underwent BCS with or without level I or II volume displacement OBS for oncological purposes. The secondary aim was to identify key factors that might impact preoperative and postoperative scores.

METHODS

Data Source

A systematic literature review was conducted by screening the PubMed (National Library of Medicine, Bethesda, MD), Embase (Elsevier, Amsterdam, the Netherlands), Web of Science (Clarivate, Philadelphia, PA), and Google Scholar (Alphabet Inc., Mountain View, CA) databases from the inception of the BREAST-Q questionnaire in August 2009 to January 31, 2023, in March 2023. The search terms included: (“breast conserving surgery” OR “breast conservation surgery” OR “breast conserving therapy” OR “breast conservation therapy” OR “partial breast reconstruction” OR “conservative breast surgery” OR “lumpectomy” [title and abstract; tiab]) OR (“oncoplastic” OR “oncoplastic surgery” OR “oncoplastic approach” OR “oncoplastic technique” OR “oncoplastic breast conservation” OR “oncoplastic breast reduction” OR “oncoplastic mastopexy” OR “level I oncoplastic” OR “level II oncoplastic” [tiab]) AND (“BREAST-Q” OR “breast questionnaire” OR “quality of life” OR “QOL” OR “satisfaction” [tiab]). The search format was appropriately tailored to the syntax of each database. The meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.¹⁰

Study Identification and Selection

Study identification was conducted by 2 independent reviewers (A.C.P. and V.H.) with a 2-stage method. As a first step, titles and abstracts were reviewed to identify eligible studies. The abstracts of these articles were then assessed in detail to identify reasons for exclusion. In the final step, the full manuscript texts of all potential studies were analyzed, and their eligibility by inclusion and exclusion criteria was verified. No inconsistencies or discrepancies occurred between A.C.P. and V.H. As an additional step (“other sources”), the reference list of each eligible article, or retrieved systematic review and MA, was manually searched for relevant literature.

Inclusion and Exclusion Criteria

Included studies had to meet the following study design or outcome inclusion criteria: (1) reporting on female patients undergoing BCS with or without OBS for oncological purposes; (2) utilization of the BREAST-Q questionnaire to report on patient health-related QOL; (3) investigation of eligible oncoplastic surgery, that is, any level I or II volume displacement procedures as defined by Clough et al; (4) provision of numerical data on the BREAST-Q scores (preoperative or postoperative); (5) publication in the English, German, French, Portuguese, Greek, Spanish, Italian, or Mandarin languages; and (6) consist of prospective or retrospective studies such as case series, randomized control trials, clinical trials, case control studies, and cohort studies.¹¹

Accordingly, we excluded the following articles: (1) reports on nonfemale patients or patients undergoing mammaplasty for nononcological purposes (ie, cosmetic surgeries); (2) investigations of volume replacement procedures such as lipofilling or flap surgery (ie, latissimus dorsi miniflap); (3) investigations of breast reconstruction procedures; (4) employment of other QOL or satisfaction assessment tools; (5) reports without original data, such as reviews and meta-analyses; (6) unpublished studies, case reports (defined as equal or fewer than 2 patients), books, cost-effectiveness studies, and animal, basic science, or cadaver studies; and (7) studies published in languages other than those mentioned above.¹²

Data Extraction

Data were extracted by 3 independent investigators to a dedicated Microsoft Excel 2020 (Microsoft, Redmond, WA) spreadsheet, and included: first author name; publication year; country based on the location of the institution treating the cohort; type of study; level of evidence; number of patients; number of patients responding to each component of the BREAST-Q; patient demographics (such as mean age, BMI, comorbidities), surgical characteristics (such as type of surgery, length of surgery, volume of resection, concomitant radiotherapy), and outcomes, including complications; and preoperative and postoperative BREAST-Q scores. Collected data were stored in an electronic laboratory notebook (LabArchives, LLC, San Marcos, CA).

Primary Outcomes

Primary outcomes included the following components of the BREAST-Q questionnaire: (1) preoperative: overall satisfaction with breast, psychosocial well-being, physical well-being, sexual well-being; (2) postoperative: overall satisfaction with breast, psychosocial well-being, physical well-being, sexual well-being, postradiotherapy well-being, satisfaction with outcome, satisfaction with the nipple areola complex (NAC). Normative values published by Mundy et al were employed for comparison.¹³

Secondary Outcomes

Secondary outcomes included: operative time, length of hospital stay (LOHS), readmission, reoperation, and complication occurrence. Complications were divided into subgroups of breast hematoma, abscess, skin necrosis, NAC necrosis, infection, breast seroma, and axillary seroma.

Quality Assessment

The quality of the included studies was independently assessed by 2 reviewers with the Newcastle-Ottawa Scale. Inconsistencies were resolved by V.H.

Subgroup Analysis

The patient cohorts were grouped according to the surgery received: BCS alone or BCS with OBS surgery. The groups were then compared by primary outcomes.

Sensitivity Analysis

The reliability of the results was verified with a leave-1-out sensitivity analysis, whereby 1 study was excluded at a time to assess the impact of this study on the overall estimate.

Statistical Analysis

A pair-wise MA was performed with the studies providing both preoperative and postoperative values in Review Manager (RevMan; version 5.4 for Mac OS; Cochrane, London, UK). A meta-analysis of proportions was performed with OpenMeta[Analyst] (version 10.12 for Mac OS [Apple, Cupertino, CA]). Both MAs were performed following the Cochrane Collaboration and the Quality of Reporting of Meta-analyses (QUOROM) guidelines.¹⁴ Continuous data were presented as mean difference (MD) with 95% confidence intervals (CIs). Categorical data were presented as odds ratios (ORs) with a 95% CI. The heterogeneity of studies was evaluated with the I² statistic. Given I² > 50%, pooled proportions (%) or weighted means and standard deviations (SDs) with a 95% CI were calculated with a random effects model. SDs were either directly provided by the studies, indirectly calculated from the CI, standard error of mean, or interquartile range, or estimated from the SDs provided by the most similar study by cohort composition and size. The differences between the preoperative and postoperative values calculated from the MA of proportions and between the normative, preoperative, and postoperative values were compared with an unpaired t test as previously described.¹⁵ A metaregression was run in OpenMeta[Analyst] (version 10.12 for Mac OS) to investigate the correlation between median age, BMI, resection weight in grams, complication rate, and follow-up time in months, and the postoperative overall satisfaction with the breast. P values less than .05 were considered statistically significant. Pearson correlation coefficients were calculated for BREAST-Q score changes relative to resected breast volume, demographics (age or BMI), and complication occurrence. Data visualization was performed with GraphPad Prism 9.

RESULTS

Studies Included in the Meta-analysis (MA)

A total of 2349 articles were identified in the initial literature search (Figure 2). After title and abstract evaluation, 2258 articles were excluded and 91 studies underwent detailed assessment. Thirty-six studies were excluded for the following reasons: irrelevance, lack of original data, or ineligible assessment methods. Finally, 55 studies comprising 75 distinct patient cohorts and 11,186 patients were included in the MA (Supplemental Table 1).

All studies were published after 2014, with 16 studies published after 2022. The majority of studies administered the breast-conserving module of the BREAST-Q (29/55, 53%), followed by those that did not specify a module (18/55, 33%), the reduction module (5/55, 9%), and the reconstruction module (3/55, 5%), with some studies administering more than 1 module. Regarding surgery performed, 29 studies with 34 cohorts presented data on BCS alone and 31 studies with 41 cohorts presented BCS + OBS patients. Varied geographical distribution was seen, with 23 studies published in Western Europe, 17 in the Americas or Caribbean, 5 in East Asia or the Pacific, 4 in the Middle East or North Africa, 3 in Eastern Europe or Central Asia, 2 in South Asia, and 1 in sub-Saharan Africa. A total of 19 studies included prospective data, and 36 reported retrospective data. Of the included manuscripts, 34 first authors were from general surgical or surgical oncology/breast departments and 14 first authors from plastic surgery departments.

Pair-wise MA—Primary outcomes

Twelve studies with 14 cohorts provided data on both preoperative and postoperative overall satisfaction with the breast. The mean difference was +8.0% (95% CI, 2.8-13.2; P = .003). Ten studies with 12 cohorts provided data on both preoperative and postoperative physical well-being. The mean difference was −9.1% (95% CI, −22.0-3.8; P = .17). Nine studies with 10 cohorts provided data on both preoperative and postoperative psychosocial well-being. The mean difference was +9.2% (95% CI, 3.5-14.8; P = .001). Seven studies with 8 cohorts provided data on both preoperative and postoperative sexual well-being. The mean difference was +6.3% (95% CI, −1.1-13.6; P = .09). The differences retained their significance or insignificance across the leave-1-out sensitivity analysis (Figure 3). The results after subgrouping according to surgery are summarized in Table 1.

The BCS group was associated with a significant increase in psychosocial well-being (P < .0001) and a significant decrease in physical well-being (P = .02). Overall satisfaction with the breast and sexual well-being did not differ from the preoperative values in this group. The results for the psychosocial and sexual well-being were unaffected by a leave-1-out sensitivity analysis. However, when excluding the study by Aristokleous et al, cohort 1A, overall satisfaction with the breast was seen to be significantly improved after surgery (MD +5.5, 95% CI, 3.1-7.9; P < .0001).¹⁶ Likewise, exclusion of the same study removed the significance of decreased physical well-being after surgery (MD −20.4, 95% CI, −41.9-1.0; P = .06). This significance of decreased physical well-being after surgery could also be removed by excluding the Huynh et al study (MD −16.8, 95% CI, −36.2-2.6; P = .09).¹⁷ The BCS + OBS group was associated with a significant increase in overall satisfaction with the breast (P = .001) and sexual well-being (P = .002). Physical well-being was not significantly lower than the preoperative values in this group. The results on overall satisfaction with the breast as well as sexual and physical well-being remained unchanged during a leave-1-out sensitivity analysis. However, although the change in psychosocial well-being was seen to be insignificant in this group, leave-1-out sensitivity analysis identified that this was driven by a single study (namely, Acea Nebril et al, cohort 3B), with the exclusion of this study yielding a mean difference of +16.0 (95% CI, 1.2-30.8; P = .03).¹⁸

MA of Proportions—Primary Outcomes

The results of the MA of proportions are summarized in Table 2 and Figure 4. The overall satisfaction with the breast was seen to be significantly higher in the BCS + OBS group (72.0, 68.0-76.1) compared to the preoperative (62.3, 59.5-65.2; P = .002) and BCS alone values (62.9, 58.3-67.5; P = .02). Similarly, sexual well-being was found to be significantly higher in the BCS + OBS group (66.6, 62.6-70.5) compared to the preoperative (58.5, 54.9-62.0; P = .01) and BCS alone values (56.4, 53.4-59.3; P < .0001). The preoperative psychosocial well-being (67.2, 63.9-70.4) was significantly lower than the normative values (71 ± 18; P = .02), but no difference was found between the normative values and postoperative psychosocial well-being (entire cohort: 76.2, 72.5-79.9, P = .19; BCS: 73.3, 68.4-78.1, P = .57; BCS + OBS: 78.9, 71.5-86.4, P = .13), suggesting a shift toward normal values. Physical well-being was the only outcome to show a decrease postoperatively and was found to be significantly lower in all groups compared to normative values (93 ± 11, all P < .0001). Physical well-being was also significantly lower postoperatively (71.1, 67.8-74.4) compared to the preoperative values (79.7, 71.3-88.0; P = .04). Postradiotherapy well-being did not differ between the 2 surgical subgroups, amounting to 80.8% (74.2-87.3) and 81.6% (69.0-94.3) for BCS and BCS + OBS respectively (P = .91). All other differences were insignificant.

MA of Proportions—Secondary Outcomes

Operative time did not differ between the BCS (146.7 minutes, 99.6-193.7) and BCS + OBS (105.8 minutes, 82.5-129.1; P = .19) groups. The 2 groups also did not differ in terms of LOHS (BCS: 2.2 ± 0.2 days vs BCS + OBS: 1.9 ± 0.64 days; P = .58). Data for readmissions was only provided for 6 cohorts, all of which were BCS + OBS cases; and the rate of readmission was 0.02% (15/768 patients). The pooled rate of reoperation or reexcision was 10.6% for the BCS group (77/686) compared to 6.6% for the BCS + OBS group (68/973; P = .15). The pooled rate of complications was 13.1% in the BCS group (156/986) and 20.7% in the BCS + OBS group (284/1341; P = .08). The weighted rate of hematoma specifically was 12.2% in the BCS group (33/271) and 2.1% in the BCS + OBS group (31/1035; P < .0001). The weighted rate of infection was 8.2% for BCS patients (26/298) and 4.5% for BCS + OBS patients (41/744; P =.15). It should be noted that the high rates of hematoma and infection seen in the BCS group were both derived from the same 2 papers.^19,20 The weighted rate of breast seroma was 12.7% in the BCS group (23/127) and 4.6% in the BCS + OBS group (66/1051; P = .08). Data on axillary seroma, NAC necrosis, skin necrosis, and abscess occurrence were only provided for the BCS + OBS group and were found to occur in 0.4% (1/226), 1.8% (15/811), 1.8% (11/620), and 0.9% (2/226) of patients, respectively.

Metaregression of Overall Satisfaction With the Breast

Metaregression identified a positive correlation between median age and overall satisfaction with the breast (coefficient 0.27, P = .29). A negative correlation was seen between BMI (coefficient −0.12, P = .82), complication rates (coefficient −0.10, P = .55), time of follow-up (coefficient −0.10, P = .26), and overall satisfaction with the breast. Resection weight did not correlate with satisfaction (coefficient 0.00; P = .95). However, none of these correlations were significant. The metaregression graphs are shown in Figure 5.

Quality Assessment

Four studies showed a level of evidence (LOE) of 3, namely Dolen et al, O’Connell et al, Rosenkranz et al, and St. Denis-Katz et al.^21–23 The remaining studies yielded a LOE of 4. Quality assessment using the Newcastle-Ottawa scale quality assessment tool showed that bias due to selection was low in the majority of the included studies, whereas bias due to comparability was high in 40% of studies. Bias due to outcome was moderate to low in all studies (Figure 6).

DISCUSSION

This MA was the largest effort to date to synthesize all studies investigating the effect of BCS and BCS with OBS on patient-reported outcomes as assessed with the BREAST-Q questionnaire, in an attempt to compare the 2 procedures. Both pair-wise MA (with preoperative scores as comparators) and an MA of proportions were run, followed by metaregression, subgroup, and sensitivity analysis.

Arguably, the most important finding was that, compared to BCS alone, BCS followed by OBS was associated with significantly better outcomes, particularly in overall satisfaction with the breast and sexual well-being. This was not surprising, because oncoplastic techniques can optimize the cosmetic outcomes preserved by BCS while resulting in excellent oncologic outcomes.²⁰ Our results substantiate that OBS can support breast cancer patients to achieve better satisfaction with body image and mental health.

Ultimately, both BCS and OBS represent effective options for breast cancer treatment associated with improvements in patient-reported outcomes. The choice between the 2 procedures can depend on a plethora of factors, including the size and location of the tumor, patient age, overall health, and personal preferences and expectations. Patient priorities in, for example, which well-being component they most value can assist in procedure selection. As a newer approach, OBS combines the principles of plastic surgery with oncology to remove the cancerous tissue while reshaping the breast to achieve better symmetry and aesthetics. Both BCS and OBS have advantages and disadvantages, which should be discussed with the patient for informed decision making. Although BCS is less invasive and is believed to be associated with a shorter hospital stay and a shorter recovery period, it may not be the most suitable option for all patients.²⁴ Our pooled data identified no difference between the 2 groups in LOHS. OBS may be a better option for patients with larger tumors, as well as those seeking better aesthetic outcomes. At the same time, the procedure is more invasive and may require a longer recovery time. Ultimately, the choice between BCS and OBS should be determined by the individual patient's circumstances and should be made in consultation with the surgeon to critically weigh the benefits and risks of each approach.

The benefits of BCS + OBS compared to BCS alone have been recently highlighted in an MA by Mohamedahmed et al, who focused on surgical outcomes and postoperative complications.²⁵ The authors reported a higher specimen weight, lower reexcision rates, and lower risk of locoregional recurrence in patients undergoing BCS + OBS compared to BCS. A lower rate of reexcision was also noted in our MA, although no significance was reached. This may be because we included a lower number of studies reporting on reexcision, because our primary outcome and inclusion criterion was a report of BREAST-Q scores. Nonetheless, taking the results of the Mohamedahmed et al MA and this MA together, BCS + OBS appears superior in complication outcomes and patient-reported outcomes.

Some other minor findings also warrant further discussion. Physical well-being was seen to decrease postoperatively, particularly in the BCS alone group. This has been previously described, with scores decreasing significantly right after surgery and gradually increasing after 1 year of follow-up.²⁶ Confounding factors may also impact the physical well-being in BCS and BCS + OBS patients, such as adjuvant chemotherapy or the presence of comorbidities. Prospective studies should include investigation of whether this is a true effect, whether this decrease in physical well-being is temporary, and at what point reversal toward baseline can be expected. Regardless, this association with possible decreased physical well-being should be discussed with patients and may help aid in decision making regarding which procedure is optimal for those whose main expectation is an improvement in long-term physical well-being.

The studies included in this MA had varying follow-up times, ranging from less than 6 months to more than 10 years. With the median follow-up time point, we ran a metaregression and identified a negative, albeit insignificant, correlation between time-from-surgery and overall satisfaction with the breast. Research has previously reported that patient-reported outcomes do change over time, although outcomes after autologous reconstruction, which is more similar to OBS than prosthetic-based reconstruction, are more stable.²⁷

Previous research has suggested a possible correlation between lower satisfaction with breasts scores and younger patients, a phenomenon which was not seen in our metaregression.²⁸ In this MA, we noted that increases in age were more likely to be associated with increases in overall satisfaction, although, likely owing to the high heterogeneity of the studies, significance during metaregression could not be established. This highlights the importance of investigating the true association between age and satisfaction, particularly given the aging population and the ever-increasing median age of patients with breast cancer.

Metaregression also allowed us to verify a finding from our previous meta-analysis on the BREAST-Q scores, in which we found no correlation between the weight of resection and satisfaction in patients undergoing breast reduction for cosmetic purposes.⁹

Strengths and Limitations

Although this MA is the most comprehensive study to pool together all published data on patient-reported outcomes following BCS with and without oncoplastic volume displacement, its limitations should be considered. A limitation inherent to most MAs pooling data from surgical papers is the overall low quality of the included studies, which are often retrospective cohort studies with a level of evidence of 4. The quality of a meta-analysis is itself limited by the quality of studies that it summarizes and their inherent biases. Of the 55 studies analyzed, only 12 studies provided the preoperative scores and were available for a pair-wise meta-analysis, although the BREAST-Q questionnaire was developed with the intention of capturing changes in patient-reported outcomes from the preoperative to the postoperative status. Although the estimates obtained from the MA of proportions provide lower certainty than the pair-wise MA, research supports that this evidence can still inform decision making, particularly in the surgical field, in which the absence of higher quality evidence, such as that provided by randomized controlled trials, is relatively common.^29,30 At the same time, the heterogeneity of the studies as assessed with the I² statistic was high, a factor that can limit the strength of an MA, particularly of an MA pooling proportions from studies that offer no comparator. The high heterogeneity may be due to the surgical techniques employed, the variable administration of chemotherapy and radiotherapy, and the inherent qualities of the population assessed, among other reasons. Importantly, given temporal and location differences between the included studies, heterogeneity is expected in the prevalence and incidence estimates, and a high I² in proportional meta-analysis is not necessarily indicative of inconsistent data. The temporal changes that occur in patient-reported outcomes after surgery are also an important consideration; for example, the lower values for physical well-being may be temporary and due to the recent surgery. These limitations underscore the necessity for high-quality, prospective studies and randomized control trials that would include investigation of appropriate comparison groups and therefore reduce bias.

CONCLUSIONS

Overall, our results suggest that BCS combined with OBS is superior to BCS alone, in all components of the BREAST-Q questionnaire assessed, with the improvement in overall satisfaction and sexual well-being holding true across subgroup and sensitivity analyses. The association between lower physical scores and BCS alone or combined with OBS requires further investigation. Including randomized controlled trials can help to validate our results and offer explanations. Nevertheless, the evidence provided here may help surgeons provide more accurate information to patients seeking breast-conserving and oncoplastic surgery.

Supplemental Material

This article contains supplemental material located online at www.aestheticsurgeryjournal.com.

Acknowledgments

Dr Panayi and Mr S. Knoedler made equal contributions to this work as co-first authors.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES

Author notes